Overland Terrace Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3515 Overland Avenue, Los Angeles, California 90034
- CMS Provider Number
- 055504
- Inspections on file
- 62
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Overland Terrace Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to follow its abuse policy when two residents were involved in an incident in which one cognitively impaired, functionally dependent resident reported being yelled at and hit in the face by a roommate who had returned from pass yelling, unsteady, and smelling of alcohol. An LVN later found the allegedly intoxicated resident on top of the other resident and observed a black eye, but the RN documented the event as an accidental elbow contact despite not witnessing it and acknowledged she did not further investigate. The Administrator later observed the injury but the facility did not initiate and complete the required abuse investigation or make the mandated notifications and written reports to authorities within the time frames specified in its policy and applicable law.
A resident with multiple behavioral health diagnoses, including PTSD and major depressive disorder, repeatedly exhibited extreme agitation, verbal and physical aggression, and used racial slurs toward a roommate and the roommate’s family. Despite documented incidents and ongoing complaints, the facility’s interventions were limited and did not effectively address the resident’s behavioral health needs, resulting in continued risk and negative psychosocial impact on others.
Two residents with multiple medical and cognitive conditions experienced disrespectful and non-person-centered care during an overnight shift, including delayed responses to call lights, lack of staff introductions, and rude interactions when requesting incontinence care. Staff interviews denied inappropriate conduct, but facility policy and the DON confirmed expectations for respectful and dignified care.
The facility did not maintain required room temperatures, with several rooms found below the federally mandated range, resulting in a resident feeling cold and uncomfortable. Additionally, a shared bathroom was observed to have chipped paint, holes, and dried fecal matter on the walls and bedside commode, with staff confirming inadequate cleaning and risk of contamination.
A resident with dementia and a history of falls experienced multiple unwitnessed falls, including one resulting in a laceration requiring hospital transfer. Despite repeated incidents, fall risk assessments were incomplete, care plan interventions were delayed, and recommended increased supervision was not implemented. Staff interviews revealed gaps in injury reporting and understanding of policy requirements.
A resident's expired medication was found stored in a food bag inside the residents' refrigerator, an area not designated for medication storage. The Dietary Supervisor and LVN confirmed that licensed nurses are responsible for checking all food and bags stored in the refrigerator, and facility policy requires medications to be stored in locked or designated areas accessible only to authorized personnel. Other medication storage areas were found compliant.
A dietary staff member was observed preparing a meal without following the prescribed recipe, specifically by not measuring black pepper as required. The staff member admitted to not using measuring utensils, and the dietary supervisor confirmed that all cooks are expected to follow recipes. The facility's menu and recipe documentation supported that the meal in question was served to all residents.
Surveyors found that the facility did not properly store, label, or date various food items in the kitchen and residents' food storage areas, with several containers missing expiration or use-by dates. Additionally, the residents' refrigerator and freezer temperatures were not maintained or recorded as required, and the Dietary Supervisor was unaware of their responsibility for these tasks, contrary to facility policy.
Staff failed to use required PPE while providing care to a resident on enhanced barrier precautions, and a shared bathroom used by two residents was found with dried fecal matter on the wall and bedside commode. Despite facility policies and available supplies, these lapses in infection control and environmental cleanliness were confirmed by staff interviews and direct observation.
Two residents with cognitive impairment and a history of falls experienced unwitnessed falls resulting in injuries that required transfer to a general acute care hospital. Despite facility policy requiring reporting of such incidents to CDPH within 24 hours, staff did not report the events due to misinterpretation of injury severity and lack of understanding of reporting requirements.
A resident with PTSD and hypertension was admitted without a baseline care plan being developed or implemented within 48 hours, as required by facility policy. Staff interviews and record reviews confirmed that no care plan addressing PTSD was created at admission, despite the diagnosis being documented. Facility policy mandates timely care planning to address residents' needs, which was not followed in this case.
A resident with an indwelling urinary catheter and multiple urological conditions was observed with the catheter drainage bag positioned above the bladder, contrary to care plan and physician orders. Staff confirmed the improper placement was due to the wheelchair lacking an appropriate attachment, and acknowledged the risk for infection. Facility policy required the drainage bag to be below the bladder, but this was not followed, resulting in a deficiency related to UTI prevention.
A resident with cognitive impairment and multiple medical conditions was found with an unlabeled tube feeding syringe and tubing set, and a water bag labeled with a date several days old. Staff confirmed that tube feeding equipment should be changed and labeled daily, in accordance with facility policy and physician orders, but this was not done.
A resident with dementia, generalized weakness, and diabetes was admitted without natural teeth or dentures and had a physician order for a dental consultation as needed. Despite facility policy requiring prompt referral to outside services, the resident was not referred to a dentist, and staff confirmed the dental consultation was not completed.
A review of facility records and observations revealed that 28 resident rooms did not meet the required minimum square footage per resident, with several multi-occupancy rooms falling below federal standards. Despite this, both residents and staff were observed to have sufficient space to move and provide care safely.
A facility failed to conduct a personal property inventory for a resident upon admission, as required by its policy. The resident, admitted with diabetes, heart failure, and insomnia, reported not receiving an inventory list during her stay. The DON confirmed the oversight, acknowledging that the inventory list was not completed, leaving personal property unaccounted for.
A resident with multiple health issues, including neoplasm of bone and morbid obesity, did not receive adequate care for mobility and incontinence needs. The resident required significant assistance for ADLs, but the care plan did not reflect current limitations, and staff struggled to meet the resident's frequent requests for repositioning and diaper changes. The facility's policies on care planning and incontinence management were not effectively implemented.
A resident with multiple medical conditions, including neoplasm of bone and morbid obesity, did not receive timely assistance for repositioning and diaper changes, leading to discomfort and potential risk of pressure injuries. The care plan failed to address the resident's mobility limitations and preferences, resulting in unmet physical and psychosocial needs. Staff interviews confirmed delays in providing necessary care due to the requirement of multiple staff members for repositioning.
A resident with Parkinson's disease, anoxic brain damage, and a history of falls was inaccurately assessed as low risk for falls upon admission. The facility's fall risk assessment failed to account for the resident's predisposing conditions and medications, leading to a deficiency in providing necessary preventive care. The DON acknowledged the assessment was not correctly coded, which could have resulted in inadequate fall prevention measures.
Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention and management policy regarding timely reporting and investigation of a resident-to-resident allegation of physical abuse. Resident 1, who had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, dysphagia, and heart failure, was cognitively moderately impaired and required maximal assistance to dependent for ADLs. On the date of the incident, an SBAR documented that another resident (Resident 2) accidentally bumped into Resident 1’s right face, hitting the right upper cheek, and that Resident 2 was apologetic. However, during an interview, Resident 1 reported that Resident 2 was yelling and arguing, then hit Resident 1 in the face with both fists, and ended up on top of Resident 1’s bed after Resident 1 tried to push the bedside table to push Resident 2 away. Resident 1 stated there were no staff present when this occurred and that he later explained the incident to staff. LVN 1 reported that Resident 2 returned from an out pass yelling, walking wobbly, and smelling of alcohol, and that he assumed Resident 2 had been drinking based on a brown paper bag with a can inside. LVN 1 stated he directed Resident 2 back to his room, where Resident 1 was also present, and then heard a loud crashing sound. Upon entering the room, LVN 1 found Resident 2 on top of Resident 1 and observed that Resident 1 subsequently had a black eye. When questioned, Resident 1 told LVN 1 that Resident 2 fell on top of him and asked that Resident 2 not be allowed to return to the room. LVN 1 stated he did not witness the actual contact and that Resident 2, who was intoxicated, could not clearly explain what had happened. LVN 1 reported the incident to RN 1. RN 1 documented in Resident 2’s progress notes that Resident 2 returned from pass, was yelling and cursing, and that while walking toward his bed, Resident 2 grabbed the bedside table for support and his elbow accidentally touched Resident 1’s right cheek, with staff supporting Resident 2 to prevent a fall. During interview, RN 1 acknowledged she had not witnessed this and that she should not have documented the event as an accidental elbow contact without further investigation. The Administrator later stated he was not in the facility when the incident occurred and that he had just seen Resident 1 with a black eye and needed to further investigate and interview staff and residents. Despite the facility’s written policy requiring the Administrator or designee to immediately initiate an investigation upon receiving an abuse allegation and to notify law enforcement and submit written SOC341 reports to the Ombudsman, law enforcement, and CDPH within two hours, the facility did not implement these reporting and investigative requirements for this resident-to-resident allegation of physical abuse and did not submit a conclusion report of investigation within five days or in accordance with state or federal law.
Failure to Provide Necessary Behavioral Health Services for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident with significant behavioral health diagnoses received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including diabetes, hypertension, stroke, PTSD, major depressive disorder, and Cluster B personality disorder, exhibited repeated episodes of extreme agitation, verbal and physical aggression, and use of racial slurs and derogatory language towards a roommate and the roommate’s family members. These behaviors were documented on multiple occasions, including incidents of yelling, screaming, hitting, spitting, and making threatening or abusive remarks, particularly when the resident felt his personal space was encroached upon or when interacting with the roommate’s visitors. Despite the ongoing and escalating behavioral issues, the facility’s interventions were limited to offering room changes, which the resident refused, and implementing care plan interventions such as discussing behaviors with the resident, removing the resident from situations, and arranging for psychiatric and psychological consults as indicated. The care plan was updated to reflect the resident’s behavioral problems and included goals to reduce agitation, but the interventions did not effectively address or mitigate the resident’s aggressive and abusive behaviors. Staff interviews revealed that the resident’s behaviors were well-known, and there was reluctance to move the resident due to anticipated issues with other roommates. The roommate’s family expressed concerns for safety and documented their experiences in a letter to the facility, but the underlying behavioral health needs of the resident were not adequately addressed. The facility’s policy on behavior management required appropriate treatment for residents displaying mental disorders or psychosocial adjustment difficulties, including the use of non-pharmacological interventions before psychoactive medications. However, the documentation and interviews indicate that the facility did not ensure the resident received comprehensive behavioral health care and services as required, resulting in ongoing risk and negative psychosocial impact on the roommate, the roommate’s family, other residents, and staff.
Failure to Provide Respectful, Person-Centered Care to Two Residents
Penalty
Summary
Two residents were not treated with respect, dignity, or person-centered care, as evidenced by their experiences during the overnight shift. One resident, with diagnoses including muscle weakness, depression, and anxiety, reported that a CNA assigned to her care expressed reluctance to provide incontinence care and did not respond when asked if there was an issue. The resident also noted that staff on the overnight shift appeared angry, did not introduce themselves, and failed to greet her when called for assistance with activities of daily living, leading her to feel scared and fear abandonment. Another resident, who had spinal stenosis, muscle weakness, COPD, cognitive impairment, and anxiety disorder, stated that he waited two hours for a call light response during the same shift. When a female nurse finally arrived, she did not introduce herself, addressed him rudely, and stated she had other residents to attend to before leaving the room without providing the requested incontinence care. The resident was unable to identify the staff member because staff wore their badges in a way that obscured their names. Facility records confirmed the staff assignments for the shift in question. Interviews with the involved CNAs denied any inappropriate behavior, but the Director of Nursing confirmed that staff are required to be polite, introduce themselves, and treat residents with dignity and respect. Facility policies reviewed also emphasized the importance of treating residents with kindness, respect, and dignity, and providing care in a person-centered manner.
Failure to Maintain Safe Room Temperatures and Sanitary Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, sanitary, and homelike environment for its residents in two key areas. First, the facility did not keep resident room temperatures within the federally required range of 71 to 81 degrees Fahrenheit. During observations, five resident rooms, including one occupied by a resident with Parkinson's disease, anemia, and high blood pressure, were found to have temperatures ranging from 62 to 68 degrees Fahrenheit. The resident reported feeling cold and uncomfortable, which made it difficult to sleep. The DON was unaware of the specific temperature requirements, and facility policy emphasized the importance of comfortable temperatures for residents. Second, the facility did not provide a clean and sanitary environment in a shared bathroom between two resident rooms. Observations revealed chipped paint, holes, and dried brown smears identified as fecal matter on the walls and bedside commode. A resident confirmed the presence of fecal matter and stated that housekeeping only cleaned the toilet and floor daily. The Director of Staff Development acknowledged that the fecal matter placed residents at risk of contamination and did not reflect good hygiene. Facility policies required cleanliness and infection control to maintain a safe and comfortable environment.
Failure to Prevent Repeated Falls and Injury Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of falls and dementia from repeated falls, resulting in injury. The resident experienced multiple falls over several months, including incidents on 10/26/2024, 12/1/2024, 12/24/2024, 12/27/2024, and 2/28/2025. Despite these repeated events, fall risk assessments were either incomplete or did not accurately reflect the resident's fall history, and the total risk scores were not documented. The care plans were updated only after several falls had already occurred, and interventions to address the resident's high risk for falls were not clearly documented or implemented in a timely manner. On 2/28/2025, the resident suffered another unwitnessed fall, resulting in a laceration to the left eyebrow that required first aid and transfer to a general acute care hospital for further evaluation and treatment. Documentation indicated that the resident was found in a crouching position in bed, confused and disoriented, with a bleeding cut above the left eye. The injury was managed by nursing staff, and emergency services were called. The resident's family had previously suggested increased supervision, such as moving the resident closer to the nurse's station, but this was not implemented prior to the incident. Interviews with facility staff revealed gaps in communication and understanding of the significance of the injury. The administrator did not report the unwitnessed fall to the state health department, stating he did not consider the laceration and bleeding to be significant, and was unaware of the medical implications due to lack of clinical training. Facility policy required safety risk evaluations and reporting of unwitnessed falls with significant injury, but these procedures were not consistently followed, contributing to the deficiency.
Improper Storage and Labeling of Medication in Resident's Refrigerator
Penalty
Summary
Facility staff failed to ensure that medications were properly labeled and stored in accordance with professional standards for one resident. During an observation of the residents' outside food storage refrigerator, multiple food items were found without expiration dates, along with expired foods and expired medication in a resident's food bag. The Dietary Supervisor stated that it is the responsibility of licensed nurses to check residents' outside food items before storage. Further interviews and observations confirmed that the resident's refrigerator is not a designated area for medication storage, and that only licensed nurses, pharmacy personnel, and those lawfully authorized are permitted access to medications, which should be stored in locked compartments or designated areas. Additional observations of medication carts and storage rooms showed that all other medications and narcotics were properly stored, dated, and accounted for. However, the presence of expired medication in a resident's food bag within the refrigerator indicated a lapse in following facility policy and procedures regarding medication storage. Both the LVN and DON acknowledged that medications should not be stored in the resident's refrigerator and that it is the licensed nurses' responsibility to check all food and bags being stored there.
Failure to Follow Food Recipe During Meal Preparation
Penalty
Summary
During an observation and interview, a dietary staff member was seen preparing lunch and not following the facility's recipe for ground beef, specifically by pouring black pepper without using measuring utensils. The dietary staff member, who has worked at the facility for eight years, admitted to not following the recipe and acknowledged that not measuring seasonings could result in using too much, which could make residents sick. The dietary supervisor confirmed that all dietary cooks are required to follow recipes and stated that staff had been in-serviced on this requirement two weeks prior. A review of the facility's recipe for Southern Style Pattie indicated that only 1/8 teaspoon of black pepper should be used, and the menu for the day confirmed that this dish was served for lunch to all residents.
Failure to Properly Store, Label, and Monitor Food Items and Temperatures
Penalty
Summary
Surveyors observed that the facility failed to properly store, label, and date food items in both the kitchen and the residents' food storage areas. Multiple food containers, including ground spices, sauces, mayonnaise, and salad dressing, were found without original labels, expiration dates, or use-by dates. Additionally, a review of dietary purchase invoices did not show records for several of these food items, and the Dietary Supervisor confirmed that if residents consume expired foods, it could make them very sick. The Registered Dietician also stated that all food items should be labeled and dated to prevent residents from consuming expired foods. Further observations revealed that the residents' outside food refrigerator and freezer were not maintained at appropriate temperatures, with the freezer above zero degrees and the refrigerator at 43 degrees Fahrenheit. There was no documented evidence that temperatures for these storage units were checked or recorded for the required period. The Dietary Supervisor was unaware of their responsibility to maintain and record these temperatures, despite facility policy stating otherwise. Facility policies also required that perishable food brought in by visitors be labeled, dated, and discarded after specific timeframes, but these procedures were not followed.
Failure to Follow Infection Control Protocols and Maintain Sanitary Environment
Penalty
Summary
Facility staff failed to adhere to infection control measures in two key areas. First, a certified nursing assistant (CNA) was observed providing activities of daily living (ADL) care to a resident on enhanced barrier precautions (EBP) without donning the required personal protective equipment (PPE), despite signage indicating the need for PPE and the availability of supplies nearby. The CNA acknowledged awareness of the requirement but stated that PPE was not present in the room at the time. Interviews with the infection prevention nurse and the director of nursing confirmed that staff are expected to use PPE when caring for residents on EBP, and that PPE is accessible for staff use. Second, the facility failed to maintain a clean and sanitary environment in a shared bathroom used by two residents. Observations revealed a dried, hard brown smear by the light switch and fecal matter on a bedside commode (BSC) inside the bathroom. A resident reported that while housekeeping cleans the toilet and floor daily, the fecal matter on the walls remained. The director of staff development confirmed the presence of fecal matter and acknowledged that housekeeping is responsible for cleaning resident bathrooms. Facility policies reviewed indicated the expectation for maintaining a safe, clean, and sanitary environment, as well as adherence to infection control procedures.
Failure to Timely Report Unwitnessed Falls with Injury
Penalty
Summary
The facility failed to report two separate incidents of unwitnessed falls with injury to the Department of Health Services (CDPH), Licensing and Certification, and the local health officer within twenty-four hours as required by facility policy. In the first incident, a resident with a history of falls, osteoporosis, cognitive impairment, and dementia experienced an unwitnessed fall in the hallway, resulting in a skin tear to the right upper eyebrow. The resident was assessed, provided first aid, and transferred to a general acute care hospital (GACH) for further evaluation. Despite the injury and transfer, the event was not reported to the appropriate authorities within the required timeframe. In the second incident, another resident with a history of falls and unspecified dementia was found on the floor with a cut to the left eyebrow after an unwitnessed fall. The resident required moderate to maximum assistance with activities of daily living and did not have the capacity to make medical decisions. The registered nurse supervisor applied pressure and steri-strips to the wound and called 911 for transfer to GACH. Although the incident involved a significant injury and emergency transfer, it was not reported to CDPH within 24 hours, as required by facility policy. Interviews with facility staff, including the DON and Administrator, revealed a lack of understanding and miscommunication regarding what constitutes a significant injury and the reporting requirements. The DON and Administrator both acknowledged that the incidents should have been reported but failed to do so, citing misinterpretation of the severity of the injuries. Facility policy clearly states that unusual occurrences affecting resident welfare, safety, or health must be reported to the appropriate agency within 24 hours by telephone and confirmed in writing, which was not followed in these cases.
Failure to Initiate Baseline Care Plan for Resident with PTSD Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and hypertension. The resident was admitted with a documented history of PTSD, and the diagnosis was entered into the medical record on the day of admission. Despite this, a review of the resident's electronic medical chart revealed that no care plan addressing PTSD was created at the time of admission, as confirmed by a Licensed Vocational Nurse (LVN) during an interview. The LVN acknowledged the absence of a care plan for PTSD and stated that such a plan is necessary to identify triggers and implement interventions to manage the resident's condition. Further interviews with facility staff, including the Director of Nursing (DON), confirmed that the facility's policy requires a care plan to be completed upon admission or the following day, especially for residents with behavioral health diagnoses such as PTSD. The facility's policy on Comprehensive Person-Centered Care Planning specifies that a baseline care plan must be developed and implemented within 48 hours of admission, reflecting the resident's goals and including interventions for identified needs. The lack of a timely care plan for the resident with PTSD constituted a failure to meet these requirements.
Improper Placement of Catheter Drainage Bag Increases UTI Risk
Penalty
Summary
Facility staff failed to ensure proper placement of an indwelling urinary catheter drainage bag for a resident with a history of obstructive and reflux uropathy, chronic kidney disease, and benign prostatic hyperplasia. The resident, who was moderately cognitively impaired and required partial assistance with activities of daily living, had a care plan and physician orders specifying that the catheter drainage bag should be positioned below the level of the bladder to prevent urinary tract infections (UTIs). However, during observation, the drainage bag was found attached to the side of the resident's wheelchair at waist level, with the tubing looped and the bag positioned above the bladder, resulting in urine not draining properly. Staff interviews confirmed that the improper placement was due to the lack of an appropriate attachment on the wheelchair, and both the LVN and DON acknowledged that the drainage bag should be below the bladder to prevent infection. Facility policy also required the catheter and tubing to be free from kinking and the collection bag to be kept below the bladder. The failure to maintain the correct position of the catheter drainage bag constituted a deficiency in providing appropriate care to prevent UTIs.
Failure to Label and Change Tube Feeding Equipment as Required
Penalty
Summary
The facility failed to properly label and change tube feeding equipment for a resident with significant medical needs. Specifically, a tube feeding syringe was observed hanging from the resident's feeding pole without a label indicating the date or time, and the tube feeding set also lacked a label to show when it had last been changed. The water bag attached to the feeding pole was labeled with a date several days prior to the observation, suggesting that the tubing set may not have been changed as required. The resident involved had diagnoses including encephalopathy, generalized weakness, and adult failure to thrive, and was dependent on staff for activities of daily living due to cognitive impairment. During interviews, staff confirmed that the tube feeding set, including the tubing, bottle, and water bag, should be changed daily and labeled with the resident's name, date, and time of change. The facility's policy also required that feeding bags and tubing be labeled and changed every 24 hours. The lack of labeling and failure to change the tube feeding set as required constituted a deviation from both facility policy and physician orders.
Failure to Provide Timely Dental Referral per Physician Order
Penalty
Summary
The facility failed to provide a dental referral for a resident as required by physician orders and facility policy. The resident was admitted with diagnoses including dementia, generalized weakness, and diabetes mellitus, and was noted to have no natural teeth or dentures. A physician order for a dental consultation on an as-needed basis was present from the time of admission, but the referral was not made. The Social Services Director confirmed that the resident had not been seen by a dentist, despite the order and the resident's lack of teeth, which was documented in both the admission record and the social services assessment. The facility's policy requires that referrals to outside services, such as dental care, be coordinated by the Director of Social Services in accordance with physician orders or the care plan. Interviews with facility staff, including the DON and Social Services Director, indicated that the process is to initiate the referral the day the order is received. However, this process was not followed for this resident, resulting in the resident not receiving the required dental consultation.
Resident Room Square Footage Below Regulatory Minimums
Penalty
Summary
The facility failed to ensure that 28 out of 39 resident rooms met the required minimum square footage per resident, as specified by federal regulations. Specifically, rooms designed for two, three, and four residents did not provide at least 80 square feet per resident, with several rooms falling short of the 160, 240, and 320 square foot minimums for 2-, 3-, and 4-person rooms, respectively. This deficiency was identified through observation, interview, and record review, including a Client Accommodation Analysis and a facility letter requesting a room waiver. Despite these findings, observations indicated that both residents and staff had enough space to move about freely and that nursing staff could safely provide care with adequate space for beds, side tables, dressers, and care equipment.
Failure to Conduct Personal Property Inventory
Penalty
Summary
The facility failed to adhere to its own Policy and Procedure (P&P) by not conducting and completing a personal property inventory for a resident upon admission. This oversight was identified during a review of the resident's admission records and confirmed through interviews. The resident, who was admitted with conditions including diabetes mellitus, heart failure, and insomnia, reported that the facility staff did not offer a personal property inventory list during her stay. The Director of Nursing (DON) acknowledged that the inventory list was not completed as required by the facility's policy, which mandates that a personal property inventory be conducted upon admission. The facility's P&P on personal property, reviewed in January 2024, outlines the procedures for safeguarding residents' belongings. It specifies that the Admissions Staff should inform residents or their representatives about marking belongings and updating the inventory list as items are added or removed. Additionally, a Certified Nursing Assistant (CNA) or designee is responsible for conducting the inventory and placing it in the medical record. The failure to complete this process for the resident left personal property unaccounted for, as confirmed by the DON during an interview.
Deficient Care for Resident's Mobility and Incontinence Needs
Penalty
Summary
The facility failed to provide necessary care and assistance for a resident, resulting in a lack of mobility and inadequate incontinent care. The resident, who was readmitted with multiple diagnoses including neoplasm of bone, morbid obesity, and muscle weakness, required maximal assistance for lower body dressing and moderate assistance for activities of daily living (ADLs). Despite these needs, the resident's care plan did not reflect current mobility limitations, and interventions were not adequately implemented to prevent episodes of incontinence. Interviews with the resident and staff revealed that the resident frequently requested to be repositioned and have their diaper changed, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which hindered their ability to perform tasks independently. Staff acknowledged the challenges in meeting the resident's needs due to the requirement of multiple staff members to assist with repositioning. The facility's policies on person-centered care planning and bowel and bladder training were not effectively followed, contributing to the deficiency in care provided to the resident.
Deficiency in Resident Care and Mobility Support
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, identified as Resident 1, to maintain or improve their range of motion and mobility. Resident 1 was readmitted to the facility with multiple diagnoses, including neoplasm of bone, morbid obesity, muscle weakness, and anxiety disorder. The resident required maximal assistance for lower body dressing and moderate assistance for toileting hygiene. Despite these needs, the care plan did not adequately address the resident's current mobility limitations, and the interventions were not effectively implemented to meet the resident's physical and psychosocial needs. Observations and interviews revealed that Resident 1 frequently requested assistance to be repositioned in bed and for diaper changes, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which made it difficult to access personal items, and reported delays in receiving assistance. Staff interviews confirmed that repositioning the resident required at least four people, which sometimes led to delays in providing the necessary care. Additionally, the resident's care plan did not reflect the resident's preferences and needs, such as having personal items on the right side of the bed. The facility's policies and procedures for person-centered care planning and bowel and bladder training were not effectively followed, resulting in neglect of the resident's needs. The failure to provide timely and adequate care had the potential to increase the resident's discomfort and risk of developing pressure injuries, as well as contribute to psychosocial decline. The facility's neglect in addressing the resident's needs and preferences was identified as a deficiency in providing care according to professional standards of practice.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident's fall risk upon admission, which led to a deficiency in providing necessary care and services to prevent accidents and falls. The resident, who was admitted with diagnoses including Parkinson's disease, anoxic brain damage, a history of falling, and diabetes mellitus, was incorrectly assessed as being at low risk for falls. The fall risk assessment did not account for the resident's predisposing conditions such as Parkinson's disease and the use of medications like anti-convulsants, hypoglycemics, and antihypertensives, which should have indicated a higher fall risk. The Director of Nursing acknowledged that the fall risk assessment was not correctly coded, failing to reflect the resident's actual risk factors. This oversight meant that the resident was not identified as being at high risk for falls, which could have led to inadequate preventive measures being implemented. The facility's policy required that fall risk factors be documented and interventions be included in the care plan, regardless of the fall risk evaluation score, but this was not done in this case.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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