Pasadena Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1570 North Fair Oaks Ave, Pasadena, California 91103
- CMS Provider Number
- 555893
- Inspections on file
- 73
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Pasadena Nursing Center during CMS and state inspections, most recent first.
Missing Advance Directive Documentation for Two Residents: The facility failed to inform and provide written information to formulate an advance directive for two residents. One resident had CKD, schizophrenia, and bipolar disorder with moderate impairment in daily decision making, while the other had bipolar disorder, anxiety disorder, and depression with intact cognition. The MRD, SSD, RN, and DON confirmed there were no signed advance directives acknowledgment forms in the chart or EMR, and there was no documented evidence that the conservator or resident was asked about advance directives or given the required information.
Unsafe and Unclean Resident Environment: The facility failed to maintain a safe, clean, and homelike environment when a resident was observed sitting on an uncovered mattress, another resident’s pillow fell into a trashcan and was placed back on the clean bed, a cup of cranberry juice was left on a bariatric Geri chair in the hallway, and soiled pants were left on the floor in a shared restroom and room. Staff and the ADON acknowledged the conditions did not follow the facility’s homelike environment and laundry expectations.
Failure to Measure Cheese in Standardized Recipe: A DA was observed adding mozzarella cheese to spinach au gratin without measuring it and used her hand to add the cheese. The DA stated the cheese was not measured, and the DSS confirmed that 32 residents received the dish and that standardized recipes required the cheese to be measured.
Food service staff failed to keep the refrigerator properly arranged for air circulation when trays of sandwiches were placed on top of milk and blocked the vent. Staff also used a can opener with chipped metal along the blade and hair-like residue from a green cleaning pad, despite policy requiring food storage areas and utensils to be kept clean and in good repair.
A resident admitted with schizophrenia, psychosis, and bipolar disorder had a positive PASARR Level I screening, but the facility did not complete the Level II PASARR evaluation after staff were unresponsive to repeated attempts by the evaluator. The ADON stated she was the PASARR contact person and that the RNS should have taken the call when she was unavailable; the DON stated the facility should coordinate with the Level II evaluator to ensure the resident’s behavior was managed and treatment was monitored.
A resident with impaired balance, coordination, and moderate cognitive impairment was observed in a room where a box fan was placed sideways on top of a 4-wheeled walker near the closet. The fan also had a taped cardboard piece attached to the front. CNA and nursing leadership stated the setup was unsafe, with concerns that the fan could fall, create a trip hazard, and that the cardboard could cause overheating and a fire hazard.
Bedside Water Not Provided to a Resident at Risk for Poor Fluid Intake: A resident with cognitive impairment and a care plan addressing risk for UTI related to poor fluid intake was observed without bedside water available. The resident filled an empty pitcher with tap water and stated staff did not refill water or offer drinks between meals. CNA confirmed no water pitcher was at bedside, and the ADM stated staff should provide adequate fluids to prevent dehydration.
An LVN left a medication cart unlocked and unattended in a hallway while entering a resident room to administer medications, and three residents were observed passing by the cart. The LVN stated she forgot to lock it and acknowledged that residents or other staff could access medications from the cart. The ADM stated the cart should be kept closed, locked, and secured when not in use, consistent with facility policy.
A resident with cancer diagnoses and moderate cognitive impairment was admitted to hospice, but the hospice binder lacked the physician certification and recertification of terminal illness, the hospice plan of care with visit frequencies, and an April calendar of expected hospice visits. The resident said he was unsure how often hospice staff came, and the LVN, ADON, RN, and DON all stated the binder should contain this information so staff could coordinate care and know when hospice visits were expected.
Uncovered GT Feeding Port Touched the Floor: A resident with GT feeding, dysphagia, diabetes, and cognitive impairment was observed with the GT feeding port touching the floor and missing its cap. An LVN confirmed the finding and later covered the port after wiping it with an alcohol pad. The IPN stated the condition was unacceptable, and the facility policy required strict aseptic technique when working with enteral nutrition systems.
Failure to offer annual influenza immunization to a resident with cognitive impairment, CKD, and DM. The IPN reviewed the immunization record and stated the resident’s flu vaccine was historical, with no influenza immunization offered since admission. The ADON stated flu vaccines should be offered to protect residents and reduce the risk of severe illness, and the facility policy required annual offering of the vaccine unless medically contraindicated or already immunized.
Failure to Offer COVID-19 Vaccine to Eligible Resident: The facility failed to offer and provide the COVID-19 vaccine to an eligible resident with immune mechanism disorder, CKD, and DM. The resident’s MDS showed moderate cognitive impairment and need for assistance or supervision with multiple ADLs, and the IPN stated the resident had only a historical COVID-19 immunization record and was never offered the vaccine on admission or afterward. The resident also reported there was no documented evidence that the vaccine had been offered.
Call Light Not Within Resident's Reach: A resident with unsteadiness, lack of coordination, anxiety, and moderate cognitive impairment was observed in bed with the call light on the floor and not within reach on two occasions. The care plan included keeping the call light within reach due to fluctuating ADLs and fall risk, and staff interviews confirmed the call light should be accessible so the resident could alert staff for help or emergencies.
A resident with schizophrenia, Parkinson’s disease, and difficulty walking was assessed on the MDS as needing partial/moderate assistance to walk, even though the RNA and a CNA reported the resident had consistently ambulated with staff supervision only and without a cane or walker. The resident was observed walking under supervision, and the MDS nurse later acknowledged that the MDS should have been coded as supervision rather than partial/moderate assistance, contrary to facility policy requiring staff to certify the accuracy of each portion of the MDS.
A resident with cognitive impairment and extensive ADL needs sustained a facial skin tear when another cognitively impaired resident with paranoid schizophrenia, vascular dementia, and a known history of aggression punched the resident during a hallway encounter. The aggressive resident had a physician’s order and care plan for one-on-one monitoring, including close supervision, restriction of access to other residents, and interventions to protect others’ safety. On the day of the incident, a CNA assigned as a one-on-one sitter focused on selecting clothes at a rack while the monitored resident sat nearby, diverting attention away from him as another resident approached and exchanged words. Staff interviews, including with the DON, DSD, and another CNA, confirmed that one-on-one monitoring required continuous visual supervision and that the CNA was not watching the resident at the time, allowing the punch to occur and resulting in a failure to protect the resident from physical abuse.
A resident with psychiatric and anxiety diagnoses, who had moderately impaired cognition but was independent in some mobility tasks, and the resident’s responsible party were not notified of or included in two multidisciplinary care conferences used to discuss needs and revise the plan of care. Documentation for these conferences did not show their attendance, and the IDON confirmed the responsible party had not been notified despite a designated area for such documentation and a facility policy encouraging resident and representative participation in care planning.
A resident with anxiety, depression, and schizoaffective disorder was started on three psychotropic medications—Paliperidone, Haldol, and Buspirone—without informed consent being obtained from the court-appointed conservator, as required by facility policy. The MAR showed these medications were administered, while interviews with an LVN and the DON confirmed that no signed informed consent was present in the record. The facility’s informed consent policy required the attending physician to obtain consent from the resident or responsible party when initiating or increasing psychotropic drugs, but this was not done in this case.
A resident with severe cognitive impairment and mental health diagnoses refused psychotropic medications, and an LVN stated she notified hospice but did not document this in the medical record. Other nursing staff and the DON confirmed that notifications to physicians or hospice about medication refusals are expected to be recorded in progress notes to inform all licensed staff. The facility’s documentation policy requires that all services, changes in condition, and communications be completely and accurately charted to support interdisciplinary communication, but this hospice notification was not documented, resulting in an inaccurate medical record.
The facility did not report an alleged abuse incident between two residents to CDPH, the ombudsman, or law enforcement within the required two-hour timeframe. Although a resident reported being struck and kicked by another resident and staff initiated an investigation, the ADM and ADON chose not to file the required reports after reviewing CCTV footage and determining there was no visible contact, contrary to facility policy and state regulations.
Two residents did not receive their prescribed controlled medications as documented in the MAR, with staff signing for administration despite the medication counts and controlled substance logs showing the doses were not given. Facility policy requires accurate documentation of controlled substances, but discrepancies were found during review and confirmed by interviews with nursing staff and leadership.
Nursing staff failed to document the administration of medications and required monitoring for three residents during an evening shift, leaving multiple entries blank in the Medication Administration Record. The affected residents had complex medical and psychiatric needs, and the lack of documentation included both prescribed medications and behavioral or side effect monitoring. Facility leadership and nursing staff confirmed that this failure was not in accordance with facility policy, which requires immediate and accurate documentation of all care provided.
A facility continued to prepare and serve meals in a kitchen with a large, uncovered hole in the ceiling above food preparation and tray transport areas, exposing food to potential contaminants. Staff interviews confirmed that the kitchen was used despite ongoing leaks and the absence of a kitchen emergency plan, with decisions about safety made without consulting dietary professionals.
A facility failed to follow its abuse investigation and reporting policies for two residents. One resident, with schizophrenia, was found with facial scratches and reported abuse, but the facility did not investigate or report the incident as required. Another resident, with schizoaffective disorder, was not provided the mandated 1:1 supervision, leading to an altercation. Staff interviews revealed a lack of communication and adherence to protocols, resulting in unreported incidents and unsupervised residents.
A resident with schizophrenia and cognitive impairment was found with scratches on his face, alleging another resident caused them. Despite the aggressive behavior history of the alleged perpetrator, the facility failed to report or investigate the incident properly, violating their policies and compromising resident safety.
The facility failed to set the low air loss mattresses (LALM) correctly for two residents, as per physician's orders and the operator's manual. One resident's LALM was set at 280 and 190 pounds instead of the prescribed 202 pounds, while another's was set at 300, 160, and 150 pounds instead of 129 pounds. This non-compliance with the prescribed settings, confirmed by staff interviews, placed the residents at risk of poor wound healing and deterioration of pressure ulcers.
The facility failed to implement its smoking safety policy for three residents who were observed smoking without the required safety aprons. Despite care plans and assessments indicating the need for aprons, the residents were not provided with them, and staff confirmed the lack of use. This oversight involved residents with cognitive impairments and mental health diagnoses, highlighting a lapse in adherence to safety protocols.
Two residents in the facility had call lights placed out of reach, leading to a deficiency in care. One resident, with severe cognitive impairment and high assistance needs, had a soft touch call light placed too high to reach. Another resident, with moderate cognitive impairment, had a call light clipped behind the bed. Staff interviews confirmed the importance of accessible call lights, as per facility policy, to ensure timely assistance and prevent potential harm.
A resident with a history of mental health issues exhibited increased aggression and assaulted a CNA, but the facility failed to inform the physician of this change in condition. Despite administering Haldol to manage the aggression, the responsible LVN did not notify the physician, contrary to the facility's policy requiring prompt communication of significant changes in a resident's condition.
A resident with severe cognitive impairment and multiple diagnoses had their hands sanitized with germicidal wipes, intended for surfaces, before nail care. This practice, observed by a CNA, was against facility policy and could cause skin irritation. The DON and IPN confirmed the misuse of wipes, emphasizing the need for proper handwashing instead.
A resident at risk for elopement due to dementia and other conditions eloped from the facility without a care plan in place. The facility failed to document the incident, notify the family or physician, or examine the resident for injuries upon return. Staff interviews revealed lapses in following the facility's policies and procedures for managing elopement risks.
A resident with type 2 diabetes and dysphagia was incorrectly administered Jevity instead of the physician-ordered Glucerna via g-tube. The facility's policy required verification of the physician's order and matching the feeding to the order, which was not followed. This error had the potential to cause uncontrolled blood sugar and inappropriate nutrition for the resident.
A facility failed to conduct a monthly Medication Regimen Review (MRR) for a resident with multiple diagnoses, including dementia and bipolar disorder. The resident was prescribed several medications, but there was no documented evidence of an MRR from January to March 2025. The Director of Nursing confirmed the oversight, and the Consultant Pharmacist stated that monthly MRRs are required by state law to ensure resident safety and medication necessity.
A facility failed to maintain accurate medical records for a resident by not signing the eMAR after administering morning medications. The resident, with diagnoses including schizophrenia and seizure disorder, had several medications not documented as administered. An LVN admitted to not signing the eMAR due to being rushed, which is against facility policy.
A facility failed to label the oxygen and enteral feeding tubes for two residents, leading to a deficiency in infection control. One resident's enteral feeding tube was not labeled with the date it was opened, risking bacterial contamination. Another resident's oxygen tubing was also unlabeled, which could lead to respiratory infections. Staff interviews confirmed the oversight, and the facility's policy requires labeling to prevent infections.
The facility failed to manage waste disposal properly, resulting in overfilled and uncovered dumpsters, with additional trash left on the ground. Staff interviews revealed that trash was left outside due to dumpsters not being returned promptly, posing potential health risks by attracting vermin and pests. The facility's policies on pest control and maintaining a clean environment were not followed, leading to an unsanitary and potentially hazardous situation.
The facility failed to post complete staffing information daily as required by their policy. The Director of Staff Development noted that the Census and Direct Care Service Hours Per Patient Day (DHPPD) form was incomplete, missing actual staffing documentation, and was not updated for two days. This failure meant that staff, residents, and visitors were not informed about the facility's actual staffing levels.
A facility failed to meet the minimum room size requirement of 80 square feet per resident in Room A, which measured 158.2 square feet for two residents. Despite this, the facility's waiver request claimed adequate space for care and privacy, and no resident complaints were noted. Observations confirmed sufficient ventilation, lighting, and space for movement and care.
Facility 1 failed to report an allegation of sexual abuse involving two residents within the required 2-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement. The incident involved a resident accused of non-consensual sexual contact with another resident. The failure to report was discovered when local law enforcement and the ombudsman visited the facility to investigate the allegation. Despite being aware of the police visit, the facility's staff did not take the necessary steps to report the incident as required by the facility's policy.
A facility failed to prevent physical abuse between two residents, resulting in one resident striking another on the head. Despite having care plans for managing aggressive behaviors, the interventions were ineffective. The residents involved had histories of mental health issues, and the facility staff acknowledged the aggressive behaviors but failed to document and implement appropriate interventions. This led to a physical altercation and injuries, highlighting a deficiency in the facility's abuse prevention and management policies.
A facility failed to readmit three residents after an emergency evacuation, leaving them at other facilities without the consent of their responsible parties. The residents, with varying degrees of cognitive impairment, were not informed or given the opportunity to return, violating the facility's policies on transfer and discharge. This resulted in a lack of communication and documentation, placing the residents at risk for psychosocial harm and compromised continuity of care.
A resident at moderate risk for falls due to gait and balance issues fell in the facility's dining/activity room. The resident's care plan was not updated to reflect the need for partial moderate assistance and contact guard assist (CGA) during ambulation, as indicated by assessments. On the day of the fall, the resident was ambulating without the required assistance, leading to a fall and a left subcapital fracture, necessitating surgery. Staff interviews revealed a lack of awareness and implementation of the resident's assistance needs.
A facility failed to complete a resident's transfer/discharge notice by omitting the required ombudsman contact information. The resident, with dementia and COPD, was assessed to have intact cognition and required partial assistance. The notice lacked the ombudsman's address, phone, fax, and email, violating the facility's policy, which mandates this information for a valid notice.
The facility failed to notify the physician and the responsible party about a resident's bruises on the right flank area, as required by policy. Multiple staff members observed the bruises but did not report them, assuming they were related to a previous fall. This lack of notification and investigation could delay treatment and affect the resident's health.
The facility failed to prevent and stop an incident of verbal abuse when one resident called another racial slurs, attempted to hit, and spat at them. Despite multiple staff members witnessing the incident, immediate action to separate and monitor the residents was not taken, leaving the affected resident feeling unsafe and anxious.
The facility failed to report an allegation of verbal abuse within the required two-hour timeframe. A resident with PTSD and anxiety disorder reported that another resident used racial slurs, attempted to hit, and spat at her. Despite witnessing the incident, an LVN did not report it to the appropriate authorities, resulting in a deficiency.
The facility failed to follow their policy and procedure regarding advance directives for three residents. For one resident, the Advance Healthcare Directive (AHCD) Acknowledgement Form was not fully filled out. For another resident, the advance directive was not accessible in the medical chart. Similarly, for a third resident, the facility failed to obtain and include the advance directive in the medical records.
The facility failed to conduct proper assessments and obtain physician's orders before using physical restraints on three residents, violating their own policy. Residents were observed using restraints like lap buddies and Geri chairs without necessary documentation, consent, or care plans.
The facility failed to follow through with PASARR recommendations for two residents, leading to potential inappropriate placement and unidentified specialized services. One resident with schizophrenia and another with encephalopathy and schizoaffective disorder did not receive the required Level II PASARR evaluations due to oversight and incorrect assumptions about discharge status.
The facility failed to provide appropriate and consistent activities for two residents, leading to potential decreases in their physical wellbeing, sense of belonging, and emotional health. Both residents had care plans requiring assistance and encouragement to participate in activities, but neither attended any activities in March 2024. Observations showed both residents lying in bed throughout the day, and staff interviews confirmed a lack of in-room or one-on-one activities and documentation.
The facility failed to ensure that LAL mattresses were set up accurately for three residents, leading to potential risks for pressure ulcer development and worsening. The incorrect settings were confirmed by staff and were not in accordance with the facility's policies and procedures.
Missing Advance Directive Documentation for Two Residents
Penalty
Summary
The facility failed to inform and provide written information to formulate an advance directive for two sampled residents, Resident 13 and Resident 20, as required by facility policy. The deficiency was identified during interview and record review, and the report states there was no signed advance directives acknowledgment form in either resident’s chart or EMR. Resident 13 was admitted and later readmitted to the facility with diagnoses including chronic kidney disease, schizophrenia, and bipolar disorder. The MDS dated [DATE] indicated moderate impairment in cognitive skills for daily decision making, along with partial/moderate assistance needed for showering and supervision needed for toileting hygiene, oral hygiene, dressing, personal hygiene, sit to lying, and walking. During an attempted interview, the surveyor was unable to speak with Resident 13’s conservator to verify whether the facility had discussed advance directives. Resident 20 was admitted with diagnoses including bipolar disorder, anxiety disorder, and depression. The MDS dated [DATE] indicated intact cognitive skills for daily decision making, with dependence for lower body dressing and footwear, substantial/maximal assistance for toileting, showering, and upper body dressing, and supervision or setup assistance for personal hygiene, eating, and oral hygiene. The MRD stated there were no signed advance directives acknowledgment forms in the chart and EMR for either resident. The SSD, RN 1, and DON each stated that a signed advance directives acknowledgment form should be in the chart, and the DON stated there was no documented evidence in the chart or progress notes that the conservator was asked whether Residents 13 and 20 had an advance directive or was given information about advance directive formulation.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. Resident 14, who had diagnoses of depression and schizophrenia and was moderately impaired in cognitive skills for daily decision making, was observed sitting on a bed with no bed sheet covering the mattress, leaving the mattress surface exposed. Resident 14 stated the bed had been uncovered for about one and a half hours and said the bed felt more comfortable when it was clean and covered. Resident 27, who had diagnoses of schizophrenia and anxiety and was cognitively intact, was observed while the bed was being changed when a brown pillow fell into a trashcan. The CNA picked up the pillow and placed it on top of the resident’s clean pillow. Resident 27 later stated the brown pillow was a gift from the resident’s mother and said the pillow felt dirty. The CNA stated she should not have put the pillow back on the bed because it was already dirty and could possibly cause sickness to the resident. The ADON reviewed the facility’s Homelike Environment policy and stated it was not followed. Additional observations showed a half-full cup of cranberry juice left at the back lower metal frame of a bariatric Geri chair parked in the hallway, and soiled black pants left on the floor in shared Restroom A and in Room A by bed C. The Administrator removed the cup after it was pointed out. Staff stated soiled laundry should not be left on the floor and should be placed in the laundry bin, and the ADM stated soiled laundry should be placed into the labeled laundry bin and not scattered on the floor.
Failure to Measure Cheese in Standardized Recipe
Penalty
Summary
The facility failed to accurately measure the mozzarella cheese used to prepare spinach au gratin served for lunch on 4/15/2026. During an observation at 11:29 AM, Dietary Aide 1 was seen adding mozzarella cheese to a tray of spinach without measuring it and used her hand to add the cheese. During an interview later that day, Dietary Aide 1 stated she did not measure the mozzarella cheese added to the spinach for the spinach au gratin and acknowledged that it should have been measured to meet the requirements of a therapeutic diet. The Dietary Service Supervisor stated that spinach au gratin was served for lunch and that 32 residents received the dish with cheese. Review of the facility's Standardized Recipes policy showed that standardized recipes shall be developed and used in food preparation, and the supervisor stated the mozzarella cheese used for the spinach au gratin should have been measured.
Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the food service area in a clean and sanitary condition and failed to follow proper food handling procedures. During a kitchen observation and interview, the refrigerator was found to have trays of sandwiches placed on top of gallons of milk, leaving insufficient space for proper internal air flow and blocking the refrigerator vent. The Dietary Supervisor stated the refrigerator was overstocked and that the placement of the sandwiches on top of the milk blocked the vent. During the same kitchen observation, the can opener was observed to have chipped metal along the blade area and a hair-like residue from a green cleaning pad. The Dietary Supervisor acknowledged the chipped metal and residue. The facility’s Policy and Procedures for Food Receiving and Storage stated refrigerated foods should be stored to promote adequate air circulation and that refrigerators should not be overcrowded, and the Sanitation policy stated utensils and equipment must be clean, maintained in good repair, and free from chipped areas that may affect use or proper cleaning. The facility did not follow these policies because the refrigerator was overcrowded and the can opener was chipped with residue present.
Failure to Coordinate Level II PASARR Evaluation
Penalty
Summary
The facility failed to coordinate a Level II PASARR evaluation for one sampled resident, who was admitted with diagnoses including schizophrenia, psychosis, and bipolar disorder. The resident’s MDS dated 4/2/2026 showed moderate impairment in cognitive skills for daily decision making, setup assistance with eating and showering, and independence with oral care, toileting, personal hygiene, dressing, and footwear. Medical records showed a positive PASARR Level I screening on 4/30/2025. During a concurrent interview and record review on 4/15/2026, the ADON stated the Level II PASARR was attempted on 5/4/2025 but was not completed because facility staff were unresponsive to two or more separate attempts from the Level II evaluator within 48 hours of the Level I screening. The ADON stated she was the contact person for PASARR screenings and that the RNS should have taken the call when she was not available. The DON stated the facility should be available to coordinate with the Level II PASARR evaluator to ensure the resident’s behavior was being managed, followed by behavioral services, and monitored to ensure treatment was effective and the resident was appropriately placed. The facility policy stated that all admissions would have the appropriate PASARR completed.
Unsafe Fan Placement in Resident Room
Penalty
Summary
The facility failed to keep a resident’s room free from accident hazards when a box fan was observed placed sideways on top of a 4-wheeled walker in the foot area of Resident 13’s room. Resident 13 had diagnoses including unsteadiness on the feet, lack of coordination, and extrapyramidal and movement disorder, and the MDS dated 3/9/2026 indicated moderate impairment in cognitive skills for daily decision making. The resident also required partial/moderate assistance with showering and supervision with toileting hygiene, oral hygiene, upper and lower body dressing, personal hygiene, sit to lying, and walking. During observation, Resident 13 was seen walking back and forth to the closet near the box fan, which had a taped cut-out piece of cardboard attached to the front. CNA 3 verified the fan was sitting sideways on top of the walker and stated it should not have been placed there for safety. The MSS stated placing a box fan on a walker was unacceptable and that the fan should be on the floor because it could fall and injure someone; the MSS also stated the taped cardboard could cause the fan to overheat and potentially start a fire. The ADON stated the cardboard was a fire hazard and that placing the fan on the walker could pose a safety risk because the fan could fall and the resident could trip and fall from it.
Bedside Water Not Provided to Resident at Risk for Poor Fluid Intake
Penalty
Summary
Facility staff failed to ensure Resident 35 had bedside water available to maintain hydration. Resident 35 was admitted with diagnoses including hyperlipidemia, hemiplegia, TIA, and cerebral infarction without residual deficits. The MDS dated 4/6/2026 indicated the resident was cognitively moderately impaired and required setup or clean-up assistance with eating, oral hygiene, and personal hygiene. The care plan revised 4/9/2026 identified the resident as at risk for UTI related to potential poor fluid intake and included interventions to offer fluids between meals, during activities, during medication pass, and during meals. During an observation and interview on 4/14/2026, Resident 35 was seen walking in the bathroom with an empty water pitcher, filling it with tap water, and drinking it. The resident stated that CNAs and facility staff did not refill the water or offer something to drink between mealtimes. On 4/15/2026, CNA 1 stated that offering and refilling water between meals and as needed should be done by facility staff for all residents, and later confirmed there was no pitcher of water at bedside for Resident 35. The Administrator stated tap water was not sterile and could pose risks to residents and make them sick, and also stated staff should provide adequate fluids to all residents to prevent dehydration. The facility policy on Hydration stated staff will provide supportive measures such as supplemental fluids for minor, uncomplicated fluid and electrolyte imbalance.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that one of two medication carts was locked and unattended in the hallway, as required by the facility policy. During a medication pass observation, an LVN left the medication cart unlocked before going into Room A to administer medications, while three residents were observed walking past the cart in the hallway. In an interview, the LVN stated she forgot to lock the cart before leaving it and acknowledged that residents or other staff could access and take medications from the unlocked cart. The Administrator stated the medication cart should be kept closed, locked, and secured when not in use or unattended, and the facility policy stated the cart is to be kept closed and locked when out of sight of the medication nurse or aide.
Missing Hospice Orders and Visit Schedule in Resident Binder
Penalty
Summary
Facility staff failed to coordinate hospice care with Hospice Agency for one sampled resident who was admitted with diagnoses including malignant neoplasm of the maxillary sinus, lower lobe of the left lung, and basal cell carcinoma of the skin of other parts of the face. The resident's MDS dated 4/2/2026 indicated moderate impairment in cognitive skills for daily decision making, setup assistance with eating and showering, and independence with oral care, toileting, personal hygiene, upper and lower body dressing, and footwear. A physician's order dated 4/3/2026 indicated the resident may be admitted to Hospice 1 service. During observation and interview on 4/14/2026, the resident was lying in bed and stated he was unsure how often hospice staff came to see him. Review of the resident's Hospice 1 binder showed it did not include an April 2026 calendar of expected hospice visits or a physician certification and recertification of the terminal illness. During later review with LVN 3 and the ADON, both stated the binder should contain the hospice order, the plan of care, the frequency of visits by the hospice interdisciplinary team, and a calendar of scheduled visits so facility staff could coordinate care with hospice staff and follow up if visits were missed. RN 1 stated the physician's order with the frequency of visits by each hospice IDT member should be in the binder so staff would know when visits were expected and ensure the resident received ordered services. The DON also stated the schedule of hospice IDT visits should be in the binder to support collaboration between hospice and facility staff. The facility's Hospice Program policy stated the facility is responsible for meeting the resident's personal care and nursing needs in coordination with the hospice representative and obtaining the most recent hospice plan of care, hospice election form, and physician certification and recertification of the terminal illness specific to each resident.
Uncovered GT Feeding Port Touched the Floor
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to observe infection control measures for one sampled resident receiving tube feeding. Resident 7 had an admission record showing diagnoses that included gastrostomy, dysphagia, and type 2 diabetes mellitus. The resident's MDS dated 2/6/2026 indicated moderate impairment in cognitive skills for daily decision making and dependence for oral hygiene, toileting hygiene, and personal hygiene, with substantial/maximal assistance needed for upper and lower body dressing. During an observation on 4/14/2026 at 9:48 AM, Resident 7's GT feeding port was observed touching the floor and without a cap covering it. During a concurrent observation later that day with LVN 3, the LVN confirmed the GT feeding port was touching the floor and missing the cap, then picked up the tube, wiped the feeding port with an alcohol pad, and covered it with the cap. LVN 3 later stated that GT feeding parts should not touch the floor for infection control reasons and should be covered with a cap when not in use. The IPN also stated that an uncovered GT feeding port touching the floor was unacceptable and posed an infection risk. The facility's policy on Enteral Feedings-safety Precautions stated to maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas.
Failure to Offer Annual Influenza Immunization
Penalty
Summary
The facility failed to offer and provide influenza immunization for one sampled resident, Resident 13, who was reviewed for infection prevention, control, and immunizations. Resident 13’s admission record showed the resident was initially admitted and later readmitted to the facility with diagnoses including disorder involving immune mechanism, chronic kidney disease, and type 2 diabetes mellitus. The Minimum Data Set dated 3/9/2026 indicated Resident 13 had moderate impairment in cognitive skills for daily decision making and required assistance or supervision with multiple activities of daily living, including showering, toileting hygiene, oral hygiene, dressing, personal hygiene, sit to lying, and walking. During a concurrent interview and record review on 4/16/2026, the Infection Prevention Nurse reviewed the influenza immunization record from 2015 through 2026 and stated Resident 13’s influenza immunization was historical, showing the resident received the vaccine on 8/21/2018. The IPN stated there was no influenza immunization offered to Resident 13 since admission. During an interview on 4/17/2026, the ADON stated influenza immunizations should be offered to residents to ensure they are protected from flu virus and that vaccination can reduce the risk of severe illness. The facility policy titled Influenza Vaccine, dated 1/21/2026, stated all residents without medical contraindications are to be offered the influenza vaccine annually and that between October 1 and March 31 the vaccine shall be offered unless medically contraindicated or already immunized.
Failure to Offer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to offer and provide COVID-19 immunization for one sampled resident, Resident 13, in accordance with the facility policy. Resident 13 was initially admitted to the facility and later readmitted with diagnoses that included a disorder involving the immune mechanism, chronic kidney disease, and type 2 diabetes mellitus. The resident’s MDS dated 3/9/2026 indicated moderate impairment in cognitive skills for daily decision making and that the resident required assistance or supervision with several activities of daily living, including showering, toileting hygiene, oral hygiene, dressing, personal hygiene, sit-to-lying, and walking. The MDS also indicated Resident 13 was not up to date with COVID-19 vaccination. During interview and record review on 4/16/2026, the Infection Prevention Nurse stated Resident 13’s COVID-19 immunization was historical, showing receipt on 1/19/2022, and stated there was no COVID-19 immunization offered to the resident upon admission or afterward. Resident 13 stated there were no records or documented evidence that the vaccine had been offered. The facility’s policy titled, Coronavirus Disease (COVID-19)- Vaccination of Residents, revised 8/2025, stated residents are offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, and that eligible residents are offered the vaccine.
Call Light Not Within Resident's Reach
Penalty
Summary
The facility failed to ensure that the call light was within arm's reach for one sampled resident in the room and bathing environment. Resident 2 was admitted and later readmitted with diagnoses including unsteadiness on the feet, lack of coordination, and an anxiety disorder. The resident's MDS dated 4/1/2026 indicated moderate impairment in cognitive skills for daily decision making and independence with eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. The care plan identified the resident as at risk for fluctuating ADLs due to mood and behavior and at risk for falls related to poor balance from psychotropic drug use, with an intervention to ensure the call light was within reach. During a concurrent observation and interview on 4/14/2026 at 8:57 AM, Resident 2 was lying in bed watching television, and the call light was found on the left side of the bed on the floor until CNA 1 clipped it within reach. During another observation later that day at 1:54 PM, the resident was again lying in bed with the call light not within reach and still on the floor. CNA 2 stated the call light should be within the resident's reach so the resident could alert staff if needed, and the ADON stated call lights should be close to residents and within reach so they could call for help or emergencies. The facility policy titled Answering the Call Light stated the call light should be accessible to the resident when in bed.
Inaccurate MDS Coding of Resident’s Walking Ability
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident’s functional ability related to walking. The resident had diagnoses including schizophrenia, Parkinson’s disease, and difficulty walking, and the MDS dated [DATE] documented that the resident required partial/moderate assistance to walk 10 feet. However, interviews with the Restorative Nurse Assistant and a CNA indicated that since admission the resident had been walking with staff supervision only and did not require a cane, walker, or physical assistance, and there had been no change in the resident’s level of assistance with walking. The resident was observed being supervised by staff in the hallway after a smoke break, consistent with the staff reports of supervision-level assistance. During a concurrent record review and interview, the MDS nurse confirmed that the resident actually required supervision with walking and acknowledged that the MDS had been incorrectly coded as needing partial/moderate assistance. The MDS nurse stated that the functional ability for walking should have been coded as supervision and affirmed the importance of MDS accuracy for developing and implementing an individualized care plan. The facility’s policy on certifying accuracy of the resident assessment, reviewed on 2/26/2026, stated that any person completing a portion of the MDS must sign and certify the accuracy of that portion, underscoring that the inaccurate coding of the resident’s walking ability was not consistent with the documented expectations for MDS completion.
Failure to Prevent Resident-to-Resident Physical Abuse During One-on-One Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident despite known risks and existing one-on-one monitoring orders. Resident 1, who had moderately impaired cognitive skills and required extensive assistance with ADLs, was in a hallway near the patio area on 3/9/2026 when an altercation occurred with Resident 2. Resident 1’s records showed diagnoses including encephalopathy, anxiety disorder, and schizoaffective disorder. At the time of the incident, Resident 1 approached Resident 2 in a wheelchair, said “excuse me,” and then made a verbal comment reported by staff as “Fuck you!” directed at Resident 2. Immediately afterward, Resident 2 punched Resident 1 in the face, causing a superficial skin tear measuring 0.4 cm on the left upper lip with slight bleeding. Resident 2’s records indicated diagnoses including iron deficiency anemia, paranoid schizophrenia, and vascular dementia, with moderately impaired cognitive skills and a need for supervision or assistance with several ADLs. Resident 2 had a documented history of aggressive behavior and prior physical interaction with another resident. His care plan, revised on 2/25/2026, identified him as being at risk for stress-related suicidal ideation and aggressive behavior, with interventions that included moving him closer to the nurse’s station, placing him on one-on-one sitter, closely monitoring him when in an aggressive posture, anticipating care needs, intervening to protect the rights and safety of others, and restricting his access to other residents for safety. A physician’s order dated 2/17/2026 required one-on-one monitoring for Resident 2. On the day of the incident, CNA 1 was assigned to provide one-on-one monitoring for Resident 2 and was responsible for supervising his behavior and ensuring his safety. CNA 1 was standing at a clothes rack selecting clothing for Resident 2 while Resident 2 sat in his wheelchair next to her. CNA 1 reported that her attention was on the clothes rack and that she had clothes in her hands when Resident 1 approached and exchanged words with Resident 2. Multiple staff interviews, including with the DON, DSD, and another CNA, confirmed that one-on-one monitoring required continuous visual attention and that residents on such monitoring should not be left unsupervised or unwatched because of the risk of unexpected movements and aggression. The DON acknowledged that CNA 1 was not watching Resident 2 at the time of the incident and stated that if CNA 1 had been watching him, the incident between the two residents could have been prevented. This lapse in supervision allowed Resident 2 to punch Resident 1, resulting in physical injury and possible psychosocial harm, and constituted a failure to protect the resident’s right to be free from abuse as required by the facility’s Abuse Prevention Program policy.
Failure to Involve Resident and Responsible Party in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and the resident’s responsible party were notified of and given the opportunity to participate in the development and implementation of the resident’s person-centered plan of care. The resident had been initially admitted and later readmitted with diagnoses including paranoid schizophrenia, bipolar disorder, and generalized anxiety disorder, and had a documented responsible party. Review of multidisciplinary care conference (MCC) records for two meetings showed no indication that the resident or the responsible party attended. The Minimum Data Set for the resident indicated moderately impaired cognitive skills for daily decision-making, independence with certain mobility tasks, and that participation in assessment and goal setting involved the resident and legal guardian. During concurrent interview and record review, the Interim Director of Nursing confirmed that there was a place in the MCC documentation to record notification of the responsible party, and acknowledged that the responsible party was not notified of the MCC held after readmission and was not notified of the quarterly MCC. The IDON explained that MCC meetings are used to discuss resident needs, changes, and recommendations to the plan of care, and that the responsible party needed to be included so they would be aware of the resident’s status and able to contribute to the plan of care. The facility’s policy on interdisciplinary care planning stated that the resident, family, and/or legal representative or surrogate are encouraged to participate in the development and revisions of the resident’s care plan, but this did not occur for this resident and responsible party for the identified MCCs.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from a resident’s court-appointed conservator prior to initiating three psychotropic medications. The resident had diagnoses including anxiety disorder, depression, and schizoaffective disorder and was readmitted to the facility with these conditions. The physician ordered Paliperidone ER 6 mg twice daily for schizoaffective disorder, Haldol 5 mg IM every eight hours as needed for schizoaffective disorder, and Buspirone 30 mg twice daily for anxiety disorder. The Minimum Data Set indicated the resident had intact cognitive skills for daily decision-making and required varying levels of assistance with activities of daily living. The Medication Administration Record showed that Paliperidone and Buspirone were administered on multiple occasions and Haldol was administered once. During interviews, an LVN stated that the resident’s three psychotropic medications should have had complete informed consent before administration and that the conservator should have been informed of the risks and benefits and asked for consent. In a concurrent record review and interview, the DON confirmed that there was no signed informed consent in the resident’s record and acknowledged that an informed consent signed by the conservator was required for the use of psychotropic medications to inform the resident or conservator of the reason for treatment, the nature and seriousness of the illness, and to provide a choice to approve or decline the medications. Review of the facility’s Informed Consent policy, revised January 16, 2025, showed that when initiating a new order or increasing psychotropic drugs, the attending physician must obtain informed consent from the resident or responsible party. Despite this policy, informed consent was not obtained before the psychotropic medications were administered.
Failure to Document Hospice Notification for Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation regarding hospice notification when a resident refused psychotropic medications. A resident with diagnoses including paranoid schizophrenia and anxiety disorder, and with severe cognitive impairment per a recent MDS, required varying levels of assistance with ADLs such as showering, toileting, dressing, oral hygiene, and eating. During interviews, an LVN reported that she had notified hospice about this resident’s refusal of psychotropic medications but could not recall if she documented the notification. Review of the resident’s record did not show documentation of hospice being informed of the refusals. Additional interviews with another LVN and the DON confirmed that the facility’s practice and expectation were that licensed staff notify the physician or hospice when a resident refuses psychotropic or other medications, and that such notifications be documented in the resident’s progress notes so other staff are aware. The facility’s “Charting and Documentation” policy, revised July 2017, states that all services provided, progress toward care plan goals, and any changes in the resident’s condition must be documented in the medical record, and that the record should facilitate communication among the interdisciplinary team. The policy further requires that documentation be objective, complete, and accurate. The lack of documented hospice notification for the resident’s medication refusals was inconsistent with this policy and resulted in an inaccurate representation of the care provided.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse involving two residents to the California Department of Public Health (CDPH), the local ombudsman, and local law enforcement within the required two-hour timeframe after the allegation was made. One resident reported that another resident intentionally rammed a wheelchair into her arm and kicked her leg. The incident was reported by the resident to multiple staff members, including two LVNs and the Assistant Director of Nursing (ADON), who then notified the Director of Nursing (DON) and the Administrator (ADM). The staff initiated an investigation, which included reviewing closed-circuit television (CCTV) footage of the hallway where the incident allegedly occurred. Despite the initiation of an investigation and acknowledgment by staff that suspected abuse should be reported immediately or within two hours, the ADM and ADON decided not to report the incident to CDPH, the ombudsman, or law enforcement. Their decision was based on their review of the CCTV footage, which they stated did not show any contact between the two residents. As a result, no SOC 341 abuse reporting form was completed, and the required notifications were not made to the appropriate authorities as outlined in both facility policy and state regulations. The facility's policies clearly state that all alleged violations involving abuse must be reported promptly to local, state, and federal agencies, including the state licensing agency, ombudsman, and law enforcement, within two hours if the allegation involves abuse or results in serious bodily injury. Staff interviews confirmed awareness of these requirements, but the reporting did not occur because the ADM and ADON did not believe abuse had occurred based on their review of the CCTV footage, despite the resident's allegation and the initiation of an investigation.
Failure to Accurately Administer and Document Controlled Medications
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and did not ensure accurate documentation of controlled substances in the Medication Administration Record (MAR) for two residents. For one resident with a history of seizures, dementia, COPD, and bipolar disorder, the MAR indicated that Clonazepam was administered on two occasions. However, a review of the resident's bubble pack and Narcotic and Hypnotic Record showed that the medication was not actually given, as the count of tablets remained unchanged and there was no documentation of administration in the controlled substance log. The nurse had signed the MAR as if the medication was given, but the physical count and records did not support this. Similarly, for another resident with depression, anxiety disorder, and schizophrenia, the MAR showed that Lorazepam was administered, but the bubble pack and Narcotic and Hypnotic Record indicated that the medication was not dispensed, as the tablet count was unchanged and there was no documentation in the controlled substance log. The nurse had again signed the MAR as if the medication was given, but the actual count and records did not match. Both discrepancies were identified during a concurrent review and interview with facility staff, who confirmed that the medications should not have been charted as given if they were not administered. Facility policy requires that controlled medications be documented accurately in both the MAR and the Narcotic and Hypnotic Record, in accordance with federal and state regulations. The Director of Nursing and Assistant Director of Nursing were not aware of the discrepancies until the review, and acknowledged the importance of regular audits to ensure medications are administered and documented correctly. The failure to accurately document and administer controlled medications was confirmed through interviews, record reviews, and medication counts.
Failure to Document Medication Administration and Monitoring in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for three sampled residents. Licensed Vocational Nurses (LVN) did not document the administration of medications on the Medication Administration Record (MAR) for the 3 PM to 11 PM shift on a specific date. This lack of documentation included both the administration of prescribed medications and required monitoring, such as behavior and side effect assessments, for residents with complex medical and psychiatric conditions. Resident 2 had multiple diagnoses, including seizures, dementia, COPD, and bipolar disorder, and required various medications and behavioral monitoring. The MAR for this resident was left blank for several medications and monitoring parameters during the identified shift. Similarly, Resident 3, who had severe cognitive impairment and required substantial assistance with daily activities, also had blank MAR entries for multiple medications and required monitoring. Resident 4, with diagnoses including COPD, hypertensive heart disease, and schizophrenia, had missing documentation for both medication administration and vital sign monitoring during the same shift. Interviews with facility staff confirmed that the standard practice is to document medication administration and monitoring immediately after providing care. Both the Administrator and Assistant Director of Nursing acknowledged that the assigned LVNs did not follow facility policy, resulting in incomplete medical records for the affected residents. Facility policies reviewed by surveyors emphasized the importance of timely and accurate documentation of all services provided, including medication administration and monitoring, to ensure proper communication and continuity of care.
Failure to Maintain Kitchen Safety During Ceiling Leak and Repairs
Penalty
Summary
The facility failed to maintain proper food handling practices and kitchen safety standards, as evidenced by the continued use of a kitchen with a large, uncovered hole in the ceiling above food preparation and tray transport areas. The hole, measuring three by four feet, exposed pipes, drywall, wood framing, and a bent steel panel, and was located directly above the handwashing sink and food tray transport rack. Observations confirmed that food trays prepared for nearly all residents were transported under this exposed area, and additional leaks in the kitchen ceiling were being managed with wet towels and pans on the floor. Interviews with facility staff revealed that the water leak and subsequent ceiling damage had been present for several days, with the kitchen remaining in use throughout this period. The Assistant Director of Nursing and the Maintenance Supervisor provided conflicting accounts regarding when the leak and ceiling removal occurred, but both confirmed that food preparation continued despite the unsafe conditions. The Administrator relied on the opinion of plumbing contractors regarding kitchen safety, without consulting the Dietary Supervisor or other food safety professionals, and confirmed that food preparation continued even after the plastic tarp previously covering the hole was removed. The Dietary Supervisor stated that the kitchen should not be used for meal preparation when the ceiling hole was uncovered, citing the risk of contaminants falling into food. Despite this, the facility lacked a specific kitchen emergency plan or policy addressing situations where the kitchen is under construction or deemed unsafe for food preparation. The only relevant policy in place pertained to general disaster emergency preparedness, which did not cover the specific circumstances of kitchen safety during repairs.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its policy and procedure for Abuse Investigation and Reporting for two residents. Resident 1, who has schizophrenia and moderate cognitive impairment, was found with scratches on his face and reported that someone else had caused them. Despite this, the facility did not conduct a thorough investigation or report the incident to the State Survey Agency, ombudsman, or local law enforcement within the required two-hour timeframe. The facility's policy mandates immediate reporting and investigation of such incidents, but this was not adhered to. Resident 2, diagnosed with schizoaffective disorder and pulmonary edema, had a history of aggressive behavior and was placed on a 1:1 supervision order due to verbal and physical aggression. However, the facility failed to ensure that Resident 2 received the required supervision, as evidenced by an altercation with Resident 1. Staff interviews revealed that the altercation was not reported to the appropriate authorities, and Resident 2 was left unsupervised at times, contrary to the physician's order. Interviews with facility staff, including CNAs and LVNs, highlighted a lack of communication and adherence to reporting protocols. Staff members were aware of the incidents but did not report them to the administrator or relevant agencies. The facility's policies on unusual occurrence reporting and abuse investigation were not followed, resulting in a failure to protect residents from potential harm and ensure their safety.
Failure to Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of physical abuse involving a resident who was found with scratch marks on the right side of his face. The resident, who has a diagnosis of schizophrenia and moderate cognitive impairment, reported that someone else had caused the scratches. Despite this, the facility did not report the incident to the appropriate authorities or conduct a proper investigation as required by their policies. Another resident, who has a history of aggressive behavior and was noted to be verbally and physically aggressive on the same day, was involved in an altercation with the first resident. This resident was placed on one-to-one monitoring due to his behavior, but the facility staff failed to ensure constant supervision. The staff did not report the altercation or the injuries sustained by the first resident to the administrator or state agency, as required by the facility's policies. Interviews with staff revealed that there was a lack of communication and reporting of the incident. A CNA reported the altercation to licensed nurses, but they did not take further action. The facility's policy requires immediate reporting of abuse or unknown injuries to the administrator and relevant agencies, but this was not done. The failure to follow these procedures compromised the safety of the resident and placed them at risk for further abuse.
Improper LALM Settings for Two Residents
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALM) for two residents were set according to the physician's orders and the operator's manual instructions. Resident 11, who was admitted with multiple diagnoses including type 2 diabetes mellitus and unspecified dementia, had a physician's order for the LALM to be set at 202 pounds. However, observations revealed that the LALM was set at 280 pounds and later at 190 pounds, which did not align with the physician's order. This discrepancy in settings was confirmed by a Certified Nursing Assistant (CNA), who stated that the bed settings are managed by the charge nurse, treatment nurse, or supervisor. Resident 29, who was admitted with conditions such as unspecified protein calorie malnutrition and pressure ulcers, had a physician's order for the LALM to be set at 129 pounds. Observations showed that the LALM was set at approximately 300 pounds, 160 pounds, and 150 pounds on different occasions, none of which matched the prescribed setting. Interviews with CNAs and Licensed Vocational Nurses (LVNs) confirmed that the responsibility for setting the LALM falls on the licensed nurses, and the settings should be based on the resident's weight as per the physician's order. The facility's policy and procedure, as well as the operator's manual for the LALM, emphasize the importance of setting the mattress according to the resident's weight to prevent skin damage and relieve pressure. The failure to adhere to these guidelines placed the residents at risk of poor wound healing and deterioration of current pressure ulcers. The report highlights the lack of compliance with physician's orders and the facility's own procedures, which could potentially lead to adverse outcomes for the residents involved.
Failure to Implement Smoking Safety Policy
Penalty
Summary
The facility failed to implement its smoking policy for three residents, identified as Residents 4, 14, and 152, who were observed smoking without the required safety aprons. Resident 4, admitted with diagnoses including schizophrenia and anxiety, was noted to have moderately impaired cognitive skills and required supervision for certain activities. Despite a care plan indicating the need for a smoking apron, Resident 4 was observed smoking without one and stated that it was never offered. Interviews with the Activity Director and MDS Nurse confirmed that Resident 4 never used a smoking apron, and there was no documentation of refusal. Resident 14, with diagnoses of schizophrenia, anxiety, schizoaffective disorder, and Intermittent Explosive Disorder, also required a smoking apron as per their smoking safety assessment. However, Resident 14 was observed smoking without an apron while holding a stuffed toy. The Activity Director and MDS Nurse confirmed that Resident 14 never used a smoking apron, despite the assessment indicating its necessity for safety. Resident 152, diagnosed with schizoaffective disorder, anxiety, and hallucinations, was deemed not competent to understand their medical condition. Their smoking safety evaluation indicated the need for supervision and a smoking apron. However, Resident 152 was observed smoking without an apron, and the care plan for smoking was initiated later than it should have been. The facility's policy required smoking safety evaluations and care plans to be in place, but these were not adequately implemented for the residents involved.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, Resident 11 and Resident 37, which could lead to delayed assistance and potential harm. Resident 11, who was severely impaired in cognitive skills and required substantial assistance for activities of daily living, had a soft touch call light placed out of reach on the top left side of the bed. Observations and interviews with CNAs revealed that Resident 11 could not reach or use the call light, which was necessary for calling for help, especially given the resident's risk for falls and inability to move independently. Resident 37, who had moderately impaired cognition and required assistance for various activities, also had a call light that was not within reach. The call light was clipped to a light pull string behind the bed, making it inaccessible. Interviews with staff, including the DON, confirmed that the call light should have been within easy reach to allow the resident to call for help in case of emergencies. The facility's policy and procedure on answering call lights emphasized the importance of having call lights within easy reach of residents. However, the observations and interviews indicated that this policy was not followed for Residents 11 and 37, leading to the deficiency. The staff acknowledged the importance of the call lights being accessible and the potential risks associated with them being out of reach.
Failure to Notify Physician of Resident's Aggressive Behavior
Penalty
Summary
The facility failed to inform the physician of a change in condition for one of the residents, identified as Resident 152, who exhibited increased aggression and physically assaulted a certified nurse assistant (CNA). Despite the incident occurring on 3/18/2025, where Resident 152 attacked CNA 5 without apparent reason, the attending physician was not notified of this significant change in behavior. The facility's policy and procedure require that any change in a resident's condition, such as physical aggression, be promptly communicated to the resident's physician, but this was not adhered to in this case. Resident 152, who has a history of schizoaffective disorder, anxiety, and hallucinations, was admitted to the facility with instructions for staff to communicate medical conditions to a family member or guardian due to the resident's incompetence in understanding their medical condition. On the night of the incident, Licensed Vocational Nurse 4 (LVN 4) administered Haldol to manage the resident's aggression but failed to inform the physician about the change in condition. This oversight was confirmed during interviews with LVN 3 and LVN 4, who acknowledged the lack of communication with the physician, despite the facility's policy mandating such notification.
Improper Use of Germicidal Wipes on Resident's Skin
Penalty
Summary
The facility failed to ensure that germicidal disposable wipes, which are not intended for use on skin, were not used to sanitize the hands of a resident prior to providing nail care. During an observation, CNA4 was seen using these wipes on Resident 11's hands before clipping their nails, despite the wipes being designed for disinfecting hard, non-porous surfaces only. The Director of Nursing and the Infection Prevention Nurse confirmed that these wipes should not be used on residents' skin as they can cause harm, especially to those with fragile skin. Resident 11, who was admitted with diagnoses including type 2 diabetes mellitus, unspecified dementia, and bipolar disorder, was noted to be severely impaired in cognitive skills and dependent on staff for activities of daily living. The facility's policy for nail care, which includes washing hands with soap and water, was not followed. Instead, the CNA used germicidal wipes, which could potentially lead to skin irritation and harm, particularly given the resident's condition and dependency on staff for care.
Failure to Prevent Resident Elopement and Document Incident
Penalty
Summary
The facility failed to prevent the elopement of a resident who was assessed as at risk for elopement. The resident, who had been admitted with diagnoses including dementia with psychotic disturbance, hypertension, generalized muscle weakness, and unsteadiness on feet, was identified as at risk for elopement upon admission. However, the facility did not develop a care plan to implement interventions to prevent elopement, such as monitoring frequency and behavior documentation, immediately after the risk assessment. On the day of the incident, the resident eloped from the facility, and there was no documented evidence of family or physician notification. The resident was found later that day by a bystander and returned to the facility by the police. Despite the incident, there was no documentation in the resident's medical record regarding the elopement, examination for injuries upon return, or any communication with the family or physician about the incident. Interviews with facility staff revealed that the Director of Nursing was unaware of the incident due to being off duty, and the care plan for elopement risk was not initiated until after the incident occurred. The facility's policies and procedures for wandering and elopement, as well as for accidents and incidents, were not followed, leading to a lack of documentation and communication regarding the resident's elopement and subsequent return.
Incorrect G-tube Formula Administered to Resident
Penalty
Summary
The facility failed to administer the correct gastrostomy tube (g-tube) formula feeding as ordered by the physician for a resident, identified as Resident 102. The resident was admitted with diagnoses including type 2 diabetes, dysphagia, schizophrenia, and shortness of breath. The resident's care plan required the administration of Glucerna, a nutritional supplement for people with diabetes, via g-tube feeding. However, during an observation, it was noted that the resident was receiving Jevity instead of Glucerna, which was not in accordance with the physician's orders. The facility's policy and procedure for enteral tube feeding required verification of the physician's order and checking the tube feeding label against the order before administration. The Director of Nursing confirmed that staff should ensure the feeding matches the ordered feeding and that a new order must be obtained if a different supplement is to be administered. The incorrect administration of Jevity instead of Glucerna had the potential to cause uncontrolled blood sugar and inappropriate nutrition for Resident 102, which could worsen the resident's health condition.
Failure to Conduct Monthly Medication Regimen Review
Penalty
Summary
The facility failed to conduct a monthly Medication Regimen Review (MRR) for one of the sampled residents, Resident 16, as required by the facility's medication policy and procedure. Resident 16 was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, bipolar disorder, and dementia. The resident's clinical physician orders indicated prescriptions for Aricept, Zyprexa, Namenda, and Klonopin. However, there was no documented evidence of an MRR being conducted for Resident 16 from January to March 2025, as confirmed by the Director of Nursing (DON). The DON acknowledged that the MRR was not conducted for Resident 16 in February 2025, which is a requirement to ensure the resident's safety and to determine the necessity of continued medication use. The facility's Consultant Pharmacist (CP) also confirmed that state law mandates monthly MRRs to safeguard residents from receiving unnecessary medications. The facility's policy and procedure, titled Medication Therapy, stipulates that the pharmacist should review each resident's medication regimen monthly. The failure to conduct the MRR for Resident 16 meant that the pharmacist did not assess for adverse reactions or the need to continue prescribed medications.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for Resident 102 by not ensuring that the electronic medication administration record (eMAR) was signed after administering the resident's 8 AM medications on March 19, 2025. This oversight was identified during a review of the resident's medication administration record, which showed that several medications due at 9 AM were not signed off by the licensed nurse. The medications included Losartan Potassium, Carvedilol, Divalproex sodium, Carbidopa-Levodopa, Insulin Lispro, Ipratropium-Albuterol, and Lactobacillus. Resident 102 was admitted to the facility with diagnoses including schizophrenia, seizure disorder, dysphagia, and gastrostomy status. The resident's Minimum Data Set (MDS) indicated intact cognitive skills for daily decision-making and required varying levels of assistance for daily activities. The failure to document the administration of medications could lead to potential medication errors, such as duplication or omission, affecting the resident's overall well-being. During interviews, Licensed Vocational Nurse (LVN) 1 admitted to administering the medications but not signing the eMAR due to being rushed. The facility's policy and procedure require that the individual administering the medication initials the resident's MAR immediately after giving each medication. The MDS nurse confirmed that the lack of signature indicated the medications were not documented as administered, which is against the facility's policy for accurate documentation.
Failure to Label Tubing Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not labeling the oxygen and enteral feeding tubes for two residents, Resident 29 and Resident 102. For Resident 29, the enteral feeding tube was observed without a label indicating the date it was opened or initially used. This oversight was confirmed during an interview with the Infection Preventionist Nurse (IPN), who stated that the enteral feeding tube should be labeled with the date it was started to ensure it is changed every 24 hours to prevent contamination and potential infection. Resident 29, who was admitted with conditions including protein calorie malnutrition and dysphagia, was found to have an unlabeled enteral feeding tube during an observation. The Director of Nursing (DON) confirmed that the lack of labeling could lead to the tube not being changed in a timely manner, increasing the risk of infection. The facility's policy requires that enteral feeding tubes be labeled with the date of initial use to prevent bacterial growth and potential harm to the resident. Similarly, Resident 102's oxygen tubing was not labeled with the date it was initially used, as observed during a facility visit. The Director of Staff Development (DSD) and a Licensed Vocational Nurse (LVN) both acknowledged the absence of labeling, which is necessary for infection control. The IPN explained that oxygen tubing should be changed weekly or if it touches the floor, as it can collect bacteria over time, posing a risk of respiratory infection. The facility's policy mandates that both enteral feeding and oxygen tubing be labeled to prevent the development and transmission of infections.
Improper Waste Management and Potential Health Risks
Penalty
Summary
The facility failed to properly manage waste disposal, leading to two garbage dumpsters being overfilled and uncovered, with additional trash left on the ground in the parking lot. This was observed on multiple occasions, with trash including decomposable food waste and yard waste, as well as dry materials like glass, paper, and cloth. The facility's policy requires that garbage and trash not accumulate and be removed daily, but this was not adhered to, resulting in trash being left outside overnight. Interviews with staff revealed that the trash was left on the ground due to the dumpsters not being returned promptly after being emptied by the garbage pick-up company. Staff members, including the Dietary Staff Supervisor and Housekeeper Staff, acknowledged that leaving trash on the ground could attract vermin and pests, posing a potential health risk to residents and staff. The Infection Preventionist also confirmed that leaving trash outside could lead to the spread of bacteria and disease, especially since the area is near a gazebo used by residents. The facility's policies on pest control, waste disposal, and maintaining a homelike environment were not followed, as trash was allowed to accumulate outside, creating an unsanitary and potentially hazardous environment. The facility administrator admitted that staff were instructed to place trash on the ground when dumpsters were unavailable, further contributing to the deficiency. This failure to manage waste disposal effectively could lead to contamination and health risks for residents and staff.
Incomplete Staffing Information Posting
Penalty
Summary
The facility failed to ensure that staffing information was complete and posted in a visible and prominent place daily, as required by their policy and procedure titled 'Posting Direct Care Daily Staffing Numbers.' During an observation and interview with the Director of Staff Development (DSD), it was noted that the Census and Direct Care Service Hours Per Patient Day (DHPPD) form, which provides staffing information for the day, was incomplete. The form, posted near the facility's entrance, was missing documentation showing the actual staffing, and only the projected staffing was completed. The DSD confirmed that the DHPPD was not completed on two specific days, and the incomplete or missing posting meant that staff, residents, and visitors were not informed about the facility's actual staffing levels. Further interviews and record reviews revealed that the facility's policy required the posting of the number of nursing personnel responsible for providing direct care to residents on a daily basis for each shift. The policy specified that the information should include the actual time worked during a shift for each nursing staff and the total number of licensed and unlicensed staff. Additionally, staffing information was required to be posted within two hours of the beginning of each shift. The DSD acknowledged that the DHPPD was incomplete and had not been updated since the weekend, indicating a failure to adhere to the facility's policy and procedure for posting staffing information.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required 80 square feet per resident in multiple resident bedrooms for one of the rooms, identified as Room A. During an observation and initial tour, it was noted that Room A did not meet this requirement, as it measured 158.2 square feet for two residents, resulting in only 79.1 square feet per resident. This deficiency was confirmed through a review of the facility's Client Accommodation Analysis Form and a Room Waiver Request, both dated the same day as the observation. The waiver request indicated that the facility believed there was enough space to provide for each resident's care, dignity, and privacy, and that the room's size did not adversely affect the residents' health and safety. The Administrator verified that all other rooms met the required square footage per resident, and there had been no complaints about Room A being too small. Random observations and interviews conducted over several days revealed that Room A had adequate ventilation and lighting, bathroom and toilet facilities, privacy curtains, and sufficient space for residents to move freely, including those in wheelchairs. Residents in Room A expressed no complaints regarding the space, and it was observed that there was enough room for staff to provide care and for residents to store their belongings.
Failure to Report Alleged Sexual Abuse in a Timely Manner
Penalty
Summary
Facility 1 failed to report an allegation of sexual abuse involving two residents within the required 2-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement. The incident involved Resident 1, who was accused of non-consensual sexual contact with Resident 2. The failure to report was discovered when local law enforcement and the ombudsman visited Facility 1 to investigate the allegation. The facility's staff, including a Licensed Vocational Nurse and an Infection Preventionist Nurse, were aware of the police visit but did not take the necessary steps to report the incident as required by the facility's policy. Resident 1, who was admitted to Facility 1 with diagnoses of schizophrenia and anxiety, had moderately impaired cognitive skills for daily decision-making. Resident 2, who was admitted with diabetes mellitus type 1 and schizoaffective disorder, had intact cognitive skills for daily decision-making. The incident came to light when Resident 2, after being transferred to another facility, reported the alleged abuse to the ombudsman, who then involved the police. The facility's policy on abuse investigation and reporting, revised in July 2017, mandates that all reports of resident abuse, neglect, and other related issues be promptly reported to the appropriate agencies and thoroughly investigated. However, the Administrator admitted to not initiating an investigation or reporting the incident to the State Survey Agency when the allegation was first made known. This oversight had the potential to result in unidentified abuse within the facility and a failure to protect other residents from harm.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, resulting in an altercation where Resident 1 struck Resident 2 on the head, causing a lump on Resident 2's head and swelling on Resident 1's hand. Resident 1, who has a history of schizoaffective disorder, bipolar disorder, and other mental health conditions, experienced a behavior exacerbation with hallucinations, leading to the incident. Despite having a care plan in place to manage Resident 1's aggressive behaviors, the interventions were not effective in preventing the physical altercation. Resident 2, who suffers from dementia and other mental health issues, was identified as having severely impaired cognitive skills and required supervision for daily activities. The facility's staff, including the Administrator and Director of Nursing, acknowledged Resident 2's aggressive and unpredictable behavior, which included episodes of spitting, hitting, and other disruptive actions. However, there was a lack of documentation and appropriate interventions to address these behaviors, which contributed to the incident with Resident 1. Interviews with facility staff revealed that Resident 2's behaviors were not adequately monitored or documented, and there was no care plan in place to manage his aggressive tendencies. The facility's policy on abuse prevention and management was not effectively implemented, as evidenced by the failure to protect residents from abuse and to address factors that could lead to abusive situations. The lack of appropriate interventions and monitoring for both residents' behaviors resulted in the physical altercation and subsequent injuries.
Failure to Readmit Residents After Evacuation
Penalty
Summary
The facility failed to readmit three residents after they were evacuated due to an emergency. Despite being cleared to repopulate, the facility did not allow these residents to return, resulting in them staying at other facilities without the knowledge or consent of their responsible parties. This action was taken without proper documentation or communication with the residents' representatives, violating the facility's policies on transfer and discharge. Resident 1, who has dementia and moderate cognitive impairment, was transferred to another facility during the evacuation. The facility's administrator and LVN decided not to readmit her, believing the new facility was a better fit, but failed to inform or obtain consent from her responsible party. Similarly, Resident 2, with severe cognitive impairment and multiple diagnoses, was not readmitted, and the decision was communicated only through a voicemail, without proper documentation or consent from the conservator. Resident 3, who has intact cognition, was also not readmitted and was moved between facilities without the knowledge of her responsible party. The facility did not follow its own policy of notifying residents and their representatives about transfers and discharges, including the reasons and the right to appeal. This lack of communication and documentation placed the residents at risk for psychosocial harm and compromised their continuity of care.
Failure to Prevent Resident Fall Due to Inadequate Care Plan and Supervision
Penalty
Summary
The facility failed to prevent a fall of a resident who was at moderate risk for falls due to gait and balance problems. The resident's care plan was not updated to reflect the need for partial moderate assistance and contact guard assist (CGA) when ambulating, despite assessments indicating these needs. The Minimum Data Set (MDS) and Physical Therapy Treatment Encounter Notes (PT Note) completed in July 2024 highlighted the resident's requirement for assistance, but this was not incorporated into the care plan. On September 22, 2024, the resident was ambulating in the dining/activity room without the necessary assistance or supervision, as outlined in their MDS and PT notes. The resident used a wheelchair as a walker without staff support, leading to a fall. The incident resulted in the resident sustaining a left subcapital fracture, which required surgical intervention. Interviews with staff revealed a lack of awareness and implementation of the resident's need for assistance during ambulation. The facility's policies and procedures for care plans and fall risk management were not adhered to, as the resident's care plan was not person-centered and did not address the specific assistance required for ambulation. The failure to implement a resident-centered fall prevention plan contributed to the resident's fall and subsequent injury. Staff interviews confirmed that the necessary assistance was not provided, and the care plan did not reflect the resident's assessed needs.
Incomplete Transfer/Discharge Notice Lacks Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure the Notice of Transfer/Discharge was completed in its entirety for a resident, resulting in incomplete documentation. The resident, who was admitted with diagnoses including dementia and chronic obstructive pulmonary disease, was assessed to have intact cognition and required partial assistance for daily activities. The physician's orders indicated a potential discharge to an assisted living facility. However, the notice of transfer/discharge was missing essential contact information for the ombudsman, which is required to be included according to the facility's policy and procedure. During interviews and record reviews, it was confirmed that the notice lacked the ombudsman's contact details, such as address, phone number, fax, and email. The ombudsman and the resident's conservator both noted the absence of this information, which is necessary for the notice to be valid. The facility's policy clearly states that the omission of any required information renders the notice invalid, highlighting a deficiency in the facility's adherence to its own transfer and discharge rights policy.
Failure to Notify Physician and Responsible Party of Resident's Bruises
Penalty
Summary
The facility failed to notify the physician and the responsible party regarding a resident's bruises on the right flank area, as required by the facility's policy. The resident, who had severe cognitive impairment and required assistance with daily activities, was observed with bruises by multiple staff members, including two Licensed Vocational Nurses (LVNs) and a Certified Nursing Assistant (CNA). Despite these observations, the physician and the resident's responsible party were not informed, and the bruises were not investigated to determine their cause or to rule out potential abuse. The staff assumed the bruises were related to a previous fall, leading to a lack of proper documentation and notification as per the facility's policies on unusual occurrences and changes in a resident's condition or status. The resident's medical records did not show any evidence that the physician or the resident's representative was notified about the bruises. Interviews with the staff revealed that the bruises were noticed before a recent fall, but no action was taken to report or investigate them. The facility's Administrator confirmed that the physician and responsible party were not notified because the staff believed the bruises were related to an earlier fall. This failure to follow the facility's policies could potentially delay treatment and affect the resident's health and well-being.
Failure to Prevent Verbal Abuse
Penalty
Summary
The facility failed to prevent and stop an incident of verbal abuse when one resident called another resident racial slurs, attempted to hit, and spat at them. Resident 1, who has PTSD and anxiety disorder, reported feeling unsafe and anxious due to the actions of Resident 2. Despite Resident 1's cognitive intactness and ability to understand her medical condition and patient rights, the facility did not take immediate action to separate the residents or monitor them to ensure their safety. Resident 2, who has metabolic encephalopathy and cerebral infarction, was noted to be severely impaired in cognitive decision-making. On the night of the incident, Resident 1 approached the nurse's station to report the verbal abuse and physical threats from Resident 2. Multiple staff members, including an LVN and a CNA, witnessed Resident 2's abusive behavior but did not take adequate steps to de-escalate the situation or protect Resident 1. Interviews with various staff members, including the MDS Nurse, RN, and Social Services Director, confirmed that the incident should have been recognized as verbal abuse and that immediate separation and monitoring of the residents were necessary. The facility's policies on preventing resident abuse were not effectively implemented, as staff failed to protect Resident 1 from the abusive behavior of Resident 2.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required two-hour timeframe to the state agency, state ombudsman, and local law enforcement. The incident involved Resident 1, who has diagnoses of PTSD and anxiety disorder, and Resident 2, who has diagnoses of metabolic encephalopathy and cerebral infarction. Resident 1 reported to LVN 1 that Resident 2 used racial slurs, attempted to hit, and spat at her. Despite witnessing the incident, LVN 1 did not report it to the appropriate authorities and only documented it in the progress notes and informed the next shift. Interviews with various staff members, including LVN 1, CNA, MDSN, RN, and SSD, confirmed that the incident should have been reported as verbal abuse within two hours. The staff members acknowledged that the use of racial slurs and the attempt to hit and spit at Resident 1 constituted verbal abuse and that the failure to report the incident was a violation of the facility's policies and procedures. The facility's policies clearly state that any allegations of abuse must be reported immediately but no later than two hours if the alleged violation involves abuse. The review of the facility's policies and procedures on abuse prevention and reporting further emphasized the requirement to report any alleged violations involving abuse, neglect, exploitation, or mistreatment within the specified timeframe. The failure to report the incident involving Resident 1 and Resident 2 resulted in a deficiency, as the facility did not adhere to its own policies and federal requirements for timely reporting of abuse allegations.
Failure to Follow Advance Directive Policies
Penalty
Summary
The facility failed to follow their policy and procedure regarding advance directives for three residents. For Resident 45, the Advance Healthcare Directive (AHCD) Acknowledgement Form was not fully filled out, leaving it unclear whether the resident had executed an advance directive. This oversight was identified during a review of the resident's admission records and confirmed by the Social Services Consultant (SSC), who acknowledged that the form should have been completed to ensure the resident's rights and staff awareness of the resident's wishes in case of an emergency. For Resident 7, the facility did not ensure that a copy of the advance directive was readily accessible in the resident's medical chart. Despite the resident's significant cognitive impairments and dependency on assistance for daily activities, no advance directive was found in the medical records. The SSC confirmed the absence of the document and emphasized the importance of having it available to meet the resident's needs during emergencies, as per the facility's policy and procedure. Similarly, for Resident 8, the facility failed to obtain and include the advance directive in the resident's medical records. Although the Physician Orders for Life-Sustaining Treatment (POLST) indicated that an advance directive was available, it was neither in the physical chart nor the electronic record. The Social Services Director (SSD) admitted that the advance directive was never obtained from the resident's responsible party, and follow-up efforts were insufficient. This failure was contrary to the facility's policy, which mandates inquiry and documentation of advance directives upon admission and annual reviews to ensure they reflect the resident's current wishes.
Failure to Conduct Assessments and Obtain Orders for Restraints
Penalty
Summary
The facility failed to conduct proper assessments and utilize alternatives before using physical restraints on three residents. Resident 50, who had severe cognitive impairments and required substantial assistance for daily activities, was observed using a lap buddy in a wheelchair without a physician's order, consent, or care plan. The facility's policy mandates that restraints should only be used after other alternatives have been tried and with a physician's order and consent, which was not followed in this case. Resident 33, diagnosed with dementia and Alzheimer's disease, was observed in a Geri chair in the activity room without an active physician's order or consent. The Director of Staff Development assistant confirmed that Resident 33 had been using the Geri chair regularly without proper assessment or documentation. The facility's policy requires a pre-restraining assessment and a physician's order for the use of restraints, which was not adhered to for Resident 33. Similarly, Resident 37, who had severe cognitive impairments and was dependent on assistance for daily activities, was observed in a Geri chair in their room. The MDS Nurse confirmed that there was no physician's order, assessment, or care plan for the use of the Geri chair for Resident 37. The facility's policy clearly states that restraints should only be used with a physician's order and after obtaining consent, which was not followed in this instance as well.
Failure to Follow PASARR Recommendations
Penalty
Summary
The facility failed to follow through with the Preadmission Screening and Resident Review (PASARR) recommendations for two residents, leading to potential inappropriate placement and unidentified specialized services. Resident 27, who was readmitted with diagnoses including schizophrenia, diabetes mellitus, and hypertension, required a Level II PASARR evaluation as indicated by a PASARR completed on 1/10/2024. However, the Registered Nurse Supervisor responsible for overseeing PASARR did not follow through with the necessary evaluation. Resident 27's Minimum Data Set (MDS) indicated moderately impaired cognitive skills and the need for various levels of assistance with daily activities, as well as the use of antipsychotic medication. Similarly, Resident 14, admitted with encephalopathy and schizoaffective disorder, also required a Level II PASARR evaluation. Despite a PASARR 2 screening letter dated 2/25/2024 indicating the need for further evaluation, the process was not completed due to an incorrect assumption that the resident had been discharged. The Registered Nurse acknowledged the error and the importance of proper PASARR screening for mental health benefits. The facility's policy required the social services department to be notified and referrals to be made to the state PASARR representative, which was not adhered to in these cases.
Failure to Provide Appropriate Activities for Residents
Penalty
Summary
The facility failed to provide appropriate and consistent activities for two residents, Resident 7 and Resident 21, which had the potential to decrease their physical wellbeing, sense of belonging, and emotional health. Resident 7, diagnosed with Alzheimer's disease and major depressive disorder, was observed to have significant cognitive and physical impairments. Despite having care plans that required assistance and encouragement to participate in activities, Resident 7 did not attend any activities in March 2024. Observations showed Resident 7 sleeping in bed throughout the day, and interviews with staff revealed that no in-room activities were offered to the resident. Resident 21, diagnosed with polyosteoarthritis and dementia, also exhibited severe cognitive impairments and required assistance with daily activities. Similar to Resident 7, Resident 21 had care plans that included goals for participating in activities. However, the Activities Log Sheets indicated that Resident 21 did not attend any activities in March 2024. Observations showed Resident 21 lying in bed throughout the day, and interviews with staff confirmed that no one-on-one activities were provided, and there was no documentation of attempts to encourage participation. Interviews with the Activities Director and other staff members highlighted a lack of documentation and understanding of the importance of offering and documenting activities for residents. The facility's policy on activity programs emphasized the need for activities to support residents' physical, mental, and psychosocial well-being, but this was not implemented effectively for Resident 7 and Resident 21. The failure to provide and document appropriate activities for these residents was a significant deficiency in their care.
Incorrect LAL Mattress Settings for Residents
Penalty
Summary
The facility failed to ensure that Low Air Loss (LAL) mattresses were set up accurately for three residents, leading to potential risks for pressure ulcer development and worsening. Resident 33, who was at risk for pressure ulcers and had an unstageable pressure ulcer on the coccyx, was observed with an LAL mattress set at 350 lbs, despite weighing only 136 lbs. This discrepancy was confirmed by a Restorative Nurse Assistant (RNA) and a Licensed Vocational Nurse (LVN), who both acknowledged the importance of setting the LAL mattress according to the resident's weight to provide therapeutic benefits. Resident 6, who had severe cognitive impairment and was at high risk for pressure ulcers, was observed with an LAL mattress set at 400 lbs, despite weighing 164 lbs. This incorrect setting was confirmed by a Registered Nurse Supervisor (RNS), who stated that the LAL mattress should be set according to the resident's weight to ensure its effectiveness. The facility's policy and procedure for pressure injury prevention and support surface guidelines were not followed in this case. Resident 29, who was also severely cognitively impaired and at high risk for pressure ulcers, was observed with an LAL mattress set at 350 lbs, despite weighing 150 lbs. This incorrect setting was confirmed by an RNS, who reiterated the importance of setting the LAL mattress according to the resident's weight. The facility's policies and procedures for selecting appropriate pressure-relieving devices were not adhered to, leading to potential risks for the residents involved.
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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