Pavilion On Pico Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5916 W. Pico Boulevard, Los Angeles, California 90035
- CMS Provider Number
- 055160
- Inspections on file
- 33
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Pavilion On Pico Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with ESRD on hemodialysis, along with multiple comorbidities including DM2, COPD, heart failure, and HTN, had a missing post-dialysis evaluation in the medical record for one treatment date. During an interview and record review, an LVN confirmed that the post-dialysis evaluation form for that date was not completed, noting this could result in missed changes of condition or undocumented medications given during treatment. Review of the facility’s dialysis management policy showed that licensed nurses are required to complete both pre- and post-dialysis evaluations and maintain all dialysis-related documentation in the resident’s medical record, which was not done in this case.
A resident with multiple health conditions and mild cognitive impairment experienced inadequate discharge planning due to the facility's failure to conduct an IDT meeting and address the resident's personal requests. The Social Services Director's approach was perceived as rude, and the resident felt forced out. Staff acknowledged the resident's rights, but the facility did not follow its discharge policy, leading to ineffective planning.
A facility failed to provide necessary behavioral health care and services to a resident with major depressive disorder, who made unrealistic demands. The facility did not develop a care plan to address these behaviors, and the Social Services Director attempted to transfer the resident without proper discharge planning. Staff interviews revealed the facility could accommodate the resident's needs, but the lack of a person-centered care plan led to a deficiency in care.
A facility failed to provide adequate social services to a resident with multiple health conditions, including major depressive disorder. The resident's specific requests, such as early rising and daily laundry, were not accommodated, leading to psychosocial distress. The Social Services Director's approach was perceived as rude, and there was no proper discharge planning or understanding of resident rights, contributing to the deficiency.
Two residents experienced a delay in receiving their meals due to a mix-up with the food trays, leading to a failure in maintaining their dignity. The facility's usual process of serving all residents simultaneously was not followed, as confirmed by an LVN and the DON.
The facility did not follow its menu plan for residents on pureed diets, serving scrambled eggs instead of the prescribed Florentine torta. This substitution was not documented or approved by the Registered Dietitian, potentially compromising the nutritional intake of five residents. The Dietary Supervisor acknowledged the issue, noting the importance of adhering to standardized recipes to ensure adequate nutrition.
The facility failed to provide food in appropriate textures for residents on pureed and soft mechanical diets. Residents on a pureed diet received lumpy oatmeal, contrary to IDDSI standards, posing a choking risk. Additionally, residents on a soft mechanical diet were served bread with hard edges, which was against the facility's guidelines and also posed a choking hazard.
The facility was found to have multiple deficiencies in food storage and hygiene practices, including uncovered trash cans, improper hand hygiene, incorrect food storage, and unsanitary kitchen equipment. These issues could lead to cross-contamination and foodborne illnesses among residents.
The facility failed to maintain a clean garbage area, with debris such as masks and dog poop bags observed around the dumpster. Additionally, a dumpster was overflowing with trash and left uncovered due to a lack of Sunday trash pickup. This failure to adhere to cleanliness and waste management guidelines posed a potential infection risk to residents.
The facility failed to maintain sanitary conditions in the food services department, with six flies observed in the kitchen over two days. The Dietary Supervisor was unaware of the last pest control visit, and the pest control report only noted treatment in the exterior garbage area. This oversight potentially exposed 53 of 54 residents to foodborne illnesses.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to document this change or notify the physician and resident's representative, as required by policy. The resident also refused a follow-up blood draw, and the physician was not informed of this refusal.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to notify the physician as required by policy. Additionally, the resident refused a follow-up TSH test, and there was no documentation of physician notification. Interviews confirmed lapses in communication and documentation, contrary to facility policy.
A resident's LAL mattress was incorrectly set for a weight of 400 lbs instead of the resident's actual weight of 187 lbs, increasing the risk of pressure ulcer development. The resident, with conditions including diabetes and hemiplegia, required maximal assistance. The facility's policies and training materials indicated that mattress settings should be based on weight, but this was not followed, leading to the deficiency.
A resident with an indwelling urinary catheter did not receive appropriate care to prevent urinary tract infections due to the absence of a securement device and improper monitoring of catheter drainage. Despite the care plan's requirements, the catheter was not secured, leading to leakage and improper function. Facility staff, including a CNA and LVN, confirmed the catheter's mismanagement, and the resident was transferred to the hospital for further evaluation.
An LVN failed to follow a physician's order to hold Amlodipine for a resident with a pulse rate below the specified threshold. The resident's pulse was 58 BPM, but the LVN prepared the medication for administration until a surveyor intervened, highlighting a significant medication error.
The facility failed to maintain the correct temperature in a medication storage room, with the thermostat reading 90°F, above the acceptable range of 68-77°F. The fan, controlled by the light switch, was off when the light was off, causing the temperature rise. The temperature log was incomplete, missing an entry for one day, contrary to facility policy.
The facility was found non-compliant with room capacity regulations, as two rooms housed five residents each. Despite this, observations indicated sufficient space for resident movement and care provision. Staff and residents reported no concerns, and the administrator requested a waiver, asserting that care was not impeded.
The facility failed to meet federal room size requirements, with 17 out of 20 rooms not providing the mandated square footage per resident. Despite this, staff reported no concerns, and observations showed sufficient space for resident movement and care. A waiver request was submitted, but measurements confirmed non-compliance.
A facility failed to monitor and supervise residents with wandering behaviors, resulting in two elopement incidents. A resident with severe cognitive impairment left the facility unsupervised and was found at a previous address. Another resident, identified as high risk for elopement, left with a family member without triggering the wander-guard alarm. The Maintenance Supervisor could not explain the alarm failure, despite regular checks. Facility policies for wandering and elopement were not effectively implemented.
Incomplete Post-Dialysis Evaluation Documentation for Hemodialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-dialysis evaluation documentation for a resident who received hemodialysis. The resident was admitted with multiple diagnoses, including DM type 2, muscle weakness, COPD, heart failure, HTN, ESRD, and dependence on renal dialysis. An MDS assessment indicated the resident had intact cognition and required varying levels of assistance with ADLs, and that the resident received hemodialysis treatments. During a concurrent interview and record review with an LVN, the surveyor reviewed the resident’s pre- and post-dialysis evaluation records for March and found that the post-dialysis evaluation for a specific treatment date was missing from the medical record. The LVN confirmed that the post-dialysis evaluation for that date was not present in the record and acknowledged that this omission could result in missing changes of condition or medications given during the treatment. Review of the facility’s “Dialysis Management” policy, last reviewed on 6/20/25, showed that a pre- and post-dialysis evaluation was required to be completed by a licensed nurse and that all documentation concerning dialysis services and care of dialysis residents must be maintained in the resident’s medical record. The missing post-dialysis evaluation demonstrated that the facility did not follow its own policy and procedures for dialysis management and did not maintain a complete medical record for this resident.
Inadequate Discharge Planning and Resident Rights Violation
Penalty
Summary
The facility failed to adequately prepare and orient a resident for a safe and orderly discharge. The deficiency involved the lack of an Interdisciplinary Team (IDT) meeting to discuss the discharge planning for a resident with multiple health conditions, including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident required maximal assistance for activities of daily living and had mild cognitive impairment. Despite these needs, the facility did not conduct an IDT meeting to ensure a comprehensive discharge plan was in place. The discharge planning was initiated not based on the resident's health needs but rather on the resident's personal requests, such as wanting to get up early and requesting daily laundry services. The Social Services Director (SSD) indicated that the facility could not accommodate these demands and sought alternative facilities for the resident, which the resident declined. The SSD's approach to the resident was perceived as rude, and the resident felt as though they were being forced out of the facility. The resident expressed a desire to remain at the facility and was particular about their living arrangements. The facility's staff, including a Certified Nursing Assistant and a Registered Nurse, acknowledged the resident's rights to make choices about their care and daily routine. However, the SSD was unable to articulate the resident's rights regarding freedom of choice and did not follow the facility's policy on discharge and transfer, which requires a discharge summary and post-discharge plan of care. The facility's failure to honor the resident's rights to be treated with kindness, respect, and dignity contributed to the incomplete and ineffective discharge planning process.
Failure to Address Behavioral Health Needs and Implement Person-Centered Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address the resident's behavior of making unrealistic demands, as required by the facility's policy on Behavior/Psychotropic Drug Management. The resident's psychosocial note from a psychiatrist highlighted the need to address the resident's mood and emotional state, which influenced her behavior towards staff. However, the Social Services Director (SSD) failed to accommodate the resident's requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD attempted to transfer the resident to another facility without conducting an interdisciplinary team meeting or understanding the facility's policy on discharge and transfer, which led to the resident feeling unwanted and neglected. Interviews with staff revealed that the facility could accommodate the resident's needs, but the SSD's approach and lack of understanding of residents' rights contributed to the deficiency. The Registered Nurse confirmed that the facility should not transfer the resident due to high demands and emphasized the importance of communicating with the resident to ensure she felt secure and respected. The facility's failure to implement a person-centered care plan and address the resident's behavioral health needs resulted in a deficiency in providing the highest practicable physical, mental, and psychosocial well-being for the resident.
Failure to Provide Adequate Social Services
Penalty
Summary
The facility failed to provide medically-related social services to Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address Resident 1's behavior of making unrealistic demands and requests, which contributed to the resident's psychosocial distress. The Social Services Director (SSD) failed to accommodate Resident 1's specific requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD's approach to Resident 1 was perceived as rude, and the resident felt pressured to leave the facility. The SSD did not conduct an interdisciplinary team meeting for discharge planning and was unaware of the facility's policy on resident rights regarding freedom of choice. This lack of appropriate social services and communication contributed to Resident 1's distress. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse, revealed that Resident 1 was generally friendly and understood the limitations of the facility's services. However, the SSD's handling of the situation, including the suggestion of transferring Resident 1 to another facility without proper planning or understanding of resident rights, was inadequate. The facility's failure to address Resident 1's psychosocial needs and demands led to a deficiency in providing the highest practicable well-being for the resident.
Failure to Serve Meals Simultaneously
Penalty
Summary
The facility failed to maintain or enhance the dignity of two residents by not serving their meals at the same time as other residents in the dining room. Resident 2, who was admitted with chronic obstructive pulmonary disease, dysphagia, and type 2 diabetes, was observed waiting for her meal while other residents were served. The Minimum Data Set indicated that Resident 2 was severely cognitively impaired and required assistance with eating. During the observation, it was noted that the first food cart arrived, and seven residents received their meals while six others, including Resident 2, continued to wait. Licensed Vocational Nurse 3 acknowledged that the trays were not served simultaneously due to a mix-up and stated that this was not the usual process. The Director of Nursing also confirmed that the expectation was for all residents to receive their meals at the same time to prevent feelings of deprivation or neglect. The delay in serving meals was attributed to a communication issue with the kitchen, resulting in Resident 2 and Resident 42 receiving their meals later than others.
Failure to Follow Menu Plan for Pureed Diets
Penalty
Summary
The facility failed to adhere to its menu plan, which resulted in five out of 54 residents on pureed texture diets receiving scrambled eggs instead of the prescribed Florentine torta. This discrepancy was identified through observation, interviews, and record reviews. The facility's daily menu spreadsheet for residents on pureed diets indicated that they should receive a pureed Florentine torta, but scrambled eggs were served instead. The Dietary Supervisor acknowledged the substitution, stating that the Florentine torta recipe was not smooth when cooked, prompting the use of scrambled eggs for a smoother consistency. However, this change was not documented on the menu spreadsheet, and the Registered Dietitian was not informed of the substitution. The facility's Policies and Procedures for Menu Planning require that any menu changes be documented and approved by the Registered Dietitian or the Food and Nutrition Services Director. The failure to follow the standardized recipe and menu plan potentially compromised the residents' nutritional intake, as the substitution was not aligned with the planned nutritional content. The Dietary Supervisor admitted that not following the standardized recipe could lead to residents receiving inadequate nutrition, which could affect their overall health and well-being.
Failure to Provide Appropriate Food Textures for Residents
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs, specifically for residents on pureed and soft mechanical diets. Residents on a pureed International Dysphagia Standardization Initiative (IDDSI) level 4 diet, which requires food to be smooth and pudding-like, were served oatmeal with lumps. This was observed during a trayline inspection, and the Dietary Supervisor confirmed that the lumpy oatmeal posed a potential choking hazard. The facility's policy and procedures, as well as the diet manual, clearly stated that pureed diets should be smooth and free of lumps, aligning with IDDSI standards. Additionally, residents on a soft mechanical diet, intended for those with chewing or swallowing difficulties, received toasted bread with hard edges. The facility's standardized recipe for mechanical soft diets specified that breads should be soft and without hard crusts. The Dietary Supervisor acknowledged that the hard crusts on the bread were inappropriate for residents on this diet, as they could also pose a choking risk. The facility's diet manual reinforced that breads with hard crusts should be avoided for residents on a mechanical soft diet.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The trash can in the handwashing sink room was not covered when not in use, which was against the facility's policy and could lead to the transport of bacteria. Staff members were observed not performing hand hygiene after touching potentially contaminated surfaces, such as the lids of garbage cans, and then handling clean trays and dishes. This lack of hand hygiene was contrary to the facility's policies and the Food Code 2022, which emphasize the importance of handwashing to prevent cross-contamination. In the kitchen, improper food storage practices were noted, with raw chicken stored above ground beef and cooked chicken stored below raw fish, violating the facility's food storage hierarchy. Additionally, several pieces of kitchen equipment and utensils were found to be in poor condition, with dust, rust, and debris present in refrigerators and freezers, and chipped and cracked trays and shelves. These conditions could lead to contamination and were not in compliance with the facility's policies or the Food Code 2022. Other issues included the improper handling of kitchenware, such as using cloths to dry steam table covers instead of air drying, and storing scoops in different orientations, which increased the risk of contamination. Staff food was also found stored in the resident's refrigerator, which could lead to mix-ups and potential allergic reactions for residents. These practices were not aligned with the facility's policies and posed a risk of foodborne illness to the residents.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The garbage area was not maintained free from debris, including masks, dog poop bags, boxes, and dirt on the floor and surroundings of the dumpster. During an observation and interview with the Dietary Supervisor, it was noted that the trash area should be cleaned for infection control purposes. The Maintenance Director also confirmed the presence of debris and stated that it was coming from people walking by, emphasizing the need for cleanliness to prevent contamination. Additionally, one of the dumpsters was observed to be overflowing with trash, and its lid was not closed. This was noted during multiple observations, and the Maintenance Director acknowledged that the trash pickup schedule did not include Sundays, leading to the overflow. The facility's policies and procedures, as well as the Food Code 2022, require that garbage areas be kept clean and receptacles covered to prevent contamination and attract pests. The failure to adhere to these guidelines posed a potential risk of infection to the facility's residents.
Sanitation Deficiency in Food Services Due to Flies
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of six flies observed in the kitchen over a two-day period. Observations were made on different occasions, with flies seen around the preparation area, preparation table, and trayline. During interviews, the Dietary Supervisor acknowledged the presence of flies and expressed uncertainty about the last pest control visit, indicating a lack of awareness regarding pest management in the kitchen. The facility's Policy and Procedures on Pest Control, dated June 28, 2024, emphasized the importance of keeping the facility free from insects and other pests to ensure the health and safety of residents, staff, and visitors. However, a review of the pest control report from October 23, 2024, showed that treatment for large flies was only applied in the exterior garbage area, with no mention of the kitchen. This oversight potentially exposed 53 of 54 residents to foodborne illnesses due to the risk of consuming contaminated food.
Failure to Document and Notify Change in Resident's Condition
Penalty
Summary
The facility failed to document a significant change in condition for a resident, identified as Resident 2, in accordance with its policy and procedure. Resident 2, who was admitted with diagnoses including hypothyroidism, generalized muscle weakness, and hypertension, had a lab result indicating an elevated thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which was significantly above the normal range. Despite this abnormal result, there was no documentation of a change of condition (COC) being completed, nor was there evidence that the attending physician or the resident's representative was notified of this change. Additionally, Resident 2 refused a follow-up blood draw for TSH, and again, there was no documented notification to the physician regarding this refusal. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed that the facility's process for handling such situations was not followed. The facility's policy requires prompt notification of the physician and the resident's representative in the event of a significant change in condition, which was not adhered to in this case.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory test results for a resident, as required by their policy and procedure. The resident, who was admitted with diagnoses including hypothyroidism, had a thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which is significantly above the normal range. Despite the facility's policy to notify the attending physician of abnormal lab results, there was no documented evidence that the physician or the resident's representative was informed of the elevated TSH level. Additionally, a change of condition (COC) was not completed, which is part of the facility's process for handling deviations from a resident's baseline condition. Furthermore, the resident refused a follow-up TSH laboratory draw that was ordered six weeks after the initial test. Again, there was no documentation indicating that the physician was notified of the resident's refusal to undergo the blood draw. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed these lapses in communication and documentation. The facility's policy requires that lab results be promptly communicated to the physician to prevent delays in necessary interventions, but this protocol was not followed in this case.
Improper LAL Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure that the Low Air Loss (LAL) mattress setting was appropriately set for a resident, identified as Resident 205, which could potentially lead to the redevelopment of pressure ulcers. Resident 205 was admitted with diagnoses including diabetes, hemiplegia, and generalized muscle weakness, and was cognitively intact but required maximal assistance for daily activities. During an observation, it was noted that the LAL mattress pump was set to a weight of 400 lbs, while the resident's actual weight was 187 lbs. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the incorrect setting could increase the risk of pressure ulcer development. The resident's care plan focused on skin integrity management and included interventions to prevent skin breakdown. The Director of Nursing (DON) confirmed that LAL mattress settings should be based on the resident's weight, and incorrect settings could lead to a high risk of skin breakdown. The facility's policy and procedures, as well as training materials, indicated that mattress settings should be adjusted according to the resident's weight to provide appropriate pressure reduction. However, the failure to adhere to these guidelines resulted in the deficiency observed during the survey.
Failure to Secure and Monitor Catheter Leads to Deficiency
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent urinary tract infections for Resident 16, who had an indwelling urinary catheter. The deficiency was identified when it was observed that the resident's suprapubic catheter did not have a securement device or anchor in place, which is necessary to prevent the catheter from being dislodged and causing trauma or infection. The resident's care plan required the catheter to be secured and assessed for proper placement and drainage, but these measures were not followed. As a result, the urine bag was not draining properly, and the resident's diaper was consistently wet, indicating leakage and improper catheter function. The resident, who was admitted with diagnoses including sepsis and acute kidney failure, was unable to understand and make decisions. Despite the care plan's instructions to assess urinary drainage and maintain proper catheter alignment, staff failed to ensure these interventions were implemented. Observations and interviews with facility staff, including a CNA and LVN, confirmed the catheter's improper management and the lack of a securement device. The Director of Nursing acknowledged the oversight, and the resident was eventually transferred to the hospital for catheter reinsertion and evaluation.
LVN Fails to Hold Amlodipine Despite Low Pulse Rate
Penalty
Summary
The Licensed Vocational Nurse (LVN) 4 failed to adhere to a physician's order regarding the administration of Amlodipine, a blood pressure medication, for a resident. The physician's order specified that Amlodipine should be held if the resident's systolic blood pressure was less than 100 or if the pulse rate was below 60 beats per minute (BPM). On the day of the incident, the resident's blood pressure was recorded at 144/73 mmHg, and the pulse rate was 58 BPM, which was below the specified threshold for administering the medication. Despite the resident's pulse rate being outside the parameters for safe administration, LVN 4 proceeded to prepare the Amlodipine for the resident. It was only after the surveyor intervened and prompted LVN 4 to review the blood pressure and pulse rate parameters that LVN 4 acknowledged the error and refrained from administering the medication. This oversight placed the resident at risk for a further decrease in heart rate, as the medication was not held as per the physician's directive.
Medication Storage Room Temperature Deficiency
Penalty
Summary
The facility failed to maintain the correct temperature in one of its medication storage rooms, which could potentially compromise the efficacy of the medications stored there. During an observation and interview, it was noted that the thermostat in the medication storage room indicated a temperature of 90 degrees Fahrenheit, which is above the acceptable range of 68 to 77 degrees Fahrenheit for controlled room temperature. The Registered Nurse Supervisor acknowledged the discrepancy in temperature. Further investigation revealed that the room's fan, which is controlled by the light switch, was not operating when the light was off, contributing to the elevated temperature. Additionally, a review of the room temperature log sheet showed that temperatures were recorded within the acceptable range from November 1 to November 15, but the entry for November 16 was left blank. The Licensed Vocational Nurse confirmed that the log should be completed daily. The facility's policy, revised in January 2018, requires that all medications be stored within specific temperature ranges as per the United States Pharmacopeia and the Centers for Disease Control guidelines. The failure to maintain the correct temperature and to consistently log the temperatures as per policy led to this deficiency.
Non-Compliance with Resident Room Capacity
Penalty
Summary
The facility was found to be non-compliant with the requirement that resident rooms hold no more than four residents. During an unannounced recertification survey, it was observed that two rooms housed five residents each. Despite the additional occupancy, the rooms were noted to have sufficient space for residents to move freely and for nursing staff to provide care. The residents had enough room to operate wheelchairs, walkers, and canes, and there was adequate space for bedside tables and other resident care equipment. Interviews with staff and residents revealed no concerns regarding the room sizes or the care provided. During a resident council meeting, attendees did not express any issues with their living space. The facility's administrator submitted a request for a waiver to allow more than four residents per room, citing that the room sizes did not impede resident care. The facility's client accommodation analysis confirmed the presence of five beds in the rooms in question.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, 17 out of 20 resident rooms did not meet the requirement of at least 80 square feet per resident. The rooms in question were designed to accommodate either two or three residents, but their sizes were insufficient, with two-bedroom units measuring only 140 square feet and three-bedroom units measuring 200 square feet. This deficiency was identified during a recertification survey, where it was noted that the rooms did not meet the federal standards of 160 square feet for two residents and 240 square feet for three residents. Despite the deficiency, staff interviews during the survey indicated no concerns regarding the room sizes, and observations showed that residents had ample space to move freely. The rooms were equipped with necessary furniture and equipment, allowing for freedom of movement and care provision. The facility had submitted a request for a room size waiver, arguing that the room sizes did not impede resident care, and the rooms provided adequate sunlight and ventilation. However, the measurements taken by the maintenance director confirmed the non-compliance with the required room dimensions.
Failure to Monitor and Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of residents with wandering behaviors, leading to two incidents of elopement. Resident 1, who had severe cognitive impairment and was at high risk for elopement, left the facility unsupervised through the front reception area doors. The resident was later found at their previous address, 3.5 miles away. The staff, including a Certified Nurse Assistant (CNA), were unaware of the resident's whereabouts, and the wander-guard alarm system did not activate to alert staff of the resident's departure. Resident 2, who also had cognitive impairments and was identified as a high risk for elopement, left the facility with a family member for a doctor's appointment. Despite wearing a wander-guard bracelet, the alarm system failed to notify staff of the resident's exit. The Maintenance Supervisor, responsible for the wander-guard system, was unable to explain why the alarm did not trigger during these incidents, despite regular checks being conducted to ensure functionality. The facility's policies and procedures for wandering and elopement, as well as the signaling device, were not effectively implemented. The policies required verification of the signaling device's placement and functionality every shift and testing of the alarm functioning of exit doors weekly. However, these measures were insufficient in preventing the elopement of residents, as evidenced by the failure of the wander-guard system to activate during the incidents involving Residents 1 and 2.
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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