Rinaldi Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Granada Hills, California.
- Location
- 16553 Rinaldi St, Granada Hills, California 91344
- CMS Provider Number
- 055906
- Inspections on file
- 75
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Rinaldi Convalescent Hospital during CMS and state inspections, most recent first.
The facility failed to follow its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program and Hiring policies by not properly completing and documenting pre-employment reference and background checks for a CNA. The CNA’s personnel file contained an incomplete Pre-Employment Reference Check List, including a reference from a staff member in a non-qualifying role and missing dates and verification details for prior employment. The DON and ADM acknowledged that pre-employment checks are intended to identify any history of abuse or related disciplinary actions and that it was unclear whether appropriate checks had been performed for this CNA, despite policy requirements to conduct such background investigations.
A resident with a G-tube and indwelling catheter did not have weekly weights obtained as ordered, and staff failed to monitor and document intake and output according to facility policy and professional standards. The resident, who was dependent on staff and had multiple complex medical conditions, did not receive required I/O monitoring from admission through hospitalization, and the omission was confirmed by interviews with nursing staff and leadership.
A resident with severe cognitive impairment and multiple complex medical conditions experienced significant unplanned weight loss and developed new and worsening pressure ulcers. Despite these major changes in health status, the facility failed to complete a required Significant Change in Status Assessment (SCSA) MDS, instead performing only a quarterly assessment, contrary to facility policy and staff acknowledgment.
A resident with severe cognitive impairment and multiple medical conditions did not receive physician-ordered lab tests, including CBC, CMP, and magnesium, due to staff failing to process the requisition and notify the physician of the missed tests.
A resident with hypertension and congestive heart failure, who was cognitively intact, exhibited a sudden change in behavior by refusing care, screaming, laughing inappropriately, and kicking a staff member. Despite staff involvement and facility policy requiring physician notification for such changes, the physician was not informed of the incident.
Two residents did not receive their prescribed medications on time, and staff failed to notify the physician prior to administering the late doses. In both cases, medications scheduled for the morning were given several hours late without prior physician input, and documentation of physician notification or assessment for adverse effects was lacking. Nursing staff and the DON confirmed that the required process for physician notification was not followed.
A nurse failed to ensure that a resident with multiple medical conditions received medications according to physician orders, including not providing required food or fluids with certain medications, not instructing the resident to rinse her mouth after inhaler use, and allowing self-administration without a physician's order or proper supervision.
A resident did not receive multiple scheduled morning medications within the required timeframe, with doses administered over three hours late and subsequent doses given in close succession. Nursing staff did not notify the physician of the missed doses or document any monitoring for adverse reactions, resulting in a failure to follow medication administration protocols.
A nurse failed to sign the treatment administration record for a resident's wound care and pleural catheter treatments, leaving uncertainty about whether care was provided. In a separate case, a nurse documented that a resident's morning medications were given before actual administration, which occurred later in the day after the resident initially refused. These actions resulted in incomplete and inaccurate medication and treatment records, as confirmed by staff interviews and policy review.
A resident with severe cognitive impairment was found with pillows placed on both sides of their body, restricting movement, without a physician's order for restraints. A CNA admitted to placing the pillows and forgetting to remove them, despite being aware that this could be considered a restraint. The LVN and DON confirmed that such use of pillows is not permitted without proper authorization, and facility policy prohibits restraints for staff convenience or fall prevention.
Surveyors found that a resident with COVID-19 did not have the required droplet precaution signage posted, another resident receiving IV antibiotics lacked enhanced barrier precaution signage and supplies, and two nurses failed to perform hand hygiene before administering medications, with one also not wearing gloves for eye drop administration. These actions were inconsistent with the facility's infection control policies.
A bottle of Pepto-Bismol was found at the bedside of a resident without a physician's order or proper labeling. The medication, brought in by the resident's family, was not listed on the Medication Administration Record and had not been assessed for self-administration. Facility staff confirmed that medications should not be left at the bedside without following required procedures.
Expired blood glucose (BG) control solutions were found in a medication cart and had been used for quality control checks after their expiration date. An LVN confirmed the solutions should have been replaced, and the DON acknowledged the risk of inaccurate readings. Facility policy required outdated medications to be returned or destroyed, but this was not followed.
The facility did not include required performance evaluations in the personnel files of four CNAs, as confirmed by record review and staff interviews. Facility policy mandates evaluations after probation and annually, but these were missing, resulting in incomplete personnel records.
Several CNAs and LVNs did not have required health exam documentation in their personnel files, including exams prior to or shortly after hire and annual health exams thereafter. The DSD and DON confirmed the lack of medical clearance for these staff, and facility policies requiring such documentation were not followed.
The facility did not provide or document required behavioral health in-service training for two CNAs, despite having residents with psychiatric and mood disorders and a scheduled training on the in-service calendar. Interviews confirmed that the CNAs had not received formal training, and the Director of Staff Development acknowledged the training was not conducted as scheduled. Facility policies require annual behavioral health training for all staff, but no evidence of such training was found in the CNAs' personnel files.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and another with a history of falls. The absence of care plans for a Restorative Nursing Assistant exercise program and a floor mat intervention led to potential inadequate care and risk of injury. Staff interviews confirmed the lack of person-centered care plans, despite facility policies emphasizing their importance.
The facility failed to update care plans for residents after changes in medication and ADL needs. A resident's anticoagulation therapy care plan was not revised after medication changes, another resident's care plan lacked specific ADL interventions, and a third resident's care plan inaccurately reflected discontinued anti-anxiety medication. These deficiencies were identified during interviews and record reviews, highlighting a lack of adherence to facility policies on care plan updates.
Two residents in an LTC facility did not receive appropriate pain management due to failures in assessing pain and documenting medication administration. Tramadol and Percocet were administered without prior pain assessment or entries in the MAR, violating facility policies. This lack of documentation hindered effective pain management and risked unmanaged pain for the residents.
Two residents in an LTC facility did not have their controlled medications properly documented in the MAR, despite being removed from the blister pack as per the CDR. This failure to document involved Xanax and Tramadol for one resident and Percocet for another, leading to potential medication errors and drug diversion. The facility's policy requires immediate documentation in both the CDR and MAR, which was not followed.
A LTC facility failed to administer Morphine Sulfate Contin to a resident as ordered, potentially increasing their pain. Additionally, two residents received midodrine despite having systolic blood pressure readings above the physician-ordered threshold, risking elevated blood pressure. The facility's medication administration policy was not followed.
The facility failed to maintain sanitary food storage practices when a scoop was left inside a bin of thickener powder used for pureed diets. This was observed during an inspection with the Dietary Supervisor, who confirmed that the scoop should not have been left in the bin to avoid contamination. This practice risked exposing five residents on pureed diets to foodborne illnesses.
A long-term care facility failed to implement proper infection control measures, including the absence of trash cans for PPE disposal, improper use of isolation gowns by an LVN, and unlabeled urinals, leading to potential cross-contamination. Additionally, personal belongings were found in a medication room, violating infection control policies.
A facility failed to ensure staff knocked and requested permission before entering the rooms of two residents, violating their rights to dignity and privacy. Both residents had intact cognitive skills and required assistance with personal care. A CNA entered their rooms without knocking, which was against the facility's policy on dignity.
A facility failed to maintain a current copy of a resident's advance directive in their medical record, as required by policy. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was admitted with conditions including hemiplegia and encephalopathy. The absence of the advance directive in the chart was confirmed by the DSS and DON, posing a risk of not honoring the resident's medical decisions.
A resident requiring moderate assistance with personal hygiene was not provided with necessary nail trimming services, despite having long and curvy fingernails. The resident, who has intact cognitive skills and medical conditions including hypertension and type 2 diabetes, expressed a desire for her nails to be trimmed but reported that no staff had offered assistance. This failure to adhere to the facility's ADL policy resulted in a deficiency in maintaining the resident's personal hygiene.
A facility failed to provide a resident-centered activities program by not meeting a resident's spiritual needs. The resident, with dementia and schizophrenia, had an MDS indicating the importance of religious services, but their care plan lacked interventions for such activities. The resident did not participate in religious activities or receive visits from religious representatives, contrary to the facility's policy.
A resident with multiple diagnoses, including dementia and malnutrition, did not receive a prescribed RNA exercise program due to lack of clarification and implementation by facility staff. The order lacked specifics on exercise type, frequency, and affected area, and the resident's restorative treatment records showed no entries, indicating a failure to provide necessary care to prevent ROM decline.
A facility failed to communicate a resident's nutritional intake and meal refusals to the RD and physician, risking weight loss. The resident, with severe cognitive impairment and malnutrition, consistently refused meals, yet staff did not document or report these refusals as required by policy.
The facility did not post the actual hours worked by nursing staff as required, instead displaying projected hours or leaving the actual hours section blank. This occurred due to a misunderstanding by the DSD, who believed actual hours were only needed at the end of the day, contrary to the facility's policy.
A facility failed to monitor a resident for side effects of Trazadone and Xanax, as required by physician orders. The resident, with various medical conditions, was prescribed these medications for depression and anxiety. Documentation was missing for the monitoring of side effects, indicating non-compliance with facility policy and physician orders. The DON highlighted the importance of monitoring to adjust dosages and prevent unnecessary medication use.
A resident with intact cognition threw water at another resident, making contact with their face, chest, and clothes, after a disagreement over television volume. The incident was substantiated as abuse, with both residents confirming the altercation. The facility's administrator acknowledged the event but felt it was a spontaneous action that could not have been prevented.
A resident with multiple diagnoses, including atrial fibrillation, experienced hematuria, leading to a physician's order to hold Xarelto. The facility failed to monitor the resident for signs of bleeding every shift as required, with no specific documentation of monitoring on several shifts. This lack of adherence to the facility's policy on acute condition changes could have led to confusion in care and services.
A facility failed to implement contact precautions for a resident diagnosed with scabies upon their return from a hospital. The resident's room lacked appropriate signage, and staff were not informed to use isolation gowns, leading to inadequate infection control measures for several days. The DON confirmed the resident should have been placed on contact precautions immediately.
The facility failed to develop a comprehensive care plan for a resident diagnosed with dermatitis consistent with scabies. The resident was transferred to a hospital for skin rashes and itching but returned without specific interventions in the care plan or contact precaution signage. Interviews confirmed the care plan was not updated as required by facility policies.
Failure to Complete and Document Pre-Employment Screening for CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program and Hiring policies by not conducting and documenting required pre-employment screening for a certified nursing assistant (CNA 1). Review of CNA 1’s personnel file, including the Personnel Action Form, showed prior employment at another skilled nursing facility. The Pre-Employment Reference Check List (PERCL) for CNA 1 contained only a name of a former employee as the first reference, with no title documented, and a second reference listing only the prior facility’s company name and the current Director of Staff Development’s (DSD) name, without an interview date, employment verification dates, or other required information. The DSD confirmed CNA 1’s date of hire and that the PERCL lacked complete documentation. During interviews, the DON stated that pre-employment reference checks are part of ensuring safety, confirming qualifications, and determining whether an applicant has any history of resident abuse, and clarified that RNA or CNA staff are not permitted to provide professional employment references or verify employment history. The DON further stated that the reference from the restorative nursing assistant appeared to be a personal reference and that the former DSD had not completed CNA 1’s PERCL prior to hire. In a separate interview, the Administrator acknowledged that the purpose of pre-employment checks is to identify any negative history and that it was difficult to determine whether such checks had been completed for CNA 1. Review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy showed a requirement to conduct employee background checks and not knowingly employ individuals with disciplinary actions related to abuse or misappropriation, and the Hiring policy allowed for background investigations for applicants and current employees, which were not properly carried out or documented for CNA 1.
Failure to Monitor Weekly Weights and Intake/Output for Resident with G-Tube and Catheter
Penalty
Summary
The facility failed to obtain weekly weights as ordered for one resident who had significant medical needs, including a gastrostomy tube (G-tube) and an indwelling catheter. The resident was admitted with diagnoses such as traumatic subarachnoid hemorrhage, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder, and was dependent on staff for most activities of daily living. Physician's orders specified weekly weights for four weeks, but documentation showed that the weight for the third week was not obtained or recorded. Staff interviews confirmed that the weekly weight was missed, and facility policy required monitoring weights to detect undesirable or unintended weight loss or gain. Additionally, the facility did not ensure that staff monitored and documented the resident's intake and output (I/O) in accordance with professional standards and facility policy. Despite the resident having a G-tube and an indwelling catheter, there was no documented evidence of I/O monitoring from admission through the resident's most recent hospitalization. Staff interviews revealed that I/O monitoring was not included in the admission orders, and as a result, staff did not perform or document I/O in the Medication Administration Record. Facility policy required I/O monitoring for at least one month for residents with a G-tube and/or indwelling catheter, but this was not done for the resident in question. Interviews with nursing staff and facility leadership confirmed that the omission of I/O monitoring was due to a failure to include it in the admission orders and a lack of subsequent identification of this omission by clinical staff. The Director of Nursing stated that I/O monitoring should have been initiated upon admission and continued for the first four weeks, especially given the resident's history of pulling out the G-tube. Facility policies reviewed indicated that I/O monitoring is required for residents with urinary catheters and should be documented and evaluated weekly, but these procedures were not followed in this case.
Failure to Complete Timely SCSA MDS for Resident with Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe for one resident who experienced notable changes in health status. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, G-tube dependence, mood disorder, and neuromuscular bladder dysfunction, was readmitted and subsequently experienced severe cognitive impairment. Despite these complex medical needs, the facility only completed a quarterly MDS assessment rather than the required comprehensive SCSA. Record reviews revealed that the resident underwent significant, unplanned weight loss over a short period, losing 57 pounds (29.4%) in 92 days. Additionally, the resident developed new and worsening pressure ulcers, including an unstageable ulcer on the sacrococcyx and a stage II pressure ulcer on the right foot. These changes represented a major decline in more than one area of the resident's health status, meeting the criteria for a significant change that would require a comprehensive reassessment and potential revision of the care plan by the interdisciplinary team (IDT). Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that a SCSA should have been completed in response to the resident's significant weight loss and the development and worsening of pressure ulcers. The facility's own policy also indicated that a SCSA is required when there is a major decline or improvement in a resident's status affecting multiple health areas and requiring IDT review. However, the facility did not complete the SCSA as required, instead performing only a quarterly assessment.
Failure to Complete Ordered Laboratory Tests for Resident
Penalty
Summary
The facility failed to follow a physician's order dated 8/26/2025 to obtain laboratory tests for one resident. The resident, who had a history of traumatic subarachnoid hemorrhage with loss of consciousness, a gastrostomy tube, and neuromuscular dysfunction of the bladder, was severely cognitively impaired and dependent on staff for most activities of daily living. The physician's order required a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and magnesium level to be performed. However, review of records and interviews with staff confirmed that these laboratory tests were not completed as ordered. Further investigation revealed that the requisition slip for the lab tests was folded, indicating that the phlebotomist did not collect the required blood samples. Staff interviews confirmed that the missed laboratory tests were not communicated to the physician. The facility's policy required staff to process test requisitions and arrange for tests as ordered by the physician, but this protocol was not followed in this instance.
Failure to Notify Physician of Resident's Sudden Behavioral Change
Penalty
Summary
The facility failed to notify the attending physician of a sudden and marked change in a patient's behavior, as required by regulation. Patient 4, who had diagnoses of hypertension and congestive heart failure and was cognitively intact, refused a shower and began screaming when staff attempted to change her soiled incontinence briefs. The situation escalated to the point where the patient was yelling, laughing inappropriately, and ultimately kicked a staff member. Multiple staff, including the Administrator and Director of Social Services, were present and attempted to address the situation, but the physician was not notified of this significant behavioral change. Interviews with staff, including the CNA, Administrator, Director of Staff Development, LVN, and Director of Nursing, confirmed that the physician should have been informed of the change in the patient's condition. The facility's own policy also required prompt notification of the physician and resident representative in the event of a change in the resident's medical or mental condition. The failure to report this incident represented a lapse in following both regulatory and facility policy requirements.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/7/2025, the RN supervisor assessed Patient 4 for any signs of adverse outcome regarding refusals to showers/bed bath. Upon explanation and discussing the importance of showers, Patient 4 was still not convinced to allow the CNA to continue with the hygienic and care procedure. CNA was relieved from her care and another CNA was assigned immediately with no further issues. Change of Condition was initiated and completed by the Charge Nurse to reflect Patient 4's behavior. MD and responsible party (RP) were made aware of patient 4's refusals. Patient 4's care plan was updated by the MDS nurse to signify her behavior change. Patient 4 will be monitored for 72-hours for any other changes. On 10/7/2025, the Director of Nursing Services (DON) and Director of Staff Development (DSD) completed an in-service to nursing staff on how to handle patient refusals of showers and notification requirements and processes for changes of condition. A policy and procedure titled, "CHANGE of CONDITION," was reviewed and discussed followed by question-and-answer evaluation. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, DSD interviewed all CNAs on shift to identify additional patients with episodes of care needs refusals, included them on a "Special Care Needs" list to ensure proper monitoring and appropriate interventions as individualized as possible. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025, DON held an in-service with all licensed nurses on P/P: Change of Condition, with an emphasis on MD/RP notification. On 10/29/2025, two additional systematic changes were implemented: 1. "Resident Special Care Needs" worksheet was modified to include patients with episodes of refusals of care needs. The list will be generally updated weekly and as changes occur by the Desk Nurse, to be shared on both nursing units. 2. "Huddle" every shift to review patients with special needs such as giving detailed attention to the patients who would tend to refuse care. Discussed with the team huddle the importance of reporting any incident of refusals to immediately implement interventions as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Weekly audits on refusals based on Change of Condition reports will be reviewed by the DON/Designee. The DON/Designee will present any findings to the QAPI/QAA Committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Failure to Notify Physician of Late Medication Administration
Penalty
Summary
The facility failed to notify the attending physician when medications were not administered on a timely basis as prescribed for two patients. For one patient, who had diagnoses including muscle weakness, GERD, depression, and cerebral infarction, multiple scheduled morning medications were not administered at the prescribed time. The medications, which included pregabalin, duloxetine, famotidine, fenofibrate, and several supplements, were given three and a half hours late without prior notification to the physician. The patient confirmed not receiving the medications on time, and the nurse acknowledged that the physician was not notified of the missed doses or the late administration. The subsequent dose was administered only a few hours after the late dose, again without physician input, and there was no documentation of assessment for adverse reactions due to the close timing of doses. For the second patient, who had paraplegia and was cognitively intact, the morning medications were not administered at the scheduled time due to the patient's refusal, except for pain medication. The nurse waited for the patient to request the medications and eventually administered them several hours late. The physician was only notified about the late administration after the survey team inquired, and not before the medications were given. The nurse stated that the physician should be notified in such situations to avoid potential double dosing, especially for medications scheduled twice daily. The facility's policy required contacting the physician if a dose was believed to be inappropriate or excessive, but this was not followed prior to the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not have a specific policy for late medication administration, but acknowledged the importance of notifying the physician before giving late doses. The staff recognized that failing to notify the physician and document instructions could lead to inappropriate medication timing and potential adverse effects. The deficiency was identified through interviews, record reviews, and direct observation, showing a lack of timely physician notification and documentation when medications were not administered as ordered.
Plan Of Correction
C 0875 - NURSING SERVICE - GENERAL Medication Administration IMMEDIATE CORRECTIVE ACTION: 1. The RN supervisor assessed Patient 10 on any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP =124/74, P = 76, R = 19, O2 Sat = 96% and Pain level = 2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. 2. The RN supervisor assessed Patient 5 for any abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96% & Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. 3. A one-on-one in-service was initiated and completed with LVN 2 and LVN 4 respectively to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. Discussed also the potential of unwanted effects from medications being administered too close of the time of the next ordered dose to be given. Reiterated in the discussion on the importance for the patients' MD be notified of circumstances that may lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. An in-service was done by the DON on 10/28/2025 on all nursing staff on how to handle patients with medications that are delayed in administration. A policy and procedure titled, "Medication Administration" was reviewed and discussed. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: All alert/oriented patients are with the potential to have set ways of taking their medications, these identified patients must be properly assessed by the RN supervisor as to the need of time adjustments on their medications to be administered. Patients with special requests or needs must be communicated to their respective MDs for proper orders to ensure ultimate safety, health and well-being of identified patients. The Medical Records Department will continue to do daily audits on both eMARs and eTARs to ensure proper charting and documentation as required. Any deviations must be reported to the DON/Designee for immediate resolutions/corrections. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: The facility had implemented a Weekly Medication Pass Audit by the DON, ADON and DSD to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations must be corrected immediately, and continued mentoring with performance improvement must be done with the specific charge nurses. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report and discuss with the QAPI/QAA committee the outcomes of Weekly Medication Administration audits including issues observed during medication pass and immediate actions done to prevent deficient practice from occurring. This will be reviewed for 3 months. E) COMPLETION DATE: 10/31/2025
Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a patient as prescribed by the physician. The patient, who had diagnoses including dysphagia, asthma, chronic respiratory failure with hypoxia, COPD, and lack of coordination, required specific administration instructions for several medications. During a medication pass, the nurse prepared and provided the medications to the patient but did not ensure that the medications were taken according to the physician's orders. Specifically, the patient did not take Metoprolol with food, did not take Potassium Chloride with the prescribed four to six ounces of water, and did not rinse her mouth after using the Pulmicort inhaler. The nurse also did not provide instructions or directions for the use of these medications and left the room before confirming that the patient had followed the required steps. The patient's care plan included interventions for swallowing problems, asthma/COPD, and nutritional risk, all of which required staff to monitor and assist with medication administration and hydration. Despite these documented needs, the nurse allowed the patient to self-administer medications without a physician's order for self-administration and without providing the necessary assistance or supervision. The nurse also failed to notify the physician when medications were not administered as prescribed, such as when Metoprolol was given more than two hours after the scheduled time and without food. Facility policy required medications to be administered as prescribed, within the appropriate time frame, and with adherence to any special instructions, such as taking medications with food or fluids and rinsing the mouth after inhaler use. The policy also specified that self-administration of medications must be authorized by the physician and documented in the care plan. In this case, the nurse did not follow these policies, resulting in the patient not receiving medications in accordance with physician orders.
Plan Of Correction
C 0900 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025 the RN supervisor immediately assessed patient 9 for any signs of adverse outcome regarding medications that were not administered per MD orders. Vital signs were taken and recorded as follows: BP=139/76, P=68, R=16, O2 Sat=96% and Pain level=0/10. Patient 9 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. RN supervisor provided patient 9 with education on proper method of taking her medication. Patient verbalized understanding. 2. On 10/7/2025 DON initiated and completed a one-on-one in-service with LVN 4 respectively to discuss the policy and procedure (P/P) on medication administration. The emphasis was on accurately following MD orders for specific medications as per MD order and/or pharmaceutical recommendation (i.e. with food with sufficient fluids, rinsing mouth between medications, etc.) DON also discussed the potential of unwanted effects from medications being administered incorrection. DON reiterated the importance of "pour, pass, and sign" medication administration procedure. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025 upon identification of deficient practice, DON, ADON, and RN Supervisor immediately completed a facility round to observe all other charge nurses during medication pass to ensure residents' medications are being administered as ordered. No additional residents were affected by the deficient practice. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025 DON completed an in-service for all nursing staff on "Medication Administration" P/P, how to handle patients with medication refusals, importance of "pour, pass, sign," and MD/RP notification prior to administration of any additional doses. The discussion was followed by question-and-answer evaluation. On 10/30/2025 facility implemented a medication pass audit that will be completed weekly at random selection by the DON, ADON and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C0900
Failure to Administer Medications on Time and Notify Physician
Penalty
Summary
A deficiency occurred when a resident did not receive their scheduled 9 a.m. medications within the required timeframe. The medications, which included Pregabalin, Duloxetine, Famotidine, Fenofibrate, and several others, were not administered within one hour of the prescribed time as required by regulation and facility policy. The delay was confirmed during a medication area inspection and through interviews with nursing staff, who acknowledged that the medications were not given as ordered and that there was no documentation of administration on the Medication Administration Record (MAR) within the required window. Further review revealed that the resident had not received any of their scheduled morning medications by the time of the inspection, and the medications were ultimately administered at 12:29 p.m., more than three hours after the scheduled time. The resident confirmed in an interview that she had not received her morning medications and stated that she does not refuse medication when woken up. Nursing staff also confirmed that the physician was not notified of the missed doses, and no reason for the omission was documented in the resident's records. Additionally, the administration of the next scheduled doses occurred at 4:10 p.m., resulting in two sets of medications being given in close succession. There was no documentation that the resident was monitored or assessed for adverse reactions following the late administration of multiple medications, including anti-constipation and seizure medications. The facility's policy requires medications to be administered within one hour of the prescribed time, and the failure to do so, along with the lack of physician notification and monitoring, constituted the deficiency.
Plan Of Correction
C 0945 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025, the RN supervisor immediately assessed Patient 10 for any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP=124/74, P=76, R=19, O2 Sat=96%, and Pain level=2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert, and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. 2. On 10/7/2025, DON completed a one-on-one in-service with LVN 2 to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. DON also discussed the importance of "pour, pass, sign." DON reiterated that MD be notified of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. C) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of deficient practice, DON, ADON, and RN Supervisor immediately interviewed all other charge nurses regarding any other medication administration delays that took place that day. No additional delays were identified, and no other residents were identified as being affected. MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: An in-service was completed by the DON on 10/28/2025 for all nursing staff on "Medication Administration" policy and procedures. The facility had implemented a Medication Pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations will be corrected immediately, and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 0965 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 4. On 10/07/2025, RN Supervisor immediately assessed patient 2 for any change of condition or abnormality of wounds - no redness, no discharge observed from affected sights (right thigh scab, right pleur x site, and spine suture site). MD was notified. LVN 4, who
Failure to Document and Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure proper documentation and administration of medications and treatments for two patients, resulting in deficiencies related to medication and treatment records. For one patient with chronic respiratory failure, asthma, and pleural effusion, the treatment nurse did not sign the electronic Treatment Administration Record (eTAR) for three ordered treatments on a specific date. The treatments included care for a right thigh scab, a right Pleur X catheter, and a post-surgical spine site. The eTAR was left blank for these treatments, while other dates were properly signed, indicating a lapse in documentation and uncertainty about whether the treatments were administered as ordered. In another instance, a cognitively intact patient with paraplegia and multiple medication orders did not receive their scheduled morning medications at the prescribed time due to refusal. The nurse documented the medications as given before actually administering them, which did not occur until later in the afternoon. This premature documentation could have led to confusion for the oncoming shift and the risk of medications being administered too close together. The nurse acknowledged documenting before administration and recognized the potential for confusion and medication errors. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require that medications and treatments be documented immediately after administration. The facility's policies also emphasize the importance of accurate and timely documentation to ensure continuity of care and adherence to physician orders. The failure to follow these procedures resulted in incomplete records and the potential for missed or improperly timed treatments and medications.
Plan Of Correction
Completed patient 2's treatment on 10/04/2025, immediately completed late entry documentation. On 10/07/2025, the RN supervisor immediately assessed Patient 5 for any change of condition or abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96%, and Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. MD was notified. On 10/7/2025, the DON initiated and completed a one-on-one in-service with LVN 4 to discuss the policy and procedure (P/P) on charting and documentation and timely medication administration. The emphasis was on signing eTAR immediately upon completion of treatment. DON also discussed the potential of unwanted effects from medications being administered too close to the time of the next ordered dose to be given. DON reiterated the importance of notifying the patient's MD of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring period would be done to ensure patient safety, followed by accurate timely documentation. **B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE:** 1. On 10/7/2025, upon identification of deficient practice, DON, ADON, and Treatment Nurse immediately reviewed all eTARS for the last 30 days to ensure that no additional gaps in documentation were identified. No additional residents were affected by the deficient practice. 2. On 10/7/2025, DON, ADON, and RN Supervisor immediately interviewed all the licensed nurses on shift to identify any other delayed medication administration. No further residents were identified to be affected by the deficient practice. 3. The Medical Records Department will continue to do daily treatment audits to ensure that any potential deficient practice does not occur by notifying the DON/Designee immediately. Further, the DON has in-services scheduled for licensed nurses for continuous education and training. **C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR:** 1. On 10/28/2025, DON completed an in-service for all nursing staff on "Charting and Documentation" policies and procedures. The discussion was followed by a question-and-answer evaluation. On 10/30/2025, the facility implemented a weekly eTAR audit to be completed by the Medical Records Department to ensure accuracy and completion of treatment documentation. Audit findings will be provided to DON and/or Designee. 2. On 10/30/2025, the facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. **D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED:** The DON/Designee will report weekly findings for eTAR audits and medication pass audits to the QAPI/QAA committee monthly for three months for recommendations. **E) COMPLETION DATE:** 10/31/2025
Improper Use of Physical Restraints Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of dementia and failure to thrive was found with pillows placed on both sides of their body, restricting their movement. The resident was dependent on staff for activities of daily living and lacked the capacity to make decisions. During an observation, a CNA admitted to placing the pillows during breakfast and forgetting to remove them, acknowledging awareness that such use of pillows could constitute a restraint. Further interviews revealed that the LVN had previously instructed the CNA not to use pillows in this manner to restrict the resident's movement, and confirmed that there were no physician orders for restraints for this resident. The DON also stated that pillows placed in a way that restricts movement and cannot be removed by the resident are considered restraints. Review of facility policy confirmed that restraints should only be used with a physician's order and not for staff convenience or fall prevention, and that any material restricting movement and not easily removed by the resident is considered a physical restraint.
Plan Of Correction
C 1130-Nursing Service - Restraints and Postural Support A) IMMEDIATE CORRECTIVE ACTION: 7. On 10/06/2025, CNA #2 immediately removed patient 4's bilateral pillows. RN Supervisor immediately assessed patient 4 for any change of condition (COC) or adverse effects that may have been caused by the bilateral pillows. No COC noted. MD and RP were notified. 8. On 10/06/2025, DSD completed a one-on-one in-service with CNA 2 on facility's restraint-free environment policies and procedures. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 4. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that no additional residents have pillows by their sides that may be used as restraints. No further residents were identified to be affected by the deficient practice. 5. The Medical Records Department continues to do daily audits on Change of Condition that reflects any incident requiring the use of restraints. At this time, no resident was identified and observed to have any form of restraint at all. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 3. On 10/28/2025, DON completed an in-service for all nursing staff on a P/P: "Restraint Usage." The discussion was followed by question-and-answer evaluation with all participants. On 10/30/2025, Social Services Director and DSD completed additional in-services on a "Restraint Free Environment." The discussion was followed by question-and-answer evaluation. 4. On 10/29/2025, Administrator updated the form "Resident Centered Care Room Rounds Report" to include "Does resident have any objects that may be a restraint?" question on daily rounds to be completed daily by assigned ambassadors and/or Manager on Duty (MOD). Any noted deviations will be corrected immediately, and surveillance tools will be submitted to the DON and/or Designee for monitoring. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Time, no resident was identified and observed to have any form of restraint at all.
Infection Control Lapses in Signage, Precautions, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection control practices. In one instance, a patient with a confirmed diagnosis of COVID-19 was not properly identified with a droplet transmission-based precaution sign outside her room. Although the patient's care plan required standard, contact, and droplet isolation with eye protection and a closed door, only an enhanced barrier precaution sign was posted. The Assistant Director of Nursing and the Infection Preventionist both acknowledged that the correct signage was not in place, which could have led to unintentional exposure of staff, visitors, and other patients to COVID-19. Another deficiency was observed with a patient who had a surgical site infection and was receiving intravenous antibiotics. Despite facility policy requiring enhanced barrier precautions for residents with indwelling medical devices or wounds, there was no EBP sign or PPE supply cart outside the patient's room. Both the Director of Staff Development and the Director of Nursing confirmed that the appropriate signage and precautions were not implemented, contrary to facility policy and infection control standards. Additional lapses in infection control were noted during medication administration. Two nurses failed to perform hand hygiene before administering medications to two patients, and one nurse did not wear gloves while administering eye drops. The soap dispenser in one patient's room was also found to be empty. These actions were inconsistent with the facility's policies on hand hygiene, medication administration, and the instillation of eye drops, as confirmed by the Director of Nursing and review of facility procedures.
Plan Of Correction
The DON/Designee will report daily findings of Room Rounds to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 1270- Nursing Service - Patients with Infectious Disease A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/06/2025, facility Infection Preventionist (IP) immediately replaced the door signage with the appropriate Droplet Precautions signage on patient 1's door to reflect the appropriate isolation precautions. All assigned staff who worked in patient 1's room were tested with a Rapid Antigen Test - all results were negative, and staff were notified to test again on days 3 and 5 and monitor themselves for any signs or symptoms of possible Covid-19. To date, no additional staff have tested positive for Covid-19, and the facility outbreak has been closed. 2. On 10/6/2025, upon identification of deficient practice, CNA 6 immediately donned the correct PPE, and IP immediately placed an EBP sign on the door of patient 6. CNA was immediately provided with a one-on-one in-service by the DSD on Enhanced Barrier Precautions. RN Supervisor immediately assessed patient 6 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. 3. On 10/7/2025, LVN 5 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 11 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 5 on the importance of hand hygiene and hand hygiene protocols during medication administration. 4. On 10/7/2025, LVN 4 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 9 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 4 on the importance of hand hygiene and hand hygiene protocols during medication administration. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 1. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other isolation signage has been posted appropriately and corresponded with the ordered isolation precautions. No additional deficient practices were identified. 2. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other staff providing care to residents on EBP were donning appropriate PPE when providing care. No additional deficient practices were identified. 3. & 4. On 10/7/2025, upon identification of deficient practice, DON, ADON, and IP immediately rounded the facility to ensure that all other charge nurses are completing hand hygiene timely and appropriately during medication administration. No additional deficient practices were identified. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 1. On 10/14/2025, clinical resource consultant completed a one-on-one in-service for the IP on Standard, Enhanced, and Transmission-based Precautions, hand hygiene, PPE use, L.A. County DPH - IPCP Guidelines for SNFs, EBP program, and assessment of all residents for EBP eligibility. 2.-4. On 10/20/2025, DSD completed an in-service for all nursing staff on infection control and types of isolations, EBP, donning and doffing PPE, and hand hygiene. On 10/28/2025, DON completed an in-service for all nursing staff on infection control and types of isolations and signage, EBP, and hand hygiene during medication administration. The discussion was followed by a question-and-answer evaluation. 3. Effective 10/30/2025, IP and/or designee will monitor EBP and other isolation signage during daily facility rounds and document performance on surveillance checklist. 4. Effective 10/30/2025, facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor charge nurses' medication administration performance on proper and accurate medication administration and hand hygiene. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The IP/Designee will report Infection Control Surveillance results to the QAPI/QAA committee monthly for three months for recommendations, if any. DON/Designee will report weekly medication pass audits to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Unlabeled Nonlegend Medication Found at Bedside Without Physician Order
Penalty
Summary
A deficiency was identified when a bottle of Pepto-Bismol, a nonlegend medication, was found at the bedside of a patient without a physician's order. The medication was observed on the patient's nightstand, unopened and without a label. The patient stated that her daughter had brought the medication for her to use if needed, and that it had been on her nightstand for some time. Review of the patient's records showed no order for Pepto-Bismol, and the medication was not listed on the Medication Administration Record. The patient had multiple diagnoses, including end stage renal disease, type 2 diabetes mellitus, and congestive heart failure, and required moderate assistance with activities of daily living. During interviews, facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, confirmed that medications should not be left at the bedside without a physician's order and an assessment for self-administration. The facility's policy requires that any medication brought in by family must be given to licensed staff for labeling, verification of an order, and assessment before being left at the bedside. The presence of the medication at the bedside without following these procedures constituted a failure to prevent unauthorized access to medication and to ensure proper medication management as required by facility policy and regulation.
Plan Of Correction
C2000 - Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/06/2025, the Charge Nurse immediately removed the Pepto-Bismol from the resident's bedside. RN supervisor immediately assessed Patient 7, who is alert and oriented x 4, for any changes of condition and/or adverse effects of having non-prescribed medications at bedside. None were noted. When the RN asked the patient about the medication, she indicated that her daughter brought it for her to use when she needs it. MD and RP were notified. The Charge Nurse obtained an order from the MD for the medication to be given as needed, medication secured in the medication cart, and the RN supervisor explained to the patient about no medications being allowed at bedside until a proper assessment is accomplished. The resident agreed to have the medication stored in the medication cart and to ask the Charge Nurse for it if she ever needed it. The DON completed a one-on-one in-service with LVN 2 regarding policies and procedures for self-administration of medications. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/6/2025, DON, ADON, and DSD immediately rounded the facility to identify any additional medications at residents' bedsides. No additional medications were noted at bedsides. Ongoing daily rounds by the RN supervisor, ADON, DON, and Ambassadors will continue to focus on the presence of medications at bedside. Any presence of medications will be dealt with accordingly. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/29/2025, the Administrator updated the Resident Centered Care Room Rounds Report to ensure room ambassadors are checking resident bedsides for any OTC and/or prescription medications. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Room ambassadors will provide Room Rounds Reports to DON/Designee upon completion, and audit results will be presented and discussed with the QAPI/QAA committee for the next three months to ensure compliance.
Expired Blood Glucose Control Solutions Used for Quality Control
Penalty
Summary
A package containing two bottles of expired blood glucose (BG) control solutions was found stored inside one of the facility's medication carts. The bottles were labeled with a handwritten open date, and according to the manufacturer's instructions, the solutions expired 90 days after opening. Despite this, the expired solutions remained in the cart and were documented as being used for quality control checks after their expiration date. The Licensed Vocational Nurse (LVN) confirmed that the solutions should have been replaced once expired. The Director of Nursing (DON) acknowledged that expired blood sugar control solutions could result in inaccurate blood sugar readings. Facility policy required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, but this procedure was not followed in this instance. The expired solutions were available for use and had been used for quality control checks beyond their expiration date.
Plan Of Correction
C2030 COMPLETION DATE: 10/31/2025 C2030-Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/07/2025, the Charge Nurse immediately removed the expired Control Solution from Medication Cart 1. The DON immediately completed a one-on-one in-service with LVN 2 regarding p/p regarding viability of expired medications and biologicals, with an emphasis on the importance of possible effects on patient's safety and well-being. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of the expired Assure Dose Control Solution, DON, ADON, and RN Supervisor checked all medication carts and medication rooms for any additional expired medications and/or biologicals. No other expired products were identified. Ongoing random monitoring of medication cart reviews are done weekly by the RN supervisor, ADON, and DON while medication pass is in progress to ensure that no biologicals are present in medication cart. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, weekly random medication cart audits will be initiated and completed by the ADON and RN supervisor. Any observed issue will be corrected immediately, and findings will be reported to DON/Designee. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report to the QAPI/QAA committee and discuss findings of random weekly medication cart audits. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025
Missing Performance Evaluations in CNA Personnel Files
Penalty
Summary
The facility failed to maintain current, complete, and accurate personnel records by not including required performance evaluations for four of eight Certified Nursing Assistants (CNAs). During a review of employee records and interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), it was confirmed that there was no documentation of current performance evaluations for these CNAs. The DSD, responsible for completing CNA evaluations, stated that the evaluations were not done and could not provide a reason, noting that the evaluations were due before her employment at the facility. The DON confirmed that performance evaluations are typically conducted after the probationary period and annually, and that these evaluations are essential for identifying staff training and education needs. A review of the facility's policies and procedures indicated that performance evaluations are required at the end of the 90-day probationary period, annually, and after promotions or transfers. The policies also specify that personnel files must include performance appraisals or evaluations. The absence of these evaluations in the personnel files for the identified CNAs was verified through record review and staff interviews, demonstrating noncompliance with both regulatory requirements and the facility's own policies.
Plan Of Correction
C4860-Employee Personnel Records A) IMMEDIATE CORRECTIVE ACTION: On 10/08/2025, DSD immediately completed performance evaluations for CNA 1, CNA 2, CNA 3, and CNA 4. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/8/2025, DSD and Assistant DSD reviewed all current CNA files to ensure the presence of an evaluation within the last 12 months. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, DSD will review all CNA anniversary dates monthly to ensure annual evaluations are completed timely and as per facility protocol. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DSD/Designee will present monthly evaluation completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025 C4905-Employee Personnel Records
Missing Staff Health Exam Documentation
Penalty
Summary
The facility failed to ensure that the personnel files for several certified nursing assistants (CNAs) and licensed vocational nurses (LVNs) contained documentation of required health examinations either 90 days prior to or within seven days after hire, as well as annual health exams thereafter. Specifically, the records for five CNAs and two LVNs did not include evidence of a health exam completed within the required timeframe upon hire. Additionally, the files for two LVNs lacked documentation of annual health exams after their initial employment. During interviews, both the Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged the absence of medical clearance for these staff members. The DSD confirmed that it is now her practice to ensure compliance with health exam requirements for new hires and annual reviews. The facility's policies and procedures require maintenance of personnel records in accordance with state and federal regulations, including documentation of the ability to perform essential job functions, but these were not followed in the cited cases.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/09/2025, DSD immediately contacted CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, LVN 1, and LVN 2 to notify them that they may not return to work until a physical exam is completed. She referred them to a clinic that completed their physicals and provided the facility with their clearance and ability to work. Staff were returned to work upon providing their physical exams to the DSD and/or Administrator. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/8/2025, DSD and Assistant DSD reviewed all other CNA and LVN files to ensure the presence of a health exam within the last 12 months. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, DSD will review all CNA and LVN anniversary dates monthly to ensure annual health exams are completed timely and as per facility protocol. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DSD/Designee will present monthly health exam completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025
Failure to Provide Required Behavioral Health Training to CNAs
Penalty
Summary
The facility failed to provide required in-service training on behavioral health for Certified Nursing Assistants (CNAs), as indicated by the facility's own in-service calendar and policies. A review of the facility assessment showed that residents commonly have psychiatric and mood disorders, including psychosis, impaired cognition, depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and other mental health conditions. The facility's annual in-service calendar scheduled behavioral health training for March, covering care of residents with dementia, mental and psychosocial disorders, substance abuse, PTSD, trauma, and trigger management for all staff. Interviews with two CNAs revealed that neither had received formal in-service or training on behavior management, and one CNA expressed a desire for such education to better handle residents' behaviors. The Director of Staff Development (DSD), who started employment in March, confirmed that the scheduled behavioral health training was not provided and was unsure if the previous DSD had conducted it. Review of personnel files for the two CNAs showed no documented evidence of behavioral health training. Facility policies require annual in-service training for nurse aides and all staff on behavioral health, with training to be completed prior to providing services, annually, and as necessary based on the facility assessment. The policies also specify that training curricula should include learning objectives, performance standards, and evaluation criteria, and that competency may be demonstrated through written exams or consistent application of interventions. Despite these requirements, the facility did not provide or document the required behavioral health training for the sampled CNAs.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential inadequate care and risk of injury. For Resident 27, who was admitted with conditions including dysphasia, dementia, seizures, severe protein-calorie malnutrition, and repeated falls, the facility did not create a care plan addressing the resident's Restorative Nursing Assistant (RNA) exercise program. Despite the resident's severe cognitive impairment and need for substantial assistance in daily activities, the care plan lacked specific interventions and goals for the RNA program, which was crucial for maintaining the resident's function and joint mobility. Similarly, the facility did not develop a comprehensive care plan for Resident 12, who was admitted with dementia, lack of coordination, a subtrochanteric fracture of the right femur, and a history of falls. The resident required maximal assistance for daily activities and had a floor mat placed next to the bed to prevent injury from falls. However, there was no documented evidence of a care plan addressing the use of the floor mat, which was necessary for consistent staff intervention and monitoring of its effectiveness in preventing falls. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the absence of person-centered care plans for both residents. The facility's policies and procedures emphasized the importance of developing comprehensive care plans based on thorough assessments, yet these were not followed, resulting in a lack of structured care and monitoring for the residents' specific needs.
Failure to Update Care Plans for Medication Changes and ADL Needs
Penalty
Summary
The facility failed to update and revise the care plan for a resident undergoing anticoagulation therapy after changes were made to the prescribed medications. Resident 29, who was readmitted to the facility with diagnoses including end-stage renal disease and paroxysmal atrial fibrillation, had their anticoagulant medications changed from Plavix and Aspirin to Eliquis. Despite this change, the care plan was not updated to reflect the new medication regimen, which was confirmed during interviews with the MDS Coordinator and the Director of Nursing. The facility's policy requires care plans to be updated with current medications, but this was not adhered to, resulting in an inaccurate medical record. Another deficiency was identified in the care plan for a resident with severe cognitive impairment and total dependence on staff for activities of daily living (ADLs). Resident 70's care plan lacked specific interventions for grooming, oral hygiene, toileting, showering, and personal hygiene needs. During a review, the MDS Coordinator acknowledged that the care plan should have included specific interventions to ensure the resident's ADL care was tailored to their needs. The absence of detailed interventions in the care plan could lead to inadequate care provision. Additionally, the facility did not update the care plan for a resident who had been prescribed anti-anxiety medication. Resident 12, who had a history of dementia and a recent femur fracture, was prescribed Xanax for anxiety, which was later discontinued. However, the care plan continued to reflect the use of Xanax, leading to potential confusion among staff. The Assistant Director of Nursing confirmed that the care plan was not updated to reflect the discontinuation of the medication, which is contrary to the facility's policy requiring accurate and complete documentation in the medical record.
Inadequate Pain Management Due to Documentation Failures
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Resident 22 and Resident 10, by not assessing their pain before and after administering controlled medications. For Resident 22, tramadol was administered on February 9, 2025, without prior pain assessment or documentation in the Medication Administration Record (MAR). The Licensed Vocational Nurse (LVN) responsible for administering the medication did not sign the MAR, which is crucial for tracking medication administration and ensuring proper pain management. The Assistant Director of Nurses confirmed the lack of documentation and emphasized the importance of signing both the Controlled Drug Record (CDR) and MAR to prevent medication errors and ensure effective pain management. Resident 10 experienced a similar issue with the administration of oxycodone with acetaminophen (Percocet) on multiple occasions. The medication was removed from the blister pack and administered without prior pain assessment or documentation in the MAR. The Director of Nurses and LVN involved confirmed the absence of corresponding entries in the MAR, which is necessary for tracking medication administration and assessing the effectiveness of pain interventions. The facility's policy requires immediate documentation of controlled medication administration, including date, time, and nurse's signature, to ensure accurate medical records and effective pain management. The facility's failure to adhere to its policies and procedures for controlled medication administration resulted in inadequate pain management for both residents. The lack of documentation in the MAR and CDR prevented proper tracking of medication administration and pain assessment, potentially leading to unmanaged pain and diminished quality of life for the residents. The facility's policies emphasize the importance of accurate documentation to prevent medication errors and ensure effective pain relief, which was not followed in these cases.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to a deficiency in medication administration documentation. Resident 22, who was admitted with diagnoses including repeated falls, depression, and anxiety disorder, had orders for Xanax and Tramadol. On a specific date, these medications were removed from the blister pack, as indicated in the Controlled Drug Record (CDR), but were not documented in the Medication Administration Record (MAR). This omission was confirmed by the Director of Staff Development and the Assistant Director of Nurses, who noted the importance of signing both the CDR and MAR to prevent medication errors and ensure proper reassessment of the medications' effectiveness. Similarly, Resident 10, who was admitted with chronic pain syndrome, had orders for Percocet. The CDR showed that Percocet was removed on three separate occasions, but these administrations were not recorded in the MAR. This discrepancy was confirmed during a medication cart observation and record review with a Licensed Vocational Nurse and the Director of Nurses. The failure to document in the MAR could lead to issues such as medication errors and drug diversion, as the MAR is crucial for tracking medication administration and assessing pain relief. The facility's policy and procedure for controlled medications require that the licensed nurse immediately document the administration details in both the CDR and MAR. However, in these cases, the nurses failed to follow this protocol, resulting in incomplete records. The lack of documentation in the MAR for both residents' medications highlights a significant lapse in the facility's adherence to its own policies, potentially compromising resident care and safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer Morphine Sulfate Contin to Resident 72 as ordered by the physician on February 1, 2025. Resident 72, who was admitted with diagnoses including infection and inflammatory reaction to prosthetic devices, acute hematogenous osteomyelitis, cellulitis, and chronic pain syndrome, did not receive the prescribed 30 mg dose of Morphine Sulfate Contin. The Minimum Data Set Nurse confirmed that the medication was not administered, and the Licensed Vocational Nurse assigned to Resident 72 on that day was unavailable for comment. The Director of Nursing acknowledged that the failure to administer the medication as ordered placed Resident 72 at risk for increased pain. The facility also failed to adhere to physician orders regarding the administration of midodrine for Residents 70 and 83. Resident 83, who was admitted with hypertension and heart failure, was given midodrine despite having systolic blood pressure readings above the physician-ordered threshold of 120 mm Hg on multiple occasions in January and February 2025. Licensed Vocational Nurses 3 and 4 confirmed that they signed off on administering the medication even when the blood pressure parameters were not met, potentially putting Resident 83 at risk for elevated blood pressure and complications. Similarly, Resident 70, who was admitted with hypertension and hypotension, received midodrine when their systolic blood pressure exceeded 120 mm Hg on several occasions in January 2025. The Director of Nursing confirmed that the medication should not have been administered under these conditions, as it could lead to elevated blood pressure and associated complications. The facility's policy on medication administration, which requires adherence to physician orders, was not followed in these instances.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During an observation and interview with the Dietary Supervisor, a container bin with a transparent cover containing a whitish powder, identified as a thickener used for pureed diets, was found with a stainless steel scoop inside. The handle of the scoop was buried in the thickener powder, which is against the facility's policy. The Dietary Supervisor acknowledged that the scoop should not have been left inside the bin to prevent contamination of the thickener powder. This practice had the potential to place five residents on pureed diets at risk for foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several deficiencies observed during the survey. In one instance, a resident's room lacked a trash can for disposing of used Personal Protective Equipment (PPE), which is crucial for maintaining transmission-based precautions. This oversight was acknowledged by the Assistant Director of Nursing, who confirmed that the absence of a trash can could lead to the spread of infection to other residents. Another deficiency was observed when a Licensed Vocational Nurse (LVN) exited a resident's room while still wearing an isolation gown, which is against the facility's Enhanced Barrier Precautions (EBP) policy. The LVN's failure to remove the gown before leaving the room resulted in potential contamination of the medication cart. The Infection Preventionist confirmed that the LVN should have removed the gown to prevent the spread of infection, as per the facility's guidelines. Additionally, the facility did not ensure that urinals were properly labeled with resident identifiers, which could lead to cross-contamination. Two residents had unlabeled urinals, one of which was improperly hung on a trash bin. The Director of Nursing acknowledged that this practice could result in the inadvertent use of urinals by other residents, increasing the risk of infection. Furthermore, a medication room was found to contain personal belongings, which is against infection control policies, as confirmed by the Assistant Director of Nursing and the LVN involved.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that staff knocked and requested permission before entering the rooms of two residents, which violated the residents' rights to dignity and privacy. Resident 40, who was admitted with diagnoses including hypertension and type 2 diabetes mellitus, had intact cognitive skills for daily decision-making and required partial assistance with personal care. During an observation, a Certified Nurse Assistant (CNA) entered Resident 40's room without knocking or asking for permission, which the CNA later acknowledged as disrespectful. Similarly, Resident 188, who was admitted with hypertension and depression, also had intact cognitive skills and required substantial assistance with personal care. The same CNA entered Resident 188's room without knocking or asking for permission. The facility's policy on dignity, which was last reviewed in January 2025, mandates that staff must knock and request permission before entering residents' rooms to promote their well-being and self-esteem. The Minimum Data Set Coordinator confirmed that this practice is essential to respect residents' rights and privacy.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives for one resident, identified as Resident 16. The deficiency was identified during a review of Resident 16's clinical records, which revealed that the facility did not maintain a current copy of the resident's advance directives in the resident's chart. This oversight was confirmed during interviews with the Director of Social Services (DSS) and the Director of Nursing (DON), both of whom acknowledged that the advance directive should have been included in the resident's medical record to guide staff in honoring the resident's medical decisions. Resident 16 was initially admitted to the facility with diagnoses including hemiplegia, hemiparesis, gastrostomy, and encephalopathy, and was noted to have severely impaired cognition and total dependence on staff for activities of daily living. The Minimum Data Set (MDS) and History and Physical (H&P) assessments indicated that Resident 16 lacked the capacity to understand and make decisions. Despite this, the facility's failure to maintain the advance directive in the resident's chart posed a risk of not honoring the resident's end-of-life treatment preferences, as outlined in the facility's revised policy on advance directives.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for a resident, specifically in trimming fingernails, which is a part of Activities of Daily Living (ADLs). The resident, who was admitted with diagnoses including hypertension and type 2 diabetes mellitus, was noted to have intact cognitive skills but required moderate assistance for personal hygiene. Despite this, the resident was observed with long and curvy fingernails and expressed a desire for them to be trimmed, indicating that no staff had offered to assist with this task. The facility's policy on Activities of Daily Living, which was last reviewed in January 2025, mandates that residents unable to independently perform ADLs should receive necessary services to maintain personal hygiene. However, during observations and interviews, it was revealed that the resident had not been offered assistance with nail trimming, which could potentially lead to skin tears if the resident scratched herself. This oversight in care was identified as a deficiency in maintaining the resident's personal hygiene and overall well-being.
Failure to Provide Resident-Centered Religious Activities
Penalty
Summary
The facility failed to implement a resident-centered activities program by not providing activities that met the spiritual or religious needs of a resident diagnosed with dementia and schizophrenia. The resident's Admission Minimum Data Set (MDS) indicated that participating in religious services was important to them. However, the care plan for activity preferences did not include any interventions to provide religious services, and the resident was not listed as having participated in any religious activities or received room visitation by a religious representative during the months reviewed. The Activity Director acknowledged that the care plan should have included an intervention to address the resident's preference for religious services. The facility's policy on spiritual and religious activities, which was last reviewed shortly before the survey, stated that such activities should be provided in accordance with residents' preferences and religious affiliations. Despite this policy, the facility failed to arrange for the resident to be visited by a religious provider, thus violating the resident's right to receive religious services.
Failure to Implement RNA Exercise Program for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent a decrease in range of motion (ROM). The resident, who was admitted with multiple diagnoses including dysphasia, unspecified dementia, seizures, severe protein-calorie malnutrition, and repeated falls, had a physician order for a Restorative Nursing Assistant (RNA) exercise program. However, the order was not clarified or implemented, as it did not specify the type of exercises, frequency, or the location of the affected area for partial weight bearing. Interviews and record reviews revealed that the resident's RNA exercise program was not carried out. A Certified Nursing Assistant (CNA) who sometimes worked as an RNA stated that she had never provided RNA exercises to the resident. The Minimum Data Set (MDS) Coordinator and the Director of Rehabilitation confirmed that the resident was enrolled in a hospice program, and as such, was not evaluated by the rehabilitation department. They acknowledged that the physician's order for the RNA exercise program required clarification, which was not done by the licensed staff. The facility's policies and procedures indicated that residents with limited ROM should receive treatment to prevent further decline, with care plans developed by the interdisciplinary team. However, the resident's restorative treatment records showed no entries for the months reviewed, indicating a lack of implementation of the RNA exercise program. This deficiency had the potential to place the resident at risk for further ROM decline.
Failure to Communicate Nutritional Intake and Meal Refusals
Penalty
Summary
The facility failed to provide appropriate care and services to maintain acceptable parameters of nutritional status for a resident, identified as Resident 27. The deficiency involved a lack of communication with the facility's Registered Dietician (RD) regarding the resident's nutritional intake percentage and failure to inform the resident's physician about the resident's refusal to eat, as indicated in her care plan. This oversight had the potential to place the resident at risk for weight loss. Resident 27 was admitted to the facility with diagnoses including dysphasia, unspecified dementia, seizure, and severe protein-calorie malnutrition. The resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills for daily decision-making and required staff supervision or assistance when eating. Despite a stable weight, the resident's meal intake log showed consistently low intake percentages, ranging from 0-25%, with multiple instances of meal refusals. Interviews with facility staff, including Certified Nursing Assistants (CNAs) and the MDS Coordinator, revealed that the resident frequently refused meals, yet there was no documentation of notifying the physician or the RD about these refusals. The facility's policy required such notifications to ensure timely assessments and interventions, but this was not followed, leading to the deficiency.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily as required by their policy and procedure on Staffing, Sufficient and Competent Nursing. On multiple occasions, the Director of Staff Development (DSD) was observed posting projected hours instead of actual hours, with the explanation that actual hours would only be available after payroll calculations the following day. This practice was observed on 2/11/2025 and 2/13/2025, where the posted documents at the nursing station contained either projected hours or were missing actual hours entirely. The Director of Nurses (DON) confirmed that the actual hours should be documented and posted by 11 a.m. after the stand-up meeting, once the DSD knows which staff is present. However, the DSD misunderstood the requirement, believing that only projected hours needed to be posted initially, with actual hours to be completed at the end of each 24-hour patient day. This misunderstanding led to the failure to post accurate staffing information, potentially keeping residents and visitors unaware of the actual staffing levels in the facility.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor a resident for side effects of Trazadone and Xanax, which are psychotropic medications. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who had been readmitted to the facility with various medical conditions including infection and inflammatory reaction to prosthetic devices, was prescribed Trazadone for depression and Xanax for anxiety. The physician orders required monitoring for side effects of these medications every shift. However, documentation was missing for the monitoring of side effects on a specific date, indicating that the licensed nurses did not perform this required task. During interviews, the Director of Nursing emphasized the importance of monitoring for side effects to determine if medication dosages needed adjustment and to prevent the resident from receiving unnecessary medication. The facility's policy on psychotherapeutic medication use also required monitoring for adverse consequences and documentation of the prescriber's rationale if medications were continued despite potential adverse effects. The lack of documentation and monitoring for side effects constituted a failure to adhere to these policies, potentially placing the resident at risk of adverse side effects from unnecessary medication.
Resident-to-Resident Altercation Involving Water Throwing
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident threw water at another resident, resulting in physical contact with the resident's face, chest, and clothes. This incident involved Resident 1, who had been admitted to the facility with diagnoses including congestive heart failure, ventricular tachycardia, and hypertension. Resident 1 was noted to have fully intact cognition and the ability to understand and make decisions. The altercation occurred when Resident 1 became frustrated after being asked to turn down the television and subsequently threw water at Resident 2. Resident 2, who had been admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and generalized anxiety disorder, was subjected to this act of aggression. The facility's investigation substantiated the abuse, confirming that Resident 1 intentionally threw water at Resident 2. Interviews with both residents corroborated the event, with Resident 1 admitting to the action and Resident 2 confirming the incident. The facility's administrator acknowledged the altercation but believed it was a spontaneous action that could not have been prevented.
Failure to Monitor Acute Condition Changes
Penalty
Summary
The facility failed to implement its policy on monitoring acute condition changes for a resident who experienced hematuria. The resident, admitted with multiple diagnoses including metabolic encephalopathy, hereditary deficiency of clotting factors, unspecified dementia, paroxysmal atrial fibrillation, and heart failure, was prescribed Xarelto, a blood thinner. Following a change in condition where the resident was found to have blood in her urine, the physician ordered the Xarelto to be held for three days. However, the facility did not monitor the resident for signs and symptoms of bleeding every shift as required by the order. The MDS Nurse confirmed that there was no specific documentation of monitoring for hematuria on several shifts following the change in condition. The facility's policy on acute condition changes requires staff to monitor and document the resident's progress and responses to treatment, which was not adhered to in this case. The lack of documentation and monitoring could have led to confusion in care and services for the resident, as the facility's policy also emphasizes the importance of communication between the interdisciplinary team regarding the resident's condition and response to care.
Failure to Implement Contact Precautions for Resident with Scabies
Penalty
Summary
The facility failed to implement infection control practices by not ensuring contact precautions were in place for a resident diagnosed with dermatitis consistent with scabies upon their return to the facility. The resident, who had a history of cervical spondylosis and actinic keratosis, was readmitted to the facility after being transferred to a general acute care hospital for a skin wound or ulcers. The hospital discharge instructions indicated the resident had a rash and was diagnosed with scabies, requiring treatment with permethrin cream. However, upon the resident's return, no contact precaution signage was posted, and staff were not informed to use isolation gowns, leading to inadequate infection control measures for several days. During an interview, the CNA assigned to the resident for two days stated she was unaware of the need for contact precautions and only used gloves while providing care. The Director of Nursing confirmed that the resident should have been placed on contact precautions immediately upon return to the facility but was not until several days later. The facility's policies on infection control and scabies treatment were reviewed, indicating that residents with scabies should be on contact precautions during the treatment period. The failure to follow these policies resulted in a potential risk of spreading scabies and cross-contamination among staff and other residents.
Failure to Develop Comprehensive Care Plan for Resident with Scabies
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident diagnosed with dermatitis consistent with scabies. The resident, who had intact cognition and was dependent on staff for various activities, was transferred to a general acute care hospital for evaluation of skin rashes and itching. Upon return, the resident's care plan did not include specific interventions for the scabies diagnosis, and there was no contact precaution signage posted in the resident's room. The resident had been experiencing on and off skin itchiness for months and had been diagnosed with scabies by his physician. During a review of the resident's care plans and interviews with the Director of Nursing and the Infection Preventionist, it was confirmed that the facility did not develop a comprehensive care plan upon identification of the resident's skin rashes and scabies diagnosis. The facility's policies and procedures indicated that care plans should reflect currently recognized standards of practice and be revised as the resident's condition changes. However, this was not done in this case, leading to a potential delay or lack of necessary care and services for the resident.
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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