Moraga Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Moraga, California.
- Location
- 348 Rheem Boulevard, Moraga, California 94556
- CMS Provider Number
- 055085
- Inspections on file
- 21
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Moraga Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain complete and accurate documentation for controlled medications, including missing shipping manifests, absent or incomplete Controlled Drug Records (CDRs), and discrepancies between CDRs, Medication Administration Records (MARs), and Automated Dispensing Cabinet (ADC) usage reports. Staff described a system in which controlled drugs were received with manifests and CDRs, secured in medication carts, and documented on MARs, but surveyors found ADC-dispensed hydrocodone-acetaminophen doses with no corresponding administration or destruction records, and multiple prescriptions where delivered tablets were not fully accounted for on CDRs. Additional CDR entries for hydrocodone-acetaminophen removals lacked matching MAR administration entries for several residents. The DON acknowledged missing documents and inaccurate record matching, and pharmacist inspection reports during the review period did not identify these controlled substance record issues despite facility policies requiring monitored, reconciled, and accurate controlled substance documentation and consultant pharmacist oversight of pharmacy services.
Surveyors found that the social services department was directed for many years by an SSD who had only a high school education and an old certificate course, with no additional training, and no qualified social worker supervising or directing the department. The OM acknowledged that the facility had revised the SSD job description to remove minimum education and experience requirements, despite earlier versions requiring a BSW and experience. The ADM confirmed that the SSD was the sole social services staff member and that there was no qualified social worker overseeing the unit, even though facility policy and the facility assessment called for a qualified social worker and full-time social worker coverage, resulting in all residents receiving social services from unqualified staff.
A resident with vascular dementia, impaired gait, lower extremity limitations, and a documented history of falls was repeatedly assessed as high risk for falls, yet fall care plans were not updated with new interventions after multiple unwitnessed falls and ongoing attempts to get out of bed unassisted. Staff relied on general measures such as low bed position, call light within reach, and periodic safety checks, and the facility did not provide one-on-one sitters, instead discussing such arrangements with families. While the primary CNA was on break and coverage was assigned to another CNA who was occupied in another room, the resident attempted to ambulate from bed to the doorway without assistance, was observed by another resident’s family member to lose balance and fall forward, and was later found by staff with a bleeding head laceration and subsequently diagnosed with a subarachnoid hemorrhage.
A resident with dementia and anxiety, who had no documented psychosis or behavioral symptoms on admission assessment, was started on and later had the dose increased of Seroquel for "vascular dementia manifested by manic behaviors," and was also given PRN Ativan for anxiety. The IDT did not document assessment of angry outbursts or hallucinations or implement person-centered non-pharmacological interventions before initiating or escalating the antipsychotic, and the use of Seroquel and Ativan was not addressed in the resident’s care plan with appropriate interventions. Informed consent forms for both medications lacked documentation that the resident’s representative had been informed and consented, and the MD confirmed she did not directly obtain consent, contrary to facility policy requiring a specifically diagnosed condition, behavioral interventions, and prescriber-obtained informed consent for psychotropic use.
A resident with occasional bowel and bladder incontinence, impaired cognition, and limited mobility did not receive appropriate continence support. The MDS showed no trial toileting program had been attempted, while the care plan called for toileting on rounds, upon request, and as needed. An LVN described short-term memory loss and impulsive unassisted bathroom use, and the DON stated the facility did not proceed with a toileting program because the resident was not appropriate due to impaired mobility and needing one-person assistance.
A resident with neutropenia, hemiplegia, hemiparesis, functional diarrhea, and heart failure was admitted directly into a conference room and remained there for six weeks, even though this area was not approved for patient housing and lacked a sink and bathroom. The care plan documented that the resident was housed in the conference room and required staff to bring water and soap for handwashing, and observations showed the resident using a bedside commode behind an improvised curtain with the door sometimes left open during care. Staff reported that the family requested a private room and chose the conference room after being told it had been used previously for residents, and leadership cited past COVID-19-related flexibility but could not provide current authorization, while state regulations and CDPH guidance reviewed by surveyors did not support using the conference room as a resident room.
The facility failed to properly label and date eye drop medications for two residents, leading to the potential use of less effective medication. Observations revealed that Latanoprost Ophthalmic solutions for both residents lacked an open date, despite instructions to discard 42 days after opening. Interviews with the ADON and Pharmacy Consultant confirmed the necessity of open dates to ensure medication effectiveness.
A facility failed to properly store and dispose of medications, as expired lorazepam was found in a refrigerator for ready-to-use medications, and a medication disposal bin was left unsecured. An LVN confirmed the expired status of the lorazepam, and the DON acknowledged the need for securing the disposal bin. Facility policies required proper disposal and secure storage of medications.
The facility did not employ a full-time registered dietitian and the Dietary Supervisor lacked the necessary qualifications for the dietary manager position, posing risks of foodborne illness and malnutrition to residents. The DS had only a Food Manager certification, while the RD worked part-time.
The facility failed to maintain kitchen equipment and environment in a sanitary and operational condition, with two ovens not functioning properly and unsanitary conditions observed. Despite awareness of these issues by the Dietary Supervisor, Maintenance Supervisor, and Administrator, no corrective actions were taken, leading to potential food safety risks.
The facility failed to maintain a record system for controlled drugs, as the DON and pharmacist did not dispose of medications quarterly as required. Logs were disorganized, and records for 2021 were missing. The pharmacist confirmed the process should occur quarterly, but the facility's policy only required records to be kept for two years, conflicting with state law.
The facility failed to maintain accurate medical records and care plans for three residents. An LPN did not document the administration of a controlled medication for a resident. Two residents had multiple undocumented medication administrations, confirmed by the DON. Another resident's care plan inaccurately restricted her movement due to infection control, despite observations of her moving freely in common areas.
A Licensed Vocational Nurse failed to perform proper hand hygiene during medication administration for three residents, including handling medications and medical instruments without changing gloves or sanitizing hands. The Director of Nursing acknowledged the importance of hand hygiene but had not conducted medication pass observations since starting in February 2023, relying instead on a nurse consultant who had previously reported handwashing as a common concern.
A facility failed to accurately complete the MDS assessment for a resident's mobility, incorrectly indicating the resident was unable to walk due to health reasons. Interviews and records showed the resident could walk with assistance, receiving help from an RNA multiple times a week. The MDS Coordinator admitted a coding error, highlighting the importance of accurate assessments to ensure proper care planning.
A facility failed to accurately complete and update the PASARR assessment for a resident over four years. The initial PASARR was completed late and inaccurately indicated no psychotropic medication use, despite the resident receiving quetiapine. A subsequent PASARR incorrectly suggested a short-term stay, although the resident remained long-term. The MDSC overlooked the need for a Level II PASARR despite the resident's mental health diagnoses.
A resident with a history of stroke and diabetes, requiring extensive assistance for personal hygiene, was found with long fingernails and blackish material under the nail tips. Despite the facility's policy on regular nail care, the assigned nurse was unaware of the need for trimming, leading to a deficiency in care.
Incomplete and Inaccurate Controlled Substance Documentation and Oversight
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate records for controlled (scheduled) medications, including shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), Automated Dispensing Cabinet (ADC) dispense reports, and destruction logs for multiple residents. The DON and Medical Records Director (MRD) described a system in which controlled medications were delivered with a shipping manifest, signed by the nurse, and stored in the medication cart with a corresponding CDR used to document each removal, while administration was documented on the MAR. However, when surveyors requested all shipping manifests, CDRs, and ADC dispense reports for a defined period, the facility was unable to produce complete documentation, and multiple discrepancies were identified between the various records. During interviews and record reviews, staff nurses and the DON confirmed that the ADC did not generate a receipt or CDR for controlled medications dispensed. An ADC usage report for a specified time frame showed that hydrocodone-acetaminophen tablets were dispensed for two residents, but the DON and MRD were unable to locate any documentation in the medical records showing that these doses were administered or destroyed. For another resident, a shipping manifest documented delivery of 90 oxycodone-acetaminophen tablets, but CDRs accounted for only 60 tablets, and the facility did not have a CDR to account for the remaining 30 tablets. Additional shipping manifests for several other residents showed delivery of various hydrocodone- and oxycodone-containing prescriptions, but the DON stated there were no corresponding CDRs for those manifests. Further comparison of existing CDRs with MARs revealed additional inconsistencies. For one resident, the DON identified a CDR for hydrocodone-acetaminophen tablets and acknowledged that a documented removal on the CDR did not have a matching administration entry on the MAR. For another resident, the DON reviewed a CDR for hydrocodone-acetaminophen and found multiple CDR removals without corresponding MAR administration entries on specific dates and times. For a third resident, the DON confirmed that a CDR removal of hydrocodone-acetaminophen did not have a corresponding MAR administration entry. The DON acknowledged that the facility lacked required shipping manifests and CDRs and that information between CDRs and MARs was inaccurate, despite facility policies on controlled substances and pharmacy services that required controlled substance inventories and related records to be monitored, reconciled, complete, and accurate. The consultant pharmacist’s role and oversight were also implicated in the deficiency. The DON produced the pharmacist’s Medication Regimen Review & Report and Monthly Pharmacy Inspection Reports for selected months within the review period and stated that these reports did not document any issues with incomplete or inaccurate controlled medication records. The DON also reviewed the facility’s policy for the role of the consultant pharmacist, which required the consultant pharmacist to provide consultation on all aspects of pharmacy services and to collaborate with the facility and medical director to develop, implement, evaluate, and revise procedures for pharmacy services. The DON stated it was the facility’s expectation that issues with scheduled medications should have been identified, but the pharmacist inspection reports did not reflect the discrepancies and missing documentation that were later found during the survey. An administrative review of the facility’s Policy for Controlled Substances, revised in November 2022, showed that the policy required controlled substance inventory to be monitored and reconciled to identify loss or potential diversion, and specified that the system of reconciling receipt, dispensing, and disposition of controlled substances must include records of personnel access and usage, MARs, and declining inventory records. Despite these written requirements, the facility’s actual practice, as demonstrated by missing shipping manifests, absent or incomplete CDRs, lack of ADC receipts or CDRs, and mismatches between CDRs and MARs, did not meet the policy standards. The DON acknowledged these discrepancies and confirmed that the facility’s expectation was that all controlled substance documentation be complete and accurate, which was not achieved during the period reviewed. Additionally, interviews with LVN staff highlighted operational gaps in the controlled medication record system. One LVN described the expected process of reviewing shipping manifests and CDRs upon receipt of controlled medications, signing the manifest, securing the medications in the cart, and using the CDR and MAR for ongoing documentation, with completed CDRs sent for retention and remaining medications and CDRs forwarded to the DON upon discontinuation. However, the same LVN reported that the ADC did not provide a receipt or CDR for controlled medications dispensed, creating a gap in the documentation chain. Another LVN identified the location and use of the Rx Now ADC but did not provide evidence of a parallel documentation process to replace the missing ADC receipts and CDRs. These descriptions, combined with the record review findings, demonstrate that the facility’s actual practices did not ensure a complete and accurate record system for controlled substances as required by its own policies. The facility’s policies for controlled substances and the role of the consultant pharmacist, as reviewed during the survey, explicitly required accurate, monitored, and reconciled documentation of controlled substances, including shipping manifests, CDRs, MARs, and records of personnel access and usage. Despite these policies, the survey findings showed that the facility did not maintain all required documents, did not reconcile controlled substance inventories, and did not identify or correct discrepancies between different record sources. The DON acknowledged that the facility did not have the required shipping manifests and CDRs and that there were inaccuracies between CDRs and MARs, and also acknowledged that the pharmacist inspection reports did not identify these issues, even though it was the facility’s expectation that such issues would be detected under the existing policies.
Unqualified Staff Directing Social Services Department
Penalty
Summary
The facility failed to ensure that its social services department was directed and supervised by a qualified social worker as required by State regulation for more than nine years. The Social Services Director (SSD) reported being the only staff member in the social services department and confirmed having worked in that role for over nine years without holding a bachelor's degree in any field. The SSD stated their only training for the position was a certificate course completed in 1997, with no continuing education or additional training since that time. Review of the SSD's 1997 resume showed high school as the highest level of education completed. Review of two SSD job descriptions dated July 2022 and December 2025 showed that the earlier version required a Bachelor of Science in Social Work and two years of experience, with an MSW preferred, while the later version listed those qualifications only as preferred and, according to the Operations Manager (OM), effectively removed any minimum education or experience requirements. The Administrator (ADM) confirmed that the SSD was the only staff member in the social services department and that there was no qualified social worker supervising or directing the department, and acknowledged awareness that the SSD did not meet qualified social worker requirements. Facility policy dated February 2024 stated that the director of social services was a qualified social worker, and the facility assessment from December 2025 identified a need for a full-time social worker on AM and PM shifts. State regulations reviewed defined social work services and required that the social work service unit be organized, directed, and supervised by a social worker, which was not met in this facility, resulting in all residents receiving social services from unqualified staff.
Failure to Adequately Supervise High-Risk Resident Resulting in Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement effective fall-prevention interventions for a resident with a known high risk for falls and cognitive impairment. The resident was admitted with diagnoses including abnormalities of gait and mobility, age-related physical debility, osteoarthritis, a lumbar compression fracture, and vascular dementia. The admission MDS documented that walking at least 10 feet in a room was not attempted due to medical or safety concerns, that the resident used a walker and wheelchair, had lower extremity range-of-motion limitations, and had a prior fall before admission. The resident’s BIMS score was 8, indicating moderately impaired mental status with inability to recall the correct year, month, and day of the week. The facility’s own assessments repeatedly identified the resident as being at high risk for falls, with fall risk assessment scores of 28, 28, and 36 on three separate dates. Interdisciplinary team notes documented multiple falls: staff heard screaming and found the resident on the floor on one occasion; on another, a staff member heard the resident calling for help and found the resident on the floor after an unwitnessed fall in which the resident reported striking her head. Despite these repeated unwitnessed falls and the resident’s ongoing behaviors of trying to get out of bed to ambulate with agitation, aggression, and hallucinations, the fall care plans dated after these events were not updated with new or enhanced interventions beyond general measures such as keeping the bed low and call light within reach. On the date of the cited incident, a family member of another resident observed the high-risk resident ambulating from her bed toward the room doorway, losing balance, and falling forward to the ground. Staff were not present at the time of the fall and were summoned by the family member. The resident was found on the floor with a laceration on the left frontal forehead and uncontrolled bleeding and was subsequently transferred to the hospital, where a subarachnoid hemorrhage was diagnosed. Interviews with staff indicated that the resident frequently attempted to get out of bed without assistance, that hourly safety checks and reminders to call for help were relied upon, and that the facility did not provide one-on-one sitters for fall-risk residents, instead discussing such arrangements with families. The facility’s fall policy required staff to identify interventions related to specific risks and causes based on evaluations and data, but the care plans were not revised with additional interventions after the repeated unwitnessed falls and escalating fall risk behaviors.
Failure to Ensure Appropriate Use and Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to prevent the use of unnecessary psychotropic medications and to ensure a resident was free from unnecessary drugs. One resident with non-Alzheimer’s dementia and an anxiety disorder had an admission MDS showing a BIMS score of 8, indicating moderately impaired cognition, but no documented hallucinations, delusions, or behavioral symptoms such as aggression, wandering, or rejection of care. Despite this, the physician ordered Seroquel 25 mg twice daily for “vascular dementia manifested by manic behaviors,” and later increased the dose after reports of aggressive outbursts and confusion. The diagnosis of vascular dementia was used as the indication for the antipsychotic, and there was no documentation that the IDT evaluated the resident’s angry outbursts or hallucinations or identified and implemented person-centered non-pharmacological interventions before starting or increasing the Seroquel. The resident was also prescribed Ativan 0.5 mg by mouth at night as needed for anxiety and received multiple PRN doses over several days. Review of the medical record, including the Order Summary Reports, MARs, and care plans, showed that the facility did not incorporate the use of Seroquel and Ativan into the resident’s care plan with appropriate interventions. The DON was unable to provide IDT documentation or a care plan addressing the resident’s angry outbursts with person-centered non-pharmacological approaches prior to the administration of Seroquel, despite facility policies requiring thorough evaluation of behavioral symptoms and use of behavioral interventions unless contraindicated. Informed consent procedures for psychotropic medications were not followed as required. The Psychotherapeutic Drug Informed Consent forms for both Seroquel and Ativan did not contain documentation that informed consent was obtained from the resident’s representative prior to their use. The physician acknowledged not speaking directly with the resident’s representative regarding informed consent for these medications and stated that nurses were expected to obtain consent. The facility’s stated process was for licensed nurses to call the resident’s representative, explain the medication, its use, and side effects, and document consent, but this was not documented in the record for this resident. These omissions occurred despite facility policies stating that psychotropic medications may only be administered when necessary to treat a specifically diagnosed condition, with appropriate documentation, behavioral interventions, and informed consent obtained by the prescribing clinician.
Failure to Provide Appropriate Toileting Support for a Resident With Occasional Incontinence
Penalty
Summary
Appropriate care for residents who are continent or incontinent of bowel and bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not provided for one sampled resident with occasional incontinence of bladder and bowel. The resident was admitted with diagnoses including history of falling, muscle wasting and atrophy, age-related osteoporosis, and dementia with mood disturbances. The MDS dated 3/3/26 indicated occasional incontinence of bladder and bowel, that a trial toileting program had not been attempted, that the resident needed moderate assistance to walk at least 10 feet, used a walker and wheelchair, was dependent for toileting hygiene, and had a BIMS score of 03 indicating impaired mental status. The B&B assessment dated 4/29/26 indicated the resident was continent with occasional incontinence episodes. The care plan for bladder incontinence, initiated 2/25/26, identified functional incontinence and included interventions to offer toileting on rounds, upon request, and as needed, and to provide incontinence care on rounds, upon request, and as needed. During interview, an LVN stated the resident had short-term memory loss and was impulsive when getting up to use the bathroom without calling for assistance. The DON stated staff offered toilet assistance during nurses' rounds and as needed, but the facility did not proceed with a toileting program because the resident was not appropriate due to impaired mobility and needing one-person assistance for toilet use. The DON could not provide the facility's policy and procedure for the bowel and bladder toileting program.
Resident Housed in Unapproved Conference Room Without Sink or Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to comply with state regulations requiring that residents be housed only in areas approved for patient housing. One resident was admitted directly into a conference room and remained there from admission through discharge, a total of six weeks. The conference room was located behind the reception desk at the facility entrance, had advertising brochures on the walls, and was separated primarily by a curtain, with the door left open during care at times. The resident’s care plan specifically documented housing in the conference room and noted that staff needed to bring in water and soap for handwashing because there was no sink in the room. The resident had multiple medical diagnoses, including neutropenia, hemiplegia, hemiparesis, functional diarrhea, and heart failure, and had an intact cognitive status based on a BIMS score of 13. Observations showed the resident in a patient bed in the conference room with a bedside commode and bedside table, and the resident reported using a bell to call for help. A CNA confirmed there was no bathroom or sink in the room, that the resident used the commode for bowel movements, and that privacy was difficult to maintain because the room was primarily separated by a curtain and the door was not fully closed during care. Interviews with staff revealed that the resident’s family requested a private room and selected the conference room after being informed it had been used in the past for resident housing. The Admissions Coordinator stated the census listed the resident in a standard room number, but the resident was always physically located in the conference room. The DON acknowledged the conference room was not ideal for patient care due to the lack of a toilet and sink. The current Administrator and former administrator referenced prior CDPH authorization during the COVID-19 pandemic to use the conference room for residents, but neither could provide dates or documentation, and a review of CDPH waivers and AFLs showed no current authorization and confirmed that temporary COVID-19 waivers had been discontinued, while state regulations prohibit housing patients in non-approved areas without temporary permission in an emergency.
Improper Labeling and Dating of Eye Drop Medications
Penalty
Summary
The facility failed to ensure the proper labeling and dating of eye drop medications for two residents, Resident 98 and Resident 100. During an observation of Medication Cart A, it was noted that Resident 98's Latanoprost Ophthalmic solution did not have an open date on the label, despite instructions to discard the medication 42 days after opening. Similarly, an observation of Medication Cart B revealed that Resident 100's Latanoprost Ophthalmic solution also lacked an open date. Both medications had an expiration date of June 2026 and required refrigeration until opening. Interviews with the Assistant Director of Nursing (ADON) confirmed that the eye drops should have had an open date to ensure they were discarded as per the instructions, preventing the use of potentially less effective medication. Resident 100 had a diagnosis of primary open-angle glaucoma, bilateral indeterminant stage, and Resident 98 had physician orders for Latanoprost to treat glaucoma. The Pharmacy Consultant Supervisor also stated that the eye drops should have an open and use-by date to maintain their effectiveness.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications, as observed during a survey. Two bottles of expired lorazepam, a medication used to treat anxiety, were found in a refrigerator designated for ready-to-use medications. This was noted during an observation in the medication room with an LVN, who acknowledged that the medications were expired and should not have been stored there. The facility's pharmacist confirmed that expired or discontinued medications should be placed in a designated disposal area for destruction. A review of Resident 10's physician orders indicated that the resident had an order for lorazepam, and the last dose was administered prior to the survey. The facility's policy stated that discontinued or outdated drugs should be returned to the pharmacy or destroyed. Additionally, the survey revealed that the lid of a black medication disposal bin in the medication storage room was loosely open, allowing easy access to its contents, which included pills, capsules, and other medication forms. The DON acknowledged that the lid should be secured, as indicated by the label on the bin, which stated that it should remain closed and items should not be removed. The facility's policy required that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in this instance.
Deficiency in Dietary Management Qualifications
Penalty
Summary
The facility failed to employ a full-time registered dietitian and did not ensure that the person designated as the director of food and nutrition services met the necessary federal and state educational qualifications for a dietary manager position. The Dietary Supervisor (DS) was working full-time in this role but only had a Food Manager certification obtained through an online training course, which was deemed insufficient for the dietary manager position. The DS had been in this role for one year, while the Registered Dietitian (RD) worked part-time, being present at the facility only two days a week. The lack of a full-time, qualified individual overseeing the food and nutrition services posed a risk to residents who consumed food from the kitchen. This deficiency increased the potential for foodborne illnesses and decreased nutrient intake, which could lead to malnutrition or even death. The Administrator acknowledged that the DS's ServSafe certification did not meet the required qualifications for the dietary manager position, highlighting a significant oversight in staffing and compliance with regulatory standards.
Deficiencies in Kitchen Equipment and Sanitation
Penalty
Summary
The facility failed to maintain its kitchen equipment and environment in a sanitary and operational condition, leading to potential food safety issues. Two ovens were not functioning properly; one oven was unable to cook chicken to the required food safety temperature, and the other was inoperable. The Dietary Supervisor and Cook were aware of these issues, and the Cook had to manually adjust cooking methods to ensure food safety. Despite being informed of the faulty ovens three to six months prior, the Maintenance Supervisor and Administrator had not addressed the necessary repairs or replacements. Additionally, the facility's kitchen environment was not maintained in a clean and sanitary condition. Observations revealed brownish black debris on a countertop toaster oven, cracked and discolored kitchen floor tiles, a dusty ceiling vent, a malodorous and insecure grease trap, and a cabinet drawer that did not fully close. The Dietary Supervisor, Maintenance Supervisor, and Administrator were aware of these issues, but no corrective actions had been taken. The facility's sanitation policy requires all kitchen areas to be clean and equipment to be in good repair, which was not adhered to in this case.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to ensure that the pharmacist provided consultation services to maintain a record system for the receipt, disposition, and reconciliation of all controlled drugs for three years. During an interview and record review with the Director of Nursing (DON), it was revealed that the controlled medication disposition binder was disorganized, with logs and medication packages unaccounted for since 10/5/2022. The DON admitted that she and the facility's pharmacist were responsible for disposing of controlled medications into the final incinerator container together, but she had not had the time to do so. Additionally, the DON was unable to locate the controlled drug disposition records for the year 2021. In a phone interview, the pharmacist confirmed that the controlled drugs in need of disposal were to be reconciled and documented for any discrepancies before being placed in sealable plastic bags with a liquid and then into an incinerator container for destruction by a contractor. The pharmacist stated that this process should occur quarterly, and the disposition documentation should be retained for three years. However, the facility's policy indicated that completed medication disposition records should be kept for at least two years, or as mandated by state law. The California Codes for Pharmacy require that such logs be retained for at least three years, highlighting a discrepancy in the facility's policy and practice.
Inaccurate Medical Records and Care Plan Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks in medication administration and care provision. For Resident 9, a Licensed Vocational Nurse (LVN) did not document the administration of a controlled medication, oxycodone, immediately after it was given. This discrepancy was noted during an observation where the nurse acknowledged administering the medication but failing to record it in the Medication Administration Record (MAR) and Controlled Drug Record (CDR). For Resident 30, there were multiple instances where medications were not documented as administered on specific dates. The Director of Nursing (DON) confirmed the absence of documentation for several medications, including those for blood pressure, insulin, and other critical treatments. LVNs responsible for these omissions cited being sidetracked or could not provide explanations for the lack of documentation, which was against the facility's policy requiring immediate documentation post-administration. Resident 15's care plan inaccurately reflected her movement restrictions due to infection control measures. Despite being on strict contact isolation, observations and interviews revealed that the resident was seen outside her room, engaging in activities like ambulation therapy and moving around in common areas. This inconsistency between the care plan and actual practice was confirmed through surveillance footage and staff interviews, indicating a failure to update and adhere to the care plan accurately.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration by a Licensed Vocational Nurse (LVN). The LVN did not perform hand hygiene while administering medications to three residents, which included handling medications, using medical instruments, and administering injections and eye drops. Specifically, the LVN did not change gloves or sanitize hands between different tasks and residents, increasing the risk of cross-contamination and infection transmission. The Director of Nursing (DON) acknowledged the importance of hand hygiene in preventing infections and stated that staff were expected to perform hand hygiene before and after medication administration and when touching items in residents' rooms. However, the DON admitted that no medication pass observations had been conducted for licensed nurses since she started in February 2023. The facility relied on a nurse consultant from a contracted pharmacy company for quarterly medication administration observations, which had previously reported handwashing as a common concern.
Inaccurate MDS Assessment on Resident Mobility
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident, specifically regarding the resident's functional status on mobility. The MDS assessment inaccurately indicated that the resident was unable to walk due to health and safety reasons. However, interviews and record reviews revealed that the resident was able to walk with assistance in the hallways and outside on the patio, receiving assistance from a Restorative Nursing Assistant (RNA) at least three times per week. This discrepancy resulted in an inaccurate reflection of the resident's medical condition. During the review, it was found that the MDS assessment under Functional Abilities incorrectly showed that walking was not attempted due to a medical condition, while the Restorative Nursing Programs section indicated that the resident walked three days in the last seven calendar days. The MDS Coordinator acknowledged that this was an item coding error and should have been coded as moderate assistance for walking. The MDS Coordinator emphasized the importance of accurate MDS assessments, as inaccuracies could affect the resident's plan of care. The Long-Term Care Facility Resident Assessment Instrument (RAI) manual requires that assessments accurately reflect the resident's status, as per federal regulations.
Failure to Accurately Complete PASARR Assessment
Penalty
Summary
The facility failed to accurately complete and update the Level I Preadmission Screening and Resident Review (PASARR) assessment for a resident over a period of more than four years. The resident was admitted in December 2018, and the initial PASARR screening was completed a week after admission, inaccurately indicating that the resident was not prescribed psychotropic medications, despite records showing she was receiving quetiapine for hospital delirium. Additionally, a PASARR completed in June 2019 for the resident's readmission inaccurately suggested that the resident's stay would require less than 30 days of nursing facility services, although she remained a long-term resident. The Minimum Data Set Coordinator (MDSC) also failed to recognize the need for a Level II PASARR screening, despite the resident having diagnoses of schizophrenia and psychosis, which could have warranted further evaluation. The facility's policy required all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders, and to refer individuals meeting certain criteria for a Level II screening. However, this process was not followed, resulting in an inaccurate reflection of the resident's medical status and potentially impacting the care and services provided.
Failure to Provide Necessary Fingernail Care
Penalty
Summary
The facility failed to provide necessary assistance for fingernail care to a resident, identified as Resident 30, who had long fingernails with blackish material under the nail tips. This deficiency was observed during an interview and observation session with the resident, who expressed a desire to have her fingernails trimmed. The resident's medical history included a stroke and diabetes mellitus, and she required extensive physical assistance for personal hygiene tasks, as documented in her Minimum Data Set and Activities of Daily Living care plan. Despite the resident's need for assistance, the assigned nurse, LVN 2, was unaware of why the resident's fingernails had not been trimmed. The facility's policy on fingernail care, revised in February 2022, emphasized the importance of cleaning the nail bed, keeping nails trimmed, and preventing infections. However, this policy was not adhered to in the case of Resident 30, leading to the potential risk of injury and infection due to the untrimmed fingernails.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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