Monrovia Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Duarte, California.
- Location
- 1220 E. Huntington Drive, Duarte, California 91010
- CMS Provider Number
- 055259
- Inspections on file
- 46
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Monrovia Post Acute during CMS and state inspections, most recent first.
The facility failed to immediately report an influenza outbreak to the county DPH after three residents with multiple comorbidities developed respiratory symptoms and subsequently tested positive for influenza within a short time frame. According to the IP, one resident with a hip fracture and acute cholecystitis, another with osteomyelitis and type 2 DM with a foot ulcer, and a third with hemiplegia, hemiparesis, and type 2 DM with neuropathy all developed cough or cough with wheezing and were confirmed influenza-positive, meeting outbreak criteria under the Influenza and other Respiratory Virus Diseases Outbreak Toolkit, yet the required notification to public health was not made immediately.
Two residents who were dependent on staff for bathing and toileting hygiene were left exposed during bed baths when CNAs failed to maintain privacy curtains and adequate covering. In one case, a cognitively impaired resident with mental illness and dementia had their blanket, gown, and brief removed, and the CNA opened the privacy curtain while the room door was open, leaving the resident’s body visible from the hallway. In another case, a resident with epilepsy and a history of falls was fully exposed during perineal care when a roommate opened the privacy curtain and the CNA did not re-cover the resident or close the curtain, continuing care despite the resident feeling upset and requesting privacy. These actions conflicted with facility policies requiring residents to be covered during bed baths and afforded privacy and dignity.
Staff failed to follow infection control and bed bath procedures during incontinence and bathing care for three residents. One CNA did not change gloves after transferring a resident and before handling clean linens, body wash, and a clean brief, and then used the same contaminated gloves to access a drawer and retrieve a sheet. In separate observations, two CNAs provided bed baths to two residents using a single basin or bucket of water and the same washcloth to cleanse multiple body areas, including the perineal and buttocks areas, without changing the bathwater as required by facility policy.
A resident with multiple chronic conditions and documented decision-making capacity repeatedly requested copies of her medical records through authorization forms and email. Facility policy required access to records within 24 hours and copies within two business days, but staff delayed fulfilling several requests well beyond this timeframe and did not honor at least one email request. The ADM and Director of Medical Records stated that response times depended on the volume of records and acknowledged that medical records staff did not document their interactions in the resident’s chart, resulting in the resident not receiving timely copies of her records as required by facility policy.
During a prolonged power outage, the facility did not ensure that the call light system remained operational for several high-risk residents with significant medical needs. Multiple residents, all requiring substantial assistance and at risk for falls, were left without a functioning call system or adequate alternative devices to request help. Staff confirmed the outage and the lack of sufficient temporary bells, and facility policies required a functional call system at all times.
Licensed staff did not sign, date, or time the receipt of pharmacy-delivered medications for three residents with complex medical needs, as required by facility policy. Review of records and staff interviews confirmed the absence of proper documentation for medication receipt.
A resident with diabetes, cognitive impairment, and other conditions repeatedly refused blood glucose checks and insulin injections, but nursing staff did not notify the physician as required by facility policy. Both the resident's physician and care coordinator confirmed they were not informed of these refusals, despite documentation and staff interviews verifying the missed notifications.
A resident with cognitive impairment and multiple medical conditions reported being verbally and physically abused by a CNA during a night shift. The CNA did not report the allegation to the charge nurse, administrator, or authorities as required. Staff interviews and record review confirmed that the facility failed to notify the Department, Ombudsman, and law enforcement within the mandated two-hour timeframe, resulting in a delay in reporting the abuse allegation.
Residents lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that declines in ADL performance were clinically unavoidable, as required, and records lacked evidence of a medical justification for the loss of function.
A resident did not receive treatment and care in accordance with physician orders and their own stated preferences and goals, as evidenced by surveyor findings and record review.
A resident with multiple pressure injuries and MASD, who was dependent on staff for care, did not have a weekly skin check documented over a two-week period. The responsible nurse confirmed missing the required wound note, which was mandated by facility policy for monitoring skin conditions.
A resident with multiple chronic conditions and moderate cognitive impairment did not receive three scheduled doses of Morphine Sulfate for pain management because the medication supply ran out and was not reordered in accordance with facility policy. The DON confirmed the lapse was due to a delay in obtaining the physician's signature, and the pharmacy did not process the refill request until after the supply was depleted.
A resident did not receive the specialized rehabilitative services that were required for their care, as the facility failed to provide or arrange for these necessary interventions.
A resident with significant cognitive and physical impairments did not have an Orthopedic consultation note available in the electronic medical record following a specialty appointment, despite a physician's order and documentation of the visit in progress notes. Both nursing staff and the DON were unable to locate the note, which was required to be accessible under facility policy as the facility transitioned to paperless charting.
A resident with diabetes and ESRD was not properly informed of a significant kidney mass found on an ultrasound, and the physician was not promptly notified for further evaluation. Documentation was lacking regarding communication of the results, and the nephrology provider did not receive the test information until the day of the resident's appointment, resulting in delayed follow-up.
A resident with a documented diagnosis of Parkinson's disease and ongoing treatment with Sinemet was not accurately coded for this condition in the MDS assessment. Despite clear evidence in medical records, physician orders, and direct observation of symptoms, the diagnosis was omitted from the MDS, and the responsible LVN could not explain the discrepancy. This failure resulted in an inaccurate assessment entry, contrary to facility policy requiring consistency between assessments and clinical documentation.
A resident receiving Sinemet for Parkinson's disease did not have a comprehensive care plan addressing the medication or its potential side effects. The resident's diagnosis was not reflected in the MDS, and staff were unaware of the omission. Despite physician orders and neurologist instructions to monitor for adverse reactions, the facility failed to document and communicate these needs as required by policy.
A consultant pharmacist did not identify or report irregularities related to Sinemet use for a resident with multiple diagnoses, including dementia and a history of Parkinsonism, during monthly medication regimen reviews. The resident's MDS did not reflect a Parkinson's diagnosis, and there was no documented monitoring or follow-up after a Levodopa trial was initiated by a neurologist. Despite facility policy requiring thorough review and reporting of medication issues, the pharmacist found no concerns and made no recommendations regarding Sinemet use or monitoring.
A resident was administered Sinemet without adequate documentation of a Parkinson's diagnosis or proper monitoring for effectiveness and adverse effects. The MDS did not reflect the neurological diagnosis, and staff acknowledged the inaccuracy and lack of follow-up. The consultant pharmacist did not identify irregularities, and facility policies for assessment and medication review were not followed.
A resident reported missing two cord holders to a CNA, who failed to report the issue to supervisors, contrary to facility policy. The resident, with no cognitive impairments and requiring substantial assistance, felt unheard as the facility's Theft and Loss Report Log showed no record of the incident, highlighting a lapse in the reporting process.
A facility failed to accurately document staff attendance at a resident's care conference, leading to inaccurate medical records. The resident, with conditions including acute embolism and morbid obesity, required substantial assistance for daily activities. The Activities Assistant was incorrectly recorded as present at the meeting, contrary to the facility's documentation policy.
The facility failed to manage pain effectively for two residents. One resident's request to change pain medication from as-needed to scheduled was not documented or followed up, leading to unmanaged pain. Another resident was given Tylenol for severe pain without proper assessment, resulting in prolonged suffering. The facility did not adhere to its pain management protocols.
A resident did not receive prescribed medications on time due to a failure by an LVN to administer them as ordered. The medications, including glipizide and metoprolol, were given after meals instead of before or with food, contrary to the facility's policy. The DON confirmed the importance of timely medication administration to ensure effectiveness and prevent health issues.
The facility failed to follow its infection control policies, as two CNAs did not perform hand hygiene before and after providing care to residents, despite signs indicating the need for Enhanced Barrier Precautions. One resident had chronic kidney disease and a diabetic foot ulcer, while another had cervical disc degeneration and hypertensive heart disease. Both CNAs acknowledged the importance of hand hygiene but did not adhere to the protocols.
A facility failed to accurately document a resident's active diagnoses on the MDS, listing an active cancer diagnosis despite the resident's history indicating past skin cancer. The resident expressed concern, and staff interviews confirmed the error, highlighting the importance of accurate MDS documentation for proper care and billing.
A resident with severe pain was inadequately assessed and documented by an LVN, who administered Tylenol without verifying the resident's pain level, leading to inappropriate pain management. The resident, with conditions including diabetes and chronic kidney disease, reported a pain level of 9 out of 10, but the LVN documented it as 3 out of 10. The DON confirmed the necessity of accurate pain assessment and documentation as per facility policy.
A resident felt singled out and belittled when a Maintenance Supervisor reprimanded him in a raised and condescending tone for charging his phone at an emergency outlet during a power outage. Despite other residents also using the outlets, only this resident was addressed, leading to feelings of embarrassment and emotional distress. The Director of Nursing emphasized the importance of treating residents with dignity and respect, as outlined in the facility's policy on Resident Rights.
A facility failed to maintain a homelike environment for a resident due to a cracked window in the resident's room, which was covered with peeling tape and had been present since the resident's last admission. The resident, who had chronic obstructive pulmonary disease and depression, felt neglected by the facility's inaction. Interviews revealed that the issue was not reported by staff, and the facility's policy on maintaining a homelike environment was not followed.
A facility failed to develop a care plan for a resident in the bowel and bladder program, despite the resident requiring maximal assistance for toileting. The resident, admitted with cellulitis and depression, had intact cognition. The facility's policy mandated a care plan for the 14-day retraining program, which was not created, potentially leading to unmet continence needs.
A resident in isolation due to COVID-19 did not receive adequate sensory stimulating activities, as the facility failed to provide sufficient reading materials despite the resident's expressed preferences. The Activities Director admitted to not closely monitoring staff to ensure isolated residents received their preferred materials, leading to the resident experiencing boredom and loneliness.
A facility failed to follow its Bladder and Bowel Program policy for a resident requiring maximal assistance for toileting. Despite a physician order for retraining, the necessary 72-hour diary form was not completed, leaving CNAs without specific toileting instructions. This oversight could hinder the resident's ability to regain continence and prevent complications like skin breakdown and UTIs.
A facility failed to document a code status for a resident with acute respiratory failure, dementia, and failure to thrive. The absence of this documentation was confirmed during record reviews and interviews with staff, including an RN and the DON, who acknowledged the importance of having the code status documented to ensure timely and respectful care. The facility's policy requires complete and accurate documentation to facilitate communication among the care team.
A resident with a history of falls and severe cognitive impairment experienced two falls in one night due to inadequate supervision and failure to update the care plan. Despite being assessed as high risk for falls, the resident was not provided with increased monitoring during periods of agitation and confusion, leading to a fracture and head laceration.
A resident with a history of falls and severe cognitive impairment experienced two falls in one night, resulting in a head injury. Despite being at high risk for falls, the care plan was not updated with new interventions after the first fall. Staff interviews indicated a lack of increased supervision or medication administration to address the resident's confusion and agitation.
A facility failed to ensure a resident with Parkinsonism and dementia was free from physical restraints. A CNA tied a fitted sheet to the grab bars of the resident's bed, restricting the resident's arm movements to prevent the resident from pulling out a Foley catheter. The incident was discovered by other CNAs and a Charge Nurse, who immediately removed the sheet and reported the situation. The responsible CNA admitted to the action and was suspended.
A facility failed to provide a low air loss (LAL) mattress as ordered by a physician for a resident with severe pressure ulcers. Despite the resident's critical need and multiple staff acknowledgments of the order, the LAL mattress was delayed due to unavailability and poor communication, resulting in the resident lying on a regular mattress for two days.
Failure to Promptly Report Influenza Outbreak to Public Health Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an influenza outbreak to the Los Angeles County Department of Public Health (DPH) as required by the Influenza and other Respiratory Virus Diseases Outbreak Toolkit. The Infection Preventionist (IP) stated that one resident first presented with influenza symptoms, including cough, on 2/1/2026 and later tested positive for influenza on 2/7/2026. A second resident developed cough and wheezing on 2/2/2026 and tested positive for influenza on 2/5/2026. A third resident began having cough on 2/4/2026 and tested positive for influenza on 2/7/2026. Despite these three confirmed influenza cases, the facility did not immediately report the outbreak to LAC DPH as required. The residents involved had multiple medical conditions documented in their admission records and Minimum Data Set (MDS) assessments. One resident had a displaced fracture of the base of the neck of the left femur and acute cholecystitis, with intact cognition and a need for partial to moderate assistance with bathing and toileting hygiene. Another resident had osteomyelitis of the right ankle and foot and type 2 diabetes mellitus with a foot ulcer, also with intact cognition and requiring partial to moderate assistance for bathing and toileting hygiene. The third resident had hemiplegia and hemiparesis affecting the left non-dominant side and type 2 diabetes mellitus with diabetic neuropathy, with impaired cognition and dependence for activities of daily living. These findings, along with the IP’s interviews and the positive influenza test results, established that an outbreak had occurred but was not promptly reported to public health authorities.
Failure to Maintain Privacy and Dignity During Bed Baths
Penalty
Summary
The deficiency involves failure to maintain resident privacy and dignity during personal care for two residents who were dependent on staff for bathing and hygiene. One resident, admitted with schizophrenia and dementia and assessed as moderately cognitively impaired and dependent for shower/bath, toileting, and personal hygiene, was observed receiving a bed bath. The CNA removed the resident’s blanket, gown, and diaper, leaving the resident’s whole body exposed while washing various body parts. During this care, the CNA opened the privacy curtain around the bed while the room door remained wide open, allowing the resident’s exposed body to be visible from the hallway. The CNA later acknowledged that residents must be covered during a bed bath and stated they forgot to cover this resident, contrary to facility policy requiring residents to be kept covered as much as possible during bed baths. A second resident, admitted with epilepsy and a history of falls, had no cognitive impairment and was also dependent on staff for shower/bath and toileting hygiene. During a bed bath, the CNA initially closed the privacy curtain, removed the resident’s blanket and gown, and cleansed multiple body areas including the perineal area and buttocks while the resident’s whole body was exposed. The resident’s roommate then opened the privacy curtain, and the CNA did not re-cover the resident or close the curtain, continuing care, applying powder to the groin, and fastening the diaper while the resident remained exposed. In a concurrent interview, the resident stated feeling upset due to the lack of privacy and reported asking the CNA to close the privacy curtain. Facility policies on bed baths and resident rights required that residents not be exposed, be covered with a bath blanket, and be afforded privacy and a dignified existence.
Inadequate Infection Control During Incontinence and Bathing Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices during personal care and incontinence care for multiple residents. For one resident admitted with obstructive and reflux uropathy and diabetes mellitus, who was dependent on staff for ADLs, surveyors observed two CNAs transfer the resident from a geriatric chair to the bed after performing hand hygiene and donning gloves. After the transfer, one CNA, without changing gloves, retrieved towels from a cabinet, placed them on a table, checked the resident’s diaper, then accessed a body wash bottle from a drawer at the foot of the roommate’s bed. Using the same gloves, the CNA applied body wash to a wet towel, cleansed the resident’s perineal area and buttocks, applied a new diaper, and then, still without changing gloves, opened the same drawer again, touched items inside, and removed a sheet to cover the resident. A second component of the deficiency involved bathing practices for two other residents who were dependent on staff for shower/bath, toileting, and personal hygiene. For one resident with mental illness and dementia, a CNA donned PPE and brought a single basin of water mixed with body wash into the room. The CNA used one towel and the same basin of water to wash the resident’s face, chest, armpits, arms, neck, legs, perineal area, back, and buttocks, rinsing the towel in the same water between body areas, without changing the bathwater prior to providing perineal care. This sequence of care did not follow the facility’s written procedure for a bed bath, which required changing the bathwater at specified intervals, including before washing the perineal area. For another resident with epilepsy, a history of falls, and dependence on staff for shower/bath and toileting hygiene, a CNA prepared supplies, donned gloves, and brought a bucket of water into the room. The CNA used one small wet towel to clean the resident’s face, armpits, and arms, rinsing the towel in the same water between areas. The CNA then used the same water to rinse the towel, applied body wash, and cleansed the perineal area, followed by pouring water from the basin over the perineal area and drying it with a towel, and then washing the buttocks with body wash. These observed practices did not align with the facility’s bed bath policy, which directed staff to change bathwater before washing the perineal area and to wash the anal area last to avoid contamination, and also differed from referenced guidance that called for clean water or new cloths when cleaning the genital area.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident timely access to and copies of her medical records as required by facility policy. The resident was admitted with multiple diagnoses including obesity, acute respiratory failure without hypoxia, basal cell carcinoma of the right upper limb/shoulder, unilateral primary osteoarthritis of the left hip, and muscle wasting and atrophy. An initial history and physical documented that the resident had capacity to understand and make decisions. The facility’s written policy, revised in May 2017, stated that residents must be provided access to their personal and medical records within 24 hours (excluding weekends and holidays) of request, and copies of records within two business days of an oral or written request. Record review showed that the facility received written Authorization for Use or Disclosure of Protected Health Information forms from the resident on multiple occasions. Requests dated 3/6/2025 and 4/4/2025 were fulfilled by the facility on 3/26/2025 and 4/14/2025 respectively, which exceeded the two-business-day timeframe in the policy. An email from the resident dated 6/23/2025 requested release of medical records, but the facility did not release the records in response to that request. Another authorization form dated 7/1/2025 was received without the resident’s signature, and the facility did not provide copies of the records at that time. The administrator later acknowledged that the 6/23/2025 request was not honored. During interviews, the administrator and Director of Medical Records described a practice of varying response times based on the volume of records requested, stating that small requests could be completed the same day, while large requests could take several days. The administrator stated that on 3/6/2025 and 4/4/2025 the resident requested a large volume of records and that the medical records department might need more than two days, and would tell residents they needed more than the 48 hours indicated in the policy. The Director of Medical Records stated that staff visit residents to help complete consent forms, that residents are informed how long it may take and asked about preferred format, but also stated that medical records staff do not document these visits in the resident’s record. The resident reported having requested records multiple times by email and phone without success, refused to sign the release form because it released the facility from liability, and stated that the medical records staff member never told her how long it would take to receive the records. The surveyors concluded that the facility failed to provide copies of requested medical records within two business days as required by its own policy, thereby violating the resident’s right to obtain records in a timely manner.
Failure to Maintain Functional Call Light System During Power Outage
Penalty
Summary
During an 11-hour power outage, the facility failed to ensure that the call light system, which allows residents to signal for assistance, remained functional for four sampled residents. These residents had significant medical conditions, including morbid obesity, history of falls, hemiplegia, hemiparesis, osteoarthritis, epilepsy, cerebral palsy, hypertension, acute respiratory failure, end stage renal disease, and cerebral infarction. All four residents were assessed as high risk for falls and required varying levels of assistance with activities of daily living such as toileting, bathing, and dressing. Their care plans specifically required that call lights be within reach and functional to ensure prompt staff response to requests for help. Interviews with the residents confirmed that the call light system was not operational during the power outage, and none of them received an alternative means to request assistance, such as a temporary bell or device. One resident reported having to yell for help when assistance was needed. Staff interviews corroborated that the call light system was nonfunctional during the outage, and although the facility had some temporary bells, there were not enough for every resident. Maintenance records confirmed the duration of the power outage, and staff acknowledged the lack of sufficient alternative signaling devices. A review of the facility's policies and procedures indicated that each resident should have a means to call staff for assistance at all times, and that the call system must remain functional. The maintenance department is responsible for ensuring that all building systems, including the call light system, are maintained in a safe and operable manner. The failure to provide a functioning call system or adequate alternatives during the power outage was inconsistent with these policies and directly affected residents who were dependent on staff for their care and safety.
Failure to Document Receipt of Pharmacy-Delivered Medications by Licensed Staff
Penalty
Summary
The facility failed to follow its own Policy and Procedure regarding the receipt and documentation of medications delivered by the pharmacy for three sampled residents. Specifically, licensed staff did not check, sign, date, or time the receipt of medications for these residents as required by the facility's policy. This was confirmed through interviews with nursing staff and a review of the Prescription Delivery Receipt records, which showed missing signatures, dates, and times for the medications received. The residents involved had significant medical histories, including morbid obesity, history of falls, acute respiratory failure, end stage renal disease, chronic obstructive pulmonary disease, osteoarthritis, and major depressive disorder. Each resident had active medication orders, such as topical antifungals, inhalation solutions, and oral antibiotics, which were not properly documented upon receipt. Staff interviews confirmed that the expected process was not followed, and the required documentation was absent from the records for these residents.
Failure to Notify Physician of Repeated Refusals of Diabetes Care
Penalty
Summary
Facility staff failed to notify a resident's physician of multiple refusals of blood glucose monitoring (accuchecks) and insulin injections on two consecutive days. The resident, who had diagnoses including Parkinson's disease, dementia, and type 2 diabetes mellitus, was moderately impaired in cognitive skills and dependent on staff for daily care. Physician orders required blood glucose checks and administration of insulin as per a sliding scale, as well as scheduled long-acting insulin injections. Documentation showed that the resident refused accuchecks and an insulin injection on several occasions, but these refusals were not communicated to the resident's physician as required by facility policy. Interviews with nursing staff confirmed that the refusals were not reported to the physician, and both the resident's primary physician and care coordinator stated they were not notified of the missed treatments. Facility policy specified that the attending physician should be notified after two or more consecutive refusals of treatment or medication, but this procedure was not followed in this case.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required two-hour timeframe to the California Department of Public Health, the Ombudsman, and local law enforcement, as mandated by the facility's policy. The incident involved a resident with diagnoses including type 2 diabetes mellitus, chronic pulmonary edema, and toxic encephalopathy, who was mildly impaired in cognitive skills and required substantial to moderate assistance with daily activities. The resident reported to the Social Service Director that a CNA told them to 'shut up' and hit them on the mouth during a night shift. The CNA involved did not report the resident's allegation to the charge nurse, administrator, or authorities as required. Interviews with facility staff, including the CNA, DON, and Administrator, confirmed that the allegation was not reported in accordance with the facility's Abuse Investigation and Reporting policy, which requires immediate reporting, but not later than two hours, for alleged violations involving abuse. Review of the resident's records and staff interviews substantiated that the required notifications were not made in a timely manner, resulting in a delay in notifying the appropriate authorities about the abuse allegation.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Document Weekly Skin Checks for Resident with Pressure Injuries
Penalty
Summary
Facility staff failed to document a weekly skin check for one resident over a two-week period, despite the resident being dependent on staff for all activities of daily living and having multiple pressure injuries and Moisture-Associated Skin Damage (MASD) upon readmission. The resident's medical record and progress notes confirmed the absence of a weekly wound note from 7/5/2025 to 7/18/2025, which was required by facility policy for tracking the progress or decline of skin conditions. The treatment nurse, who was responsible for completing the weekly wound note, acknowledged missing the documentation during this period. The facility's policy and procedure specified that weekly skin checks must be conducted by a licensed nurse and documented in the electronic medical record, but this was not done for the resident in question.
Failure to Timely Reorder and Administer Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's supply of Morphine Sulfate, a medication prescribed for pain management, was restocked and available when needed. The resident, who had diagnoses including Parkinson's disease, dementia, and type 2 diabetes mellitus, was dependent on staff for daily care and had moderate cognitive impairment. The medication order required Morphine Sulfate 15 mg to be administered every 12 hours. According to the Medication Administration Record, the resident did not receive three scheduled doses because the medication supply ran out. The Director of Nursing confirmed that the supply was depleted due to the ordering physician not signing for the refill in time. The contracted pharmacist stated that the refill request was not processed until after the supply had already run out, and that the pharmacy did not begin the refill process until the day after the medication was depleted. Facility policy required that medications, especially Schedule II controlled substances like Morphine, be reordered when a three to five-day supply remained, and specifically that the pharmacy be notified when a five-day supply remained. The failure to follow these procedures resulted in the resident missing multiple doses of prescribed pain medication.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which were necessary to meet the resident's assessed needs. This deficiency was identified during the survey based on the lack of evidence that the required rehabilitative interventions were implemented for the resident.
Failure to Maintain Readily Accessible Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were readily accessible, specifically by not having the resident's Orthopedic consultation note from a follow-up appointment available in the electronic medical record. The resident, who had a history of right-sided hemiplegia and hemiparesis following a cerebral infarction, aphasia, and osteoarthritis of the left hip and knee, had a physician's order for an Orthopedic consult due to left hip and knee pain. Progress notes indicated that the resident attended the Orthopedic appointment and received a recommendation for a cortisone injection, but the actual consultation note documenting this visit was missing from the electronic records. During the review, both a registered nurse and the DON confirmed that they were unable to locate the Orthopedic note in the electronic system, which was being used as the facility transitioned to paperless charting. The absence of this record meant that staff could not verify the most current recommendations for the resident's care. The facility's policy required that all current medical records be maintained and safeguarded, but the Orthopedic note was not accessible as required.
Failure to Notify Resident and Physician of Significant Diagnostic Test Result
Penalty
Summary
The facility failed to ensure that a resident was properly notified of a significant diagnostic test result and that appropriate follow-up was completed by the resident's physician. Specifically, a retroperitoneal ultrasound identified a 3.4 cm mass on the resident's right kidney, with recommendations for further imaging to differentiate the mass. Although progress notes indicated the resident was informed of the results and a nephrology referral was made, the resident later stated he was unaware of the kidney issue until a nephrology appointment months later. The nephrology nurse practitioner also reported not receiving the ultrasound results until the day of the appointment, due to the facility's delay in faxing the information. The resident had a history of diabetes mellitus and end stage renal disease, with cognitive skills intact and independence in activities of daily living. Documentation did not show that the resident was given a copy of the test results or that the physician was informed of the need for further imaging. The facility's policy required timely review, communication, and documentation of diagnostic results, but there was no evidence that these steps were followed, resulting in a delay in medical treatment and communication to both the resident and the physician.
Failure to Accurately Document Parkinson's Disease in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's active diagnosis of Parkinson's disease. Despite documentation in the resident's admission record, physician orders, and neurology consultation notes indicating a diagnosis of Parkinson's disease and ongoing treatment with Sinemet, the MDS did not include Parkinson's disease under the active diagnoses section. The resident was observed to have symptoms consistent with Parkinson's, such as noticeable tremors, and was able to verbally confirm the diagnosis. A review of medication administration records further confirmed that the resident was receiving Sinemet for Parkinson's disease, with periods of discontinuation and restart as ordered by the neurologist. During interviews, the LVN responsible for the MDS assessment was unable to explain why Parkinson's disease was omitted from the MDS and acknowledged the inaccuracy. The neurologist who evaluated the resident noted that follow-up was not conducted by the facility after initiating a Levodopa trial, despite instructions to monitor for adverse reactions. The facility's policy requires that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not followed in this case, resulting in an inaccurate assessment entry for the resident.
Failure to Develop Comprehensive Care Plan for Sinemet Administration
Penalty
Summary
The facility failed to develop a comprehensive care plan to address medication administration and monitoring for side effects related to Sinemet for a resident who was receiving the medication for Parkinson's disease. The resident, who was cognitively severely impaired and unable to make her own decisions, had a physician's order for Sinemet administered via G-tube, but there was no care plan in place addressing the diagnosis of Parkinson's disease or the use of Sinemet. Additionally, the resident's Minimum Data Set (MDS) did not reflect the diagnosis of Parkinson's disease, and the medication administration records showed periods where Sinemet was both discontinued and restarted without corresponding updates to the care plan or MDS documentation. During interviews and record reviews, it was revealed that staff were unaware of why the Parkinson's diagnosis was not coded in the MDS, and the neurologist's consultation had specifically instructed staff to monitor for adverse reactions to Levodopa, a component of Sinemet. Facility policies required that all services, progress toward care plan goals, and changes in the resident's condition be documented and communicated among the interdisciplinary team, but these requirements were not met in this case. As a result, the resident's medication regimen and potential side effects were not adequately addressed through care planning or interdisciplinary communication.
Failure to Identify and Report Medication Irregularities in Pharmacist Review
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified medication irregularities related to the use of Sinemet for a resident during the monthly medication regimen review. The resident, who had a complex medical history including urinary tract infection, type 2 diabetes, atrial fibrillation, iron deficiency anemia, unspecified dementia, hypothyroidism, bipolar disorder, acute embolism and thrombosis, and hypotension, was prescribed Sinemet for Parkinson's disease. However, the resident's Minimum Data Set (MDS) did not reflect a diagnosis of Parkinson's disease, and the medication administration records showed periods where Sinemet was both discontinued and restarted. Observations revealed that the resident exhibited noticeable tremors, and interviews with nursing staff indicated uncertainty about the accuracy of the resident's documented diagnoses. The neurologist's consultation noted that the findings were atypical for idiopathic Parkinson's disease and that a trial of Levodopa (Sinemet) was initiated, with instructions to monitor for adverse reactions. Despite this, there was no evidence that the pharmacist identified or reported any irregularities or made recommendations regarding the use or monitoring of Sinemet during the medication regimen reviews from January to April. The pharmacist also stated there were no concerns and that no adverse effects had been reported by staff. A review of facility policy confirmed that the consultant pharmacist is responsible for thoroughly reviewing each resident's medical record to identify and report medication-related problems, including inadequate monitoring or use of medications without proper indication. In this case, the lack of identification and reporting of irregularities related to Sinemet use constituted a deficiency, as the pharmacist did not follow established guidelines for medication regimen review and irregularity reporting.
Failure to Document Indication and Monitor Sinemet Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not documenting an adequate indication for the use of Sinemet, a medication used to manage symptoms of Parkinson's disease. The resident in question had multiple diagnoses, including unspecified dementia, diabetes, atrial fibrillation, and a history of tremors, but the Minimum Data Set (MDS) did not reflect a diagnosis of Parkinson's disease, despite a physician order for Sinemet. The neurologist's consultation noted that the findings were atypical for idiopathic Parkinson's disease and that a trial of Levodopa (Sinemet) was initiated, with instructions to monitor for adverse reactions. However, there was no documentation of follow-up or monitoring for effectiveness or side effects after the medication was started. Observations revealed that the resident exhibited noticeable tremors, and interviews with nursing staff confirmed that the MDS was inaccurate and did not include the Parkinson's diagnosis. The staff member acknowledged the importance of accurate diagnosis coding and proper monitoring of Sinemet due to its potential for adverse effects. The neurologist also stated that follow-up could have occurred shortly after starting the medication, but no such follow-up was documented or communicated by the facility. Additionally, the facility's consultant pharmacist did not identify any irregularities or make recommendations regarding the use of Sinemet during medication regimen reviews from January to April. Facility policies required comprehensive assessments and medication regimen reviews to ensure appropriate use and monitoring of medications, but these were not followed in this case, resulting in the resident receiving Sinemet without adequate documentation of indication or monitoring for effectiveness and adverse effects.
Failure to Assist Resident in Locating Missing Personal Belongings
Penalty
Summary
The facility failed to assist a resident in locating her missing personal belongings, specifically two cord holders. The resident, who was admitted with diagnoses including acute embolism, thrombosis, morbid obesity, and a history of falls, reported the missing items to a Certified Nursing Assistant (CNA). Despite the resident having no cognitive impairments and requiring substantial assistance for daily activities, the CNA did not report the missing items to their supervisors, as required by the facility's policy. The Director of Nursing (DON) confirmed that the facility's Theft and Loss Report Log did not list any reports of missing items for the relevant months, indicating a failure in the reporting process. The facility's policy on personal property, which emphasizes treating resident belongings with respect, was not followed. This oversight had the potential to make the resident feel unheard and disrespected, as the facility did not take appropriate action to address the resident's concerns about her missing belongings.
Inaccurate Documentation of Care Conference Attendance
Penalty
Summary
The facility failed to accurately document the attendance of staff members at a quarterly care conference for one of the residents. The resident, who was admitted with diagnoses including acute embolism, thrombosis, morbid obesity, and a history of falls, had no cognitive impairments and required substantial assistance for certain activities of daily living. During the care conference, it was inaccurately documented that the Activities Assistant (AA) was present, although the AA confirmed they did not attend the meeting. The Director of Nursing (DON) reviewed the documentation and confirmed the expectation that all relevant disciplines should meet together to ensure consistency in the care plan. The facility's policy on charting and documentation, which requires records to be objective, complete, and accurate, was not adhered to in this instance, resulting in inaccurate information being recorded in the resident's medical records.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide effective pain management for two residents, Resident 2 and Resident 3, as per the facility's policies and procedures. Resident 2 requested that their pain medications, ibuprofen and Tylenol, be changed from as-needed to scheduled doses to better manage their pain. This request was communicated by LVN 5 to the physician via text but was not documented in the medical record, nor was it followed up on, resulting in Resident 2's pain not being effectively managed. Resident 3 experienced severe pain that was not appropriately addressed by the facility. On a specific day, LVN 4 administered Tylenol to Resident 3 for a pain score of three out of ten, without assessing the actual pain level, which was later revealed to be nine out of ten. This inappropriate administration of medication led to Resident 3 experiencing severe pain for several hours until they were given Norco. LVN 4 admitted to not asking Resident 3 about their pain level before administering the medication and incorrectly documenting the pain score. The Director of Nursing confirmed that the facility's protocol requires licensed nurses to notify physicians of medication change requests and to assess pain levels before administering medication. The failure to adhere to these protocols resulted in inadequate pain management for both residents, potentially causing psychosocial harm and a decline in health. The facility's policies on pain management and changes in resident condition were not followed, leading to these deficiencies.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received prescribed medications in accordance with the facility's policy and procedure. The deficiency involved a Licensed Vocational Nurse (LVN) who did not administer medications to a resident as ordered by the physician. The medications involved included calcium, Freshkote ophthalmic solution, glipizide, metoprolol, and muro 128 ophthalmic solution. These medications were not given on time, which was contrary to the facility's policy that required medications to be administered within one hour of their prescribed time unless specified otherwise. The resident, who had been admitted with diagnoses including type II diabetes mellitus, hypertensive heart disease, and ischemic cardiomyopathy, was supposed to receive glipizide before meals and metoprolol with food or a snack. However, the LVN administered these medications after the resident's meal, which could potentially affect the medications' effectiveness and the resident's health. The LVN acknowledged that the medications were due at specific times and that administering them late could lead to issues such as high blood sugar and stomach upset. The Director of Nursing (DON) confirmed that medications should be given according to the order they are due and not by room number. The DON emphasized the importance of following medication orders, especially those that specify administration before meals or with food, to ensure proper absorption and effectiveness. The facility's policy on administering medications highlighted the need for timely administration to enhance therapeutic effects and prevent interactions, which was not adhered to in this case.
Failure to Follow Hand Hygiene and EBP Protocols
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding hand hygiene and Enhanced Barrier Precautions (EBP). Certified Nurse Assistant (CNA) 2 did not perform hand hygiene before and after providing care to a resident with chronic kidney disease and type II diabetes mellitus, who also had a diabetic foot ulcer. Despite a sign indicating the need for hand hygiene before entering and upon exiting the resident's room, CNA 2 entered and exited without performing the required hand hygiene. During an interview, CNA 2 acknowledged the importance of hand hygiene but incorrectly believed it was unnecessary in this instance. Similarly, CNA 3 failed to perform hand hygiene before and after entering the room of another resident with cervical disc degeneration, hypertensive heart disease, and hyperlipidemia. Despite the presence of a sign indicating the need for hand hygiene, CNA 3 entered the room, repositioned the resident's bedside table, and exited without sanitizing hands. CNA 3 admitted to not following the policy despite being in-serviced on the importance of hand hygiene. The Director of Nursing confirmed that staff were expected to perform hand hygiene to prevent the spread of infections.
Inaccurate Documentation of Active Diagnoses on MDS
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's active diagnoses on the Minimum Data Set (MDS), which is a critical resident assessment tool. This deficiency was identified for one resident who was admitted with a history of squamous cell carcinoma, among other conditions. The MDS inaccurately reflected an active diagnosis of cancer, despite the resident's medical records and personal statements indicating a past history of skin cancer, with no current active cancer diagnosis. The resident expressed concern about the incorrect active cancer diagnosis, which was confirmed by interviews with facility staff, including the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON). The MDSN and DON both acknowledged that the active diagnoses were typically derived from hospital records upon admission, and the DON confirmed that the resident did not have active cancer. The facility's policy and procedure for resident assessments require that all portions of the MDS be completed accurately and signed by the responsible staff, attesting to the accuracy of the information. The inaccurate documentation on the MDS had the potential to negatively impact the resident's plan of care and the delivery of necessary services, as the MDS is used for monitoring and billing purposes.
Inaccurate Pain Assessment and Documentation
Penalty
Summary
The facility failed to ensure accurate documentation on the medication administration record (MAR) for a resident, identified as Resident 3, according to the facility's policy and procedure titled, Charting and Documentation. Licensed Vocational Nurse (LVN) 4 did not accurately document Resident 3's pain score when administering Tylenol, a medication used to treat mild pain. Instead of assessing the resident's pain level, LVN 4 documented a pain score of 3 out of 10, despite the resident experiencing severe pain rated at 9 out of 10. Resident 3, who had been admitted with diagnoses including type II diabetes mellitus, chronic kidney disease, and hydronephrosis, was observed to have severely impaired cognition and frequently experienced pain. On the day of the incident, Resident 3 reported being in significant pain, stating a pain level of 9 out of 10, and expressed distress over the inadequacy of the pain management. LVN 4 administered Tylenol without assessing the resident's pain level, as the resident could not receive more Norco until later due to dosage timing restrictions. The Director of Nursing (DON) confirmed that licensed nurses are required to assess residents' pain scores before administering medication to ensure appropriate treatment. The facility's policy mandates that all services provided, including pain management, be documented accurately and objectively. The failure to assess and document the resident's pain level accurately led to inappropriate pain management, potentially exacerbating the resident's condition.
Resident Dignity Compromised During Power Outage
Penalty
Summary
The facility failed to ensure that a staff member treated a resident, identified as Resident 44, with respect and dignity. During a power outage caused by California wildfires, Resident 44 was charging his cell phone at an emergency outlet near the facility entrance. The Maintenance Supervisor (MS) approached Resident 44 and, in a raised and condescending tone, instructed him not to use the emergency outlet for charging his phone, stating it was only for emergency purposes. This interaction made Resident 44 feel singled out, embarrassed, emotionally distressed, angry, and belittled, as he was the only resident reprimanded despite others also using the emergency outlets. Resident 44's roommate, identified as Resident 41, corroborated the incident, stating that the MS yelled at Resident 44 in a rude and impolite manner, while not addressing other residents who were also charging their phones. Resident 41 expressed feeling awful and embarrassed for Resident 44, noting that the situation could have been handled more calmly and respectfully. Both residents were cognitively intact and required supervision or touching assistance with activities of daily living and mobility. The Director of Nursing (DON) emphasized that staff are expected to uphold a standard of care that includes dignity, respect, and effective communication. The facility's policy on Resident Rights guarantees residents the right to a dignified existence and to be treated with respect, kindness, and dignity. The incident highlights a failure to adhere to these standards, resulting in a deficiency in treating Resident 44 with the respect and dignity he is entitled to.
Failure to Maintain Homelike Environment Due to Unreported Cracked Window
Penalty
Summary
The facility failed to ensure a homelike environment for a resident, identified as Resident 21, due to a cracked window in the resident's room. The resident, who had been readmitted to the facility with chronic obstructive pulmonary disease and depression, expressed feelings of neglect regarding the appearance of their living space, describing it as 'ghetto and tacky.' The cracked window, covered with peeling blue tape, had been present since the resident's last admission in October 2024, but had not been reported to maintenance by the resident or noticed by staff. Interviews with facility staff revealed a lack of communication and reporting regarding the maintenance issue. The Housekeeping Supervisor stated that no reports of a cracked window had been made, and the Maintenance Supervisor was unaware of the damage until it was pointed out during the survey. The housekeeper responsible for cleaning the windows admitted that windows were only cleaned when visibly dirty or upon request, and had not noticed the crack. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unreported and unrepaired window damage in the resident's room.
Failure to Develop Care Plan for Bowel and Bladder Program
Penalty
Summary
The facility failed to develop a care plan for a resident participating in the bowel and bladder program. This deficiency was identified during an interview and record review, where it was found that the resident, who required maximal assistance for toileting hygiene and transfers, did not have a care plan addressing their participation in the bowel and bladder retraining program. The absence of a care plan meant that staff lacked guidance on the interventions needed for the resident and did not have a clear goal, such as achieving continence by discharge. The resident in question was admitted with multiple diagnoses, including cellulitis of the left lower limb and depression, and had intact cognition. The facility's policy required the initiation of a 14-day bowel and bladder retraining program and the development of a corresponding care plan, which was not done. This oversight had the potential to result in unmet bowel and bladder continence needs for the resident.
Failure to Provide Adequate Activities for Isolated Resident
Penalty
Summary
The facility failed to provide an ongoing sensory stimulating activities program tailored to meet the interests of a resident, identified as Resident 226. This resident was admitted with diagnoses including a periprosthetic left hip joint fracture, a fracture of the left radial styloid process, and dysphagia. The resident's activity preferences, as documented in the Activity Interview for Daily and Activity Preferences, included reading mystery books and doing word search puzzles. Despite being cognitively intact and able to communicate effectively, the resident was dependent on staff for emotional, intellectual, and social needs, as outlined in the care plan. During an observation, it was noted that the resident was in isolation due to COVID-19 and expressed feelings of boredom and loneliness, having only received one mystery book despite requests for more reading materials. The Activities Director acknowledged that the resident liked to read and do crossword puzzles and admitted to not closely monitoring staff to ensure that residents in isolation received their preferred materials. The facility's policy indicated that activity programs should be designed to meet the interests and support the well-being of each resident, but this was not adequately implemented for the resident in question.
Failure to Follow Bladder and Bowel Program Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure for the Bladder and Bowel Program for a resident who was placed in the program. The resident, who had intact cognition and required maximal assistance for toileting hygiene and transfers, was admitted with multiple diagnoses, including cellulitis and depression. A physician order was in place for bowel and bladder retraining for 14 days, starting on a specified date, per family request. However, the facility did not complete the necessary 72-hour diary form, which was crucial for identifying the optimal times to toilet the resident. During interviews, it was revealed that the Certified Nursing Assistant (CNA) assisting the resident did not have specific toileting instructions and attempted to assist the resident every two hours. The lack of specific instructions and the absence of the 72-hour diary form meant that the CNAs were not informed of the precise hours to toilet the resident, as required by the facility's policy. This oversight had the potential to prevent the resident from regaining bowel and bladder continence and could lead to issues such as skin breakdown and urinary tract infections.
Failure to Document Code Status for Resident
Penalty
Summary
The facility failed to document a code status for a resident, identified as Resident 27, on the Admission Record, Electronic Health Record (EHR) dashboard banner, and the physical medical record. This deficiency was identified during a review of Resident 27's records, which revealed that the resident was admitted with serious medical conditions, including acute respiratory failure with hypoxia, dementia, and failure to thrive. The Minimum Data Set (MDS) indicated that the resident was dependent on others for activities of daily living and had limited mobility due to medical conditions. Furthermore, a follow-up visit confirmed that Resident 27 lacked the capacity to make decisions independently. During interviews and record reviews, Registered Nurse (RN) 2 confirmed the absence of a documented code status in all relevant records for Resident 27. The RN emphasized the importance of having the code status documented to promote patient-centered care, enhance communication, and ensure timely and respectful care in accordance with the resident's wishes. The Director of Nursing (DON) also acknowledged the potential serious consequences of failing to document the code status, highlighting the importance of accurate and accessible documentation to protect residents' rights and ensure appropriate care delivery. The facility's policy on charting and documentation requires that all services and changes in a resident's condition be documented to facilitate communication among the interdisciplinary team.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent falls for a resident who was assessed as high risk for falls. The resident, who had a history of traumatic subarachnoid hemorrhage, COVID-19, and gait abnormalities, was admitted to the facility and was noted to have severely impaired cognition and required substantial assistance for daily activities. Despite these assessments, the facility did not ensure that the resident received the necessary supervision, especially during periods of increased agitation and confusion. On the night of the incident, the resident experienced increased confusion and repeatedly attempted to get out of bed unassisted. The Certified Nursing Assistant (CNA) on duty noted the resident's agitation and attempted to monitor the situation by sitting near the resident's room. However, the CNA was unable to provide continuous supervision, and the resident experienced two falls within a short period. After the first fall, which was unwitnessed, the resident was found sitting on the floor without injuries. Despite this incident, no new interventions were implemented to prevent further falls. The second fall occurred shortly after the first, resulting in a laceration on the resident's head and a fracture of the left femur. The Licensed Vocational Nurse (LVN) on duty did not revise the resident's care plan or increase supervision following the first fall, as required by the facility's policies. The Director of Nursing later confirmed that supervision should have been increased, and the care plan should have been updated to prevent further incidents. The facility's failure to implement timely interventions and provide adequate supervision directly contributed to the resident's injuries.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan and implement new interventions for a resident after the resident experienced a fall. The resident, who was admitted with a history of traumatic subarachnoid hemorrhage, COVID-19, and gait abnormalities, was identified as being at high risk for falls. Despite this, after the resident's first fall, the care plan was not updated to include new interventions to prevent further falls. The resident's Minimum Data Set indicated severely impaired cognition and a need for substantial assistance with daily activities. On the night of the incident, the resident was confused and restless, repeatedly getting out of bed unassisted. The resident experienced two falls within a short period, the second resulting in a head laceration. Despite these events, there was no documented evidence of increased supervision or medication administration to address the resident's agitation and confusion. Interviews with staff revealed that the resident required frequent cueing and supervision, yet the care plan was not adjusted to reflect these needs. The facility's policies on safety and fall risk management emphasize the importance of revising care plans based on changes in a resident's condition, but this was not done in this case, leading to the deficiency.
Failure to Ensure Resident was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which led to a violation of the resident's rights and potential harm. The incident involved a resident with diagnoses of Parkinsonism, dementia, and a history of falling. The resident required substantial assistance for daily activities and had severely impaired cognition. Despite these needs, a Certified Nurse Assistant (CNA) tied a fitted sheet to the grab bars of the resident's bed, restricting the resident's arm movements to prevent the resident from pulling out a Foley catheter. This action was taken without proper authorization and was not in the resident's best interest. The incident was discovered when other CNAs and a Charge Nurse found the resident with limited mobility due to the fitted sheet being tied to the grab bars. The fitted sheet was immediately removed, and the situation was reported to the appropriate nursing staff. Interviews with the involved CNAs and Licensed Vocational Nurses (LVNs) confirmed that the resident's arms were restricted under the fitted sheet, which was tied in a knot on one side and wrapped around the grab bars on the other side. The resident was covered with additional blankets, further limiting movement. The CNA responsible for tying the fitted sheet admitted to doing so to prevent the resident from harming himself by pulling out the catheter. The CNA acknowledged that it was a busy period and that the action was taken to manage the resident's restlessness. The facility's policies on abuse prevention and the use of restraints clearly state that residents have the right to be free from physical restraints not required to treat their symptoms. The CNA was suspended immediately following the incident, and the facility's administration was made aware of the situation.
Failure to Provide Ordered Low Air Loss Mattress
Penalty
Summary
The facility failed to provide a low air loss (LAL) mattress as per the physician's order for a resident who was readmitted with severe pressure ulcers. The resident had diagnoses including acute kidney failure, pressure ulcer of the sacral region, and muscle wasting and atrophy. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and dependence on assistance for various activities, including rolling in bed. Despite the physician's order and care plan specifying the need for a LAL mattress, the resident was observed lying on a regular mattress multiple times over two days. Licensed Vocational Nurses (LVNs) and a Registered Nurse (RN) acknowledged the physician's order for the LAL mattress but cited unavailability as the reason for the delay. The facility had no available LAL mattresses in storage, and the staff were waiting for one to become available. The importance of the LAL mattress for wound management and pressure relief was recognized by the staff, but the communication and coordination to obtain the mattress were lacking. Observations and interviews revealed that the LAL mattress was eventually brought to the facility but remained in the hallway without being set up for the resident. The facility's job description for the LVN Treatment Nurse emphasized the responsibility to provide treatment per physician orders and ensure appropriate prophylaxis and treatment for residents with pressure ulcers. However, the failure to promptly provide the LAL mattress as ordered led to a deficiency in the resident's care.
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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