Rio Hondo Subacute & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montebello, California.
- Location
- 273 E Beverly Boulevard, Montebello, California 90640
- CMS Provider Number
- 056487
- Inspections on file
- 114
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 74
Citation history
Health deficiencies cited at Rio Hondo Subacute & Nursing Center during CMS and state inspections, most recent first.
A resident with CHF, type 2 DM, gait abnormalities, toe amputations, and moderately impaired cognition, who required supervision for transfers and ambulation and was known to walk the halls and sit at the nurse’s station at night, was admitted without completion of a required Leave of Absence without Notice (LAWN) elopement risk assessment or an elopement care plan. One night, after sitting in a wheelchair at the nurse’s station with no staff present, the resident stood, walked to the front entrance, followed an unidentified woman, and exited through a front door that was propped open and programmed so its alarm only sounded if held open for at least one minute. The resident left the building unnoticed, leaving the wheelchair at the front door, walked away, and remained missing for several hours until found at a nearby bus stop, while staff later confirmed that the admission elopement assessment had not been completed as required by facility policy.
A resident with quadriplegia and intact cognition reported missing personal belongings from a van parked on facility property and stated he had spoken with multiple staff, but his concerns were not addressed. The grievance was not documented in the facility’s grievance binder, and the ADM acknowledged there was no follow-up or documented resolution, despite the van remaining on-site. The SSA reported discussing the van with the resident and offering a grievance but could not recall documenting any communication or details of the belongings, while also noting that grievances are typically resolved within a short timeframe. Review of the facility’s grievance policy showed that staff were required to initiate and log grievances and that leadership and social services were responsible for investigation and follow-up, which did not occur in this case.
A resident admitted without pressure ulcers and with paraplegia and severe mobility limitations did not receive a completed Braden Scale risk assessment, and no pressure ulcer prevention care plan or specific interventions such as repositioning or a low air loss mattress were implemented. Over several days, staff documented no skin breakdown, and the IDT did not address pressure ulcer risk, while the resident remained on a regular mattress and required maximal assistance for turning and hygiene. A family member later discovered redness and open skin on the buttocks during an incontinent brief change, after an earlier refused change and unknown duration of soiling. An LVN subsequently documented a DTI on the buttock and a Stage 3 sacrococcygeal ulcer but did not measure the wound, did not timely enter or implement treatment orders, and no wound care was documented for the first two days after identification. Later assessment documented a 5 x 7 x 0.2 cm Stage 3 sacrococcygeal ulcer requiring surgical debridement, and leadership confirmed failures in admission risk assessment, care planning, wound measurement, and timely treatment, which the report states placed the resident at risk for infection, discomfort, and pain.
A cognitively intact resident with sepsis and type 2 DM, who required assistance with ADLs and had a care plan emphasizing her preference for meaningful daily routines and choice of bathing method, did not receive a shower on her regular shower day. Documentation for that day showed no bath type provided, and the resident reported that staff often failed to help her shower despite repeated requests, causing her to feel depressed and useless. The assigned CNA stated she initially offered a shower, which the resident declined at that moment due to pain, but then did not return to re-offer the shower, did not arrange for another staff member to assist, and did not notify anyone that the shower was missed, explaining she was too busy and forgot, contrary to the DON’s expectation that missed showers be reported so they can be completed.
A cognitively intact resident with a history of substance abuse and prior overdose had an active care plan requiring monitoring for signs of substance use, but staff did not document such monitoring despite repeated episodes involving contraband and substance use. Over time, staff observed the resident with vape devices, pills, and marijuana-like smoke in the room, and later saw the resident smoking an unknown substance outside with a family member, yet the care plan was not meaningfully revised and no consistent monitoring was documented. The same family member later admitted giving the resident alcohol after the resident was found vomiting with alcohol odor and was hospitalized for alcohol intoxication, but the facility still allowed this visitor and others to continue unsupervised, unrestricted visitation, and did not inform the MD of earlier incidents or instruct staff on specific behaviors to monitor, contrary to the facility’s own visitation and substance use policies.
A resident with sepsis and type 2 DM, who was cognitively intact, reported to a dialysis social worker that facility staff failed to respond to requests for assistance and behaved unprofessionally, including cursing while at work. The dialysis social worker twice contacted the facility SSD about these concerns, and the SSD initially stated she would follow up with the resident, but there was no documentation of the grievance in the grievance log or progress notes and no written resolution provided. In interviews, the resident and the dialysis social worker reported that no one from the facility had addressed the concerns, and the SSD acknowledged she does not document verbal concerns or initiate grievance forms unless specifically requested, resulting in no recorded grievance or resolution for this resident.
A cognitively intact resident with hemiplegia reported that a CNA handled him roughly during incontinence care, causing pain and prompting him to scream, which was corroborated by his roommate and reported by a family member to an LVN and an RN. The facility’s abuse policy required immediate identification of possible abuse, removal of the alleged perpetrator from duty, initiation of an investigation within two hours, protection of the resident during the investigation, and timely reporting to appropriate agencies, but staff did not recognize or process the complaint as an abuse allegation. Although the CNA was briefly reassigned that shift, the CNA was placed back on assignment with the same resident on a later shift, the Administrator/abuse coordinator was not notified, and no timely investigation or mandated protective measures were implemented, resulting in noncompliance with the facility’s abuse prohibition procedures.
A resident with hemiplegia and intact cognition and the resident’s family member reported to an LVN that a CNA was rough during incontinence care and caused pain, and the family member requested that the CNA not be assigned to the resident again. The facility’s abuse policy required reporting alleged abuse to CDPH, law enforcement, the Ombudsman, and other agencies within two hours, initiating an investigation, and protecting residents from further harm, but the LVN did not notify the ADM or DON and no required external reports were made. Staffing records later showed the same CNA was reassigned to the resident on a subsequent night shift, after which the family member found the resident in a soaking wet brief and the resident reported that no one had checked on him during the night.
A resident with a history of substance abuse and paraplegia was not adequately assessed, monitored, or supervised despite multiple documented episodes of suspected and confirmed substance use. Staff noted a frequent visitor staying overnight with suspicious behavior, observed the resident vaping what smelled like marijuana in his room, and found vape pens and non‑prescribed erectile enhancement pills in his belongings, but there was no thorough investigation, consistent monitoring, or timely physician notification. The resident, who was under the legal smoking age and assessed as unable to safely hold a cigarette, was later seen outside with a visitor placing an unknown smoking material in his mouth, and no sustained reassessment or structured supervision of visits followed. On a subsequent visit, staff found the room smelling of smoke, marijuana, and alcohol, and the resident was vomiting and foaming at the mouth; the visitor admitted providing alcohol, and the resident was diagnosed with acute alcohol intoxication. Despite these events, the same visitor continued to have unsupervised and unrestricted access, and staff reported they were not directed to monitor for substance use behaviors or to control contraband brought in by visitors.
A paraplegic resident with intact cognition and a history of substance use disorder had a physician order for an electric wheelchair to address mobility needs, but the facility did not follow through on obtaining the device. The Social Services policy required provision of medically related social services, including ambulation equipment, yet there was no documented follow-up by the case manager after the order. An IDT later decided against providing the electric wheelchair due to concerns about the resident’s prior fentanyl use and recent contraband incidents, despite the resident relying on a manual wheelchair that he could not safely self-propel, as confirmed by PT. The resident and family reported ongoing requests for the electric wheelchair, feelings of isolation, and restricted freedom of movement, while facility leadership gave conflicting accounts of Social Services’ responsibility for arranging DME for custodial residents.
A resident who was cognitively intact and fully dependent on staff due to quadriplegia was subjected to derogatory and inappropriate comments by two CNAs during a fecal disimpaction procedure. The CNAs engaged in personal conversation and made offensive remarks in the resident's presence, causing the resident to feel uncomfortable and upset. Facility policy required staff to treat residents with dignity and respect at all times, and the incident was confirmed by staff interviews.
A resident with Parkinson's Disease and a history of falls did not have required bolster pillows attached to the bed as outlined in the care plan, despite being dependent on staff for mobility and having frequent involuntary movements. Multiple staff confirmed the absence of bolsters, and observations showed the intervention was not implemented after room transfer, leading to continued risk of falls.
A resident with severe cognitive impairment and a stage 4 pressure ulcer was not adequately represented in care planning, as the responsible party was not included in interdisciplinary care conferences and was only given limited information after meetings. Staff did not provide regular or detailed updates about the wound's stage or treatment, leaving the responsible party unaware of the wound's severity and progression, in violation of facility policy.
A resident with multiple medical conditions did not receive prescribed nystatin cream, Zoryve foam, and normal saline flushes as ordered, with facility records showing missed administrations and blank documentation. Nursing staff confirmed these treatments were not given or documented, and the resident reported not receiving his medications, contrary to facility policy requiring timely administration and documentation.
A resident with severe cognitive impairment and a stage four pressure ulcer did not have consistent documentation of required turning and repositioning every two hours, as ordered by the physician. Facility staff, including CNAs and nurses, failed to record care in accordance with policy, resulting in multiple gaps in the medical record over several days.
The facility did not post accurate and current nurse staffing data as required, instead displaying outdated and projected staffing hours rather than actual hours worked for each shift. This occurred after the staff member responsible for updating the postings went on leave, and no other staff was assigned to maintain the daily updates.
Two residents experienced deficiencies in dignity and respect when one waited at least 19 minutes for staff response after activating a call light, despite staff presence at the Nurses' Station, and another was subjected to derogatory language by a CNA and subsequently felt neglected. Both incidents were confirmed through interviews, observations, and record reviews, showing a failure to follow facility policies on timely response and respectful communication.
A resident with cognitive impairment and a history of inappropriate physical contact did not have a comprehensive, person-centered care plan that clearly defined behaviors to monitor or provided specific interventions for one-to-one supervision. Facility staff failed to consistently implement the required supervision, and the care plan lacked sufficient detail to guide staff actions, resulting in lapses in monitoring after reported incidents.
A resident with a right ankle fracture experienced ongoing pain and refused to ambulate, but staff failed to consistently assess, document, and communicate the pain to the NP or physician. Despite policy requirements, pain assessments and reassessments were incomplete, and pain interventions were not always evaluated for effectiveness, leading to poor pain control and decreased mobility.
Surveyors found that the facility did not have an infection prevention and control program in place, indicating a lack of systematic measures to address infection risks for residents and staff.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident's prescribed medications were left unattended at the bedside and documented as administered in the MAR, despite not being taken. The nurse placed the medications on the bedside table and left the room, contrary to facility policy requiring medications to be given in the nurse's presence. The resident, who was alert and cognitively intact, had a history of missed and incorrect medication administration, as noted in multiple care plans.
A resident's room was found cluttered and unsanitary, with trash, empty boxes, and used utensils left for about two weeks, despite facility policy and a care plan requiring a clean, clutter-free environment. The resident, who was fully alert and had chronic medical conditions, reported the ongoing issue, and the ADON confirmed that staff did not ensure regular cleaning or removal of debris.
Two residents experienced unsafe transfers when staff failed to use the correct size sling and did not follow two-person assistance protocols during mechanical lift transfers. One resident fell and sustained a head injury after being transferred with a sling that was too small, while another was transferred by a CNA working alone, contrary to policy. Staff interviews revealed a lack of training and awareness regarding sling sizing and safe transfer procedures.
A resident with chronic pain syndrome and multiple comorbidities experienced unrelieved pain after staff failed to ensure timely physician authorization and pharmacy delivery of a fentanyl patch, resulting in missed doses. Despite the resident's repeated reports of severe pain, staff did not consistently assess or document pain levels according to the care plan, and communication lapses led to delays in addressing the medication shortage.
A facility failed to ensure that CNAs were properly trained and competent in selecting the correct sling size for use with a mechanical lift, resulting in a resident with significant mobility impairments being transferred with an incorrectly sized sling. The resident slipped from the sling, sustained a head injury, and required hospital evaluation. Staff interviews and record reviews revealed widespread lack of training and awareness regarding sling sizes, and the facility's competency assessments did not address this critical aspect of safe resident transfer.
Two residents who required mechanical lift transfers did not have comprehensive care plans developed or implemented to address their assessed needs. One resident experienced a fall and head injury after being transferred with an incorrectly sized sling by two CNAs who lacked training on sling selection. Another resident, fully dependent for transfers, was observed being transferred by a single CNA despite the requirement for two-person assistance. In both cases, the absence of individualized care plans and clear instructions led to unsafe transfer practices.
A resident with a low potassium level and physician's order for daily KCL did not receive all prescribed doses, despite the MAR indicating administration. Physical counts of medication packets showed three doses were missed, and both the resident and a family member reported missed administrations. Nursing staff documented KCL as given even when it was not, leading to a discrepancy confirmed by the pharmacist and DON.
A resident with multiple serious diagnoses expired, but their medications remained in a locked box in the medication room, with staff unaware of the contents or how to access them. The facility lacked a specific policy for handling medications after a resident's death, and there was no record of the drugs stored, creating a risk for diversion or misuse.
A facility failed to maintain a complete and signed inventory of a resident's personal effects, omitting the resident's car and car keys from documentation. The omission was discovered after the resident's car, which had been parked and vandalized on facility property for an extended period, was involved in a fire and subsequently towed for an arson investigation. Staff and family interviews confirmed the car's presence and lack of documentation, and facility policy requiring proper listing and signatures was not followed.
Facility staff failed to address an abandoned, vandalized vehicle belonging to a resident, which remained in the parking lot for about two years in a state of disrepair. Despite being observed by multiple staff members, the car was not reported or removed, eventually catching fire and requiring emergency response. The incident placed residents, staff, and visitors at risk, and the vehicle was later determined to be involved in an arson investigation.
The facility failed to develop, revise, and implement individualized care plans for two residents, including one with COPD and a hematoma who did not have care plans addressing oxygen therapy or new skin issues, and another with severe immobility and a Stage 3 pressure injury who did not receive timely incontinence care or repositioning as required. Staff did not update care plans to reflect changes in condition, and documentation was inconsistent with facility policy.
Two residents at risk for skin breakdown did not receive care in accordance with their care plans and facility policy. One resident with a Stage 3 pressure ulcer and MASD was not checked for incontinence or repositioned as required, remaining on his back for over six hours. Another resident with a hematoma and skin discoloration on the trunk had no care plan or interventions developed or implemented for the condition, and documentation of skin assessments was inconsistent. Staff interviews and record reviews confirmed these deficiencies in care and documentation.
A resident with ESBL resistance in the urine did not have Enhanced Barrier Precautions implemented as ordered, including the absence of required signage and PPE availability. Staff were unaware of the need for EBP, and direct care was provided without appropriate PPE during medication administration and incontinence care, contrary to facility policy and physician orders.
A resident with multiple medical conditions reported being punched on the leg by a nurse. The allegation was documented by an LVN but was not reported to CDPH, the Ombudsman, or law enforcement within the required two-hour window, as mandated by facility policy. The DON became aware of the incident two days later and then made the required reports, resulting in a delay in investigation.
A resident with a history of falls and impaired balance slipped to the floor during a transfer when wheelchair brakes were not properly locked. After the fall, CNAs moved the resident without a licensed nurse assessment, and the incident was not documented or reported according to facility policy.
A resident with COPD and heart failure did not receive appropriate respiratory care due to missing documentation, lack of clear physician orders for oxygen therapy parameters, and absence of a comprehensive, individualized care plan. Staff failed to document when oxygen was administered or discontinued, did not notify the physician about the resident's oxygen needs, and did not follow facility policies for monitoring and care planning.
A resident with chronic pain and recent leg surgery experienced severe, unrelieved pain after readmission when only acetaminophen was available, despite clear indications that stronger pain management was needed. Staff did not assess or address the resident's pain adequately, and appropriate pain medication was not provided until the following day, contrary to the facility's pain management policy.
The facility failed to provide adequate supervision and enforce safe storage of smoking materials for several residents who required supervision, resulting in a smoking-related incident where a resident set fire to bed linens and multiple residents were found with unsupervised access to cigarettes and lighters. Staff were not consistently aware of residents' possession of smoking materials, and required Interdisciplinary Team meetings and care plans addressing smoking safety were not completed for all residents who smoked.
A resident with alcoholic cirrhosis did not receive necessary behavioral health services, including psychiatric referral and person-centered care planning, despite documented agreements and observed behaviors indicating ongoing risk. Facility staff did not implement or document interventions for substance abuse, and required behavioral health services were not provided.
A resident with diabetes and a history of hypoglycemia was readmitted from the hospital without proper review or implementation of discharge orders for blood sugar monitoring and insulin administration. Nursing staff failed to clarify missing orders, did not monitor for hypoglycemia or hyperglycemia, and administered insulin without checking blood sugar. When the resident developed severe hypoglycemia and altered consciousness, staff delayed emergency response and failed to notify the physician promptly, resulting in the resident's transfer to the ICU and subsequent death.
Two residents were not protected from physical abuse by another resident with a history of aggression. After one resident was struck with a metal bar, the aggressor was moved to share a room with a legally blind resident, who was later hit in the face with a radio. Staff failed to assess roommate compatibility, did not act on reports of aggressive behavior, and did not follow abuse prevention policies, resulting in harm and emotional distress to both victims.
A physical altercation occurred between two residents, where one was reportedly struck by another using a wheelchair armrest. Staff failed to obtain separate, accurate statements from both residents and did not conduct a comprehensive investigation as required by facility policy. Documentation was incomplete, and the administrator could not provide evidence of a thorough investigation into the incident.
A resident with a history of acute respiratory failure and diabetes was transitioned to an oral diet, and GT feedings were stopped. After a failed attempt by a PA to remove the GT, staff did not promptly refer the resident to a GI specialist as recommended, resulting in the tube remaining in place and not being flushed for several weeks. Facility staff did not follow up on the recommendation or notify the attending physician, contrary to facility policy.
A resident requiring hemodialysis did not receive timely assistance to be ready for scheduled treatments, resulting in frequent delays in transportation and late dialysis sessions. Facility staff also failed to document post-dialysis assessments, vital signs, and return times as required by policy, leading to incomplete records and delayed care.
A resident with renal failure and diabetes had significant discrepancies in weight documentation, with staff copying weights from hemodialysis records without reweighing the resident. The RD and nursing staff did not verify or address the incorrect weight entries, resulting in inaccurate records despite facility policy requiring accurate and timely weight documentation.
The facility failed to implement an effective infection prevention and control program, leading to the spread of scabies among residents. A resident diagnosed with scabies did not receive timely treatment, and their roommate was not placed under contact isolation as required. The infection preventionist did not adequately manage the situation, resulting in potential transmission of the infection.
Three residents at high risk for falls experienced repeated incidents due to the facility's failure to update care plans, analyze root causes, and implement effective interventions. One resident suffered a fractured ankle after multiple falls without timely care plan updates, another fractured a shoulder after slipping on medication powder left on the floor, and a third was repeatedly found on the floor due to inadequate supervision and staff communication. Staff interviews confirmed lapses in monitoring, environmental safety, and individualized care planning.
Multiple residents with catheters or incontinence experienced delayed physician notification of critical lab results, inconsistent monitoring and documentation of catheter care, and inadequate incontinence care, leading to recurrent UTIs and hospital transfers. Staff did not consistently follow protocols for assessment, documentation, or timely reporting of significant changes in condition.
Four residents did not receive proper pressure ulcer care, including one who developed and experienced worsening of pressure ulcers due to inconsistent repositioning and incontinence care. Two residents with healed ulcers did not have their low air loss mattresses set or checked as ordered, and another resident with a Stage 4 ulcer lacked weekly wound assessments and communication with the wound specialist. Documentation and monitoring practices did not meet facility policy requirements.
Failure to Assess Elopement Risk and Secure Entrance Door Leads to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to implement required elopement risk assessments and care planning, and to maintain environmental controls to prevent a resident from leaving the building unnoticed. The resident was admitted with diagnoses including congestive heart failure, type 2 DM, abnormalities of gait and mobility, and amputation of the right great toe and other right toes. An MDS dated 4/13/2026 documented moderately impaired cognition and a need for supervision or touching assistance for sit-to-stand and walking 50 feet with two turns, and staff reported the resident liked to walk around the facility and had a habit of being up at night in a wheelchair near the nurse’s station. Despite these factors, the admission record and subsequent chart review showed no completed elopement assessment or Leave of Absence without Notice (LAWN) assessment, and the care plan from 4/1/2026 to 4/23/2026 contained no elopement care plan, contrary to facility policy requiring LAWN evaluation upon admission and at set intervals. In the early morning hours of 4/23/2026, the resident was last seen by the night-shift RN at the nurse’s station at approximately 2:20–2:31 AM, after which the resident was no longer present. The resident later reported that, after sitting in the wheelchair in front of the nurse’s station and noticing no staff present, he stood up, walked to the front entrance, and followed an unidentified woman to the front door. The resident stated the front entrance door was propped open with no staff present, allowing him to walk out of the facility, cross several streets, and go to a bus stop where he slept for a few hours while waiting for a bus. The resident’s wheelchair was later found left at the front door, and facility documentation indicated the resident had eloped from the facility on foot at about 2:20 AM. Environmental observations and staff interviews showed that the front entrance door was programmed so that the alarm would only sound if the door was held open for at least one minute, and that all other doors were locked at night while the front entrance remained accessible. The maintenance supervisor demonstrated that the front door alarm did not activate until the door was held open for one minute, and the RN confirmed that if a resident exited and closed the door, no alarm would sound and staff would not immediately know a resident had left. The DON and ADON confirmed that the admitting RN was responsible for completing the LAWN assessment upon admission and that this had not been done for this resident, despite facility policies stating that residents at risk for wandering or elopement are to be evaluated by the IDT and monitored, with precautions taken to ensure their safety. The resident remained missing for approximately 3.5 hours before being located at a nearby bus stop and assessed as alert, oriented, and in no distress.
Failure to Document and Resolve Resident Grievance About Missing Belongings
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and resolve a resident’s grievance regarding missing personal belongings from his van and to keep him informed of progress toward resolution, as required by the facility’s grievance policy. The resident was readmitted with diagnoses including quadriplegia, atherosclerosis of native arteries of other extremities with ulceration, and chronic pain syndrome. A History and Physical dated 1/3/2026 and an MDS dated 4/1/2026 documented that the resident had decision-making capacity and intact cognition. A complaint received on 4/17/2026 indicated the resident had previously reported missing belongings from his car, including a speaker, stereo, clothing, wires, and miscellaneous items. During an interview, the resident stated he had spoken with several unidentified facility staff about his van and personal belongings, but his concerns were not addressed. He indicated he no longer wished to discuss the incident and reported that he had spoken with the Ombudsman. Review of the facility’s grievance binder showed no documented grievances for this resident from 11/2025 through 04/2026. The Administrator acknowledged that the resident had a van parked at the facility, that he did not follow up with the resident regarding the missing items, and that there was no documentation of any resolution. The Administrator further stated that nothing had been done to resolve the resident’s grievance and that the van remained in the facility parking lot. Observations of the van showed it parked with windows closed, doors locked, no exterior damage, and a damaged steering wheel with some miscellaneous personal items inside. The Maintenance Supervisor reported the van was delivered by an auto-insurance company and left in the middle of the parking lot. The Social Services Assistant stated he spoke with the resident, who asked how the van got there, and he replied that he did not know. The Social Services Assistant recalled that there was a lot of the resident’s belongings in the van but could not specify what they were, did not notice if the steering wheel was broken, and could not recall documenting any communication with the resident about the van, belongings, or offering a grievance. He stated any staff could write a grievance on behalf of a resident, that grievances are given to social services and forwarded to the appropriate department, that the resident did not file a grievance about the van, and that grievances usually have a 48‑hour resolution. The facility’s grievance policy required staff to initiate a Grievance/Concern Form upon receipt of a concern, document it on the Grievance/Concern Log, and for leadership to investigate, document, and follow up on all formal concerns, with the Administrator serving as Grievance Officer and social services serving as resident advocates; these steps were not carried out for this resident’s concerns.
Failure to Assess, Care Plan, and Treat Leading to Development of Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and treatment for a newly admitted resident who was admitted without pressure ulcers and had paraplegia, muscle weakness, and lack of coordination. The admission record and history and physical documented no pressure ulcers on admission, and therapy evaluations showed the resident required maximal assistance for bed mobility, activities, and personal hygiene. Despite this high-risk profile, the Braden Scale for Predicting Pressure Ulcer Risk completed on the admission date was left incomplete, with no scoring or staff signature, and the resident’s risk level for pressure ulcer development was not determined as required by the facility’s Skin Integrity Management policy. From admission through several days, weekly body checks documented no skin breakdown, and the interdisciplinary care conference did not identify or address any pressure ulcer risk or presence. From admission through more than a week, the facility did not develop a comprehensive care plan with specific interventions to prevent pressure ulcers for this resident. No care plan was in place to address pressure ulcer prevention or to incorporate interventions such as repositioning, use of a low air loss mattress, or incontinence management, despite the resident’s dependence on staff for turning and repositioning. During this period, the resident remained on a regular mattress rather than a low air loss mattress. On one day, the resident’s family member assisted a CNA with an incontinent brief change and observed new redness and open skin on the buttocks/sacrococcyx area that had not been present previously. The CNA reported that the resident had refused an earlier brief change, did not know how long the brief had been soiled, and did not directly observe the buttock area during the change because she was holding the resident while the family member performed the cleaning. Later that same day, an LVN was informed by the family member about the skin issue and initially had not yet assessed the resident’s skin or notified the physician. After assessing the resident, the LVN documented a change in condition note indicating a deep tissue injury on the left buttock and a Stage 3 pressure ulcer with surrounding deep tissue injury on the sacrococcyx and reported notifying the physician with a recommendation for wound consultation and treatment orders. However, there was no documentation of physician wound treatment orders on that date, and the wound was not measured for length, width, depth, or other characteristics at the time of initial identification. Physician orders for wound treatment were documented the following day, directing cleansing with normal saline, application of Medi-Honey and barrier cream to the sacrococcyx Stage 3 ulcer, and zinc oxide to the left buttock DTI. The MAR/TAR showed no evidence that any initial wound or skin treatments were provided on the day the Stage 3 ulcer was identified, and no evidence that the ordered treatments were performed the following day. The LVN later stated she had received a telephone order for treatment but did not enter it into the electronic MAR/TAR because she did not know how, and she did not perform the initial wound treatments, assuming treatment nurses would do so. Subsequent wound assessment by a physician assistant documented a Stage 3 pressure ulcer on the sacrococcyx with purple discoloration, measuring 5 cm by 7 cm by 0.2 cm, with light serosanguineous drainage, and noted that surgical debridement was performed. Later observations confirmed the resident continued to lie in bed without a low air loss mattress, even after the pressure ulcer was identified. A Braden Scale completed several days after ulcer identification showed the resident at moderate risk for pressure ulcer development. Nursing leadership and staff interviews confirmed that the Braden Scale had not been properly completed on admission, that no pressure ulcer prevention care plan had been developed from admission through the period when the ulcer developed, that the wound was not initially measured, and that ordered wound treatments were not provided on the first two days after identification. Staff also acknowledged that the resident required assistance of two people for turning and repositioning and that interventions such as repositioning, maintaining clean and dry skin, frequent incontinence care, and use of a low air loss mattress were standard preventive measures that were not implemented in a timely manner for this resident. The report states that as a result of these deficient practices, the resident developed a deep tissue injury and a Stage 3 pressure ulcer on the sacrococcyx that required surgical debridement. The report further states that these deficient practices placed the resident at risk for infection, discomfort, and pain at the pressure ulcer site.
Failure to Honor Resident Choice and Provide Scheduled Shower
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to exercise choice and autonomy regarding bathing on a regularly scheduled shower day. The resident, admitted with diagnoses including sepsis and type 2 diabetes mellitus, required substantial/maximal assistance with several ADLs, including shower/bath, and had a care plan indicating she needed partial/moderate assistance for bathing as necessary. Her care plan also documented that it was important for her to have daily routines and preferences accommodated, including choosing between a tub bath, shower, bed bath, or sponge bath. On the date in question, facility documentation for the resident’s bathing task listed all bathing-related items as “not applicable,” indicating no bath type was provided or recorded. On that same day, the resident reported she did not receive a shower despite it being her regular shower day and stated that staff often did not help her shower even when she asked multiple times, which made her feel depressed and useless. She stated she had her own personal hygiene products and did not understand why staff would not assist her. The assigned CNA confirmed that the resident’s regular shower days were Tuesdays and Thursdays and acknowledged that the resident did not receive a shower because the CNA was busy. The CNA reported that when she first approached the resident in the morning, the resident declined a shower at that time due to pain, and the CNA did not return later to offer the shower, nor did she notify anyone else that the shower had not been provided, stating she was busy and forgot. The DON stated that residents should receive showers on scheduled days and that CNAs who cannot provide a scheduled shower are expected to notify the charge nurse so another staff member can assist.
Failure to Restrict and Monitor Visitor Access for Resident With Ongoing Substance Use Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its visitation and substance use disorder policies for a resident with a known history of psychoactive substance abuse and prior fentanyl overdose. The resident, who was cognitively intact but dependent on staff for transfers and with impaired mobility, had an active care plan for substance use that called for monitoring for signs and symptoms of substance use and abuse, such as confusion, drowsiness, outbursts of anger, and mood changes. Despite this, there was no documented evidence over multiple months that staff monitored the resident for these signs as outlined in the care plan. The facility’s visitation policy allowed for limiting or supervising visitors who abused, coerced, or exploited residents or who had a history of bringing illegal substances into the facility, but the facility did not operationalize these restrictions for this resident. Multiple documented incidents showed that the resident possessed or used substances and smoking materials, often in the presence of a specific family member visitor. On one occasion, staff observed the family member staying almost every night in the resident’s room and notified the DON and police due to suspicious behavior, but there was no documented investigation to determine the source of contraband. On another date, staff found the resident with vape devices and Blue Chew pills; these items were removed and given to a family member, and a late entry note by the DON recommended ongoing monitoring due to the resident’s substance-related history. However, there was no subsequent documentation that the resident was supervised or monitored for suspicious behaviors or signs of substance use as recommended. Later, staff documented that the resident’s room smelled like marijuana while the resident was with a visitor, and both were educated on facility policy, but the care plan was not revised to add new interventions related to this event. Further incidents continued without changes to visitation practices or documented monitoring. A restorative nursing assistant reported seeing the resident outside the facility with the same family member, who appeared to place an unknown smoking material to the resident’s mouth; this was reported to nursing and the administrator, and an order was obtained to closely monitor the resident for changes in level of consciousness, but there was no documentation that such monitoring occurred. Subsequently, the resident was found in his room vomiting, with foaming at the mouth and a smell of alcohol present; the family member at the bedside admitted giving the resident alcohol, and the resident was sent to the hospital and diagnosed with alcohol intoxication and alcohol abuse. When the resident returned from the hospital, there was no documentation that supervision or monitoring of the resident or the family member’s visits was implemented. Visitor sign-in records showed that the same family member and other friends continued to visit without restrictions or supervision. Interviews with the administrator, DON, nursing staff, and receptionist confirmed that no visitation restrictions or supervision were put in place for this family member, that there was no investigation into earlier contraband incidents, that the physician was not informed of key events, and that staff were not instructed on specific behaviors to monitor, despite the resident’s history and repeated episodes involving visitor-introduced substances.
Failure to Document and Resolve Resident Grievance Regarding Staff Responsiveness and Professionalism
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to promptly address and resolve a resident’s grievance. The facility’s policy titled “Grievances/Concerns,” dated 8/25/2021, states that upon receipt of a grievance or concern, staff will initiate a grievance/concern form and document it on the Grievance/Concern Log, and that the department manager will notify the person filing the grievance of the resolution and/or status within 72 hours. Despite this policy, there was no grievance form or log entry for the concerns raised about staff responsiveness and professionalism, and no written resolution was provided within the required timeframe. The resident involved was originally admitted and later readmitted with diagnoses including sepsis and type 2 diabetes mellitus. A History and Physical dated 12/30/2025 documented that the resident had capacity to understand and make decisions, and a Minimum Data Set dated 1/02/2026 indicated the resident was cognitively intact. On 12/22/2025, during dialysis, the resident reported to the dialysis social worker that staff at the facility did not respond when assistance was requested and that staff behaved unprofessionally, including cursing while at work. The dialysis social worker documented contacting the facility’s Social Services Director (SSD) by phone that same day, with the resident present, and the SSD stated she would follow up with the resident upon her return to the facility. Subsequent documentation from the dialysis center dated 1/12/2026 showed that the dialysis social worker attempted to contact the SSD again, left a voicemail, and did not receive a response. The facility’s grievance/complaint log for December 2025 contained no entries for this resident, and the resident’s progress notes from 12/22/2025 to 1/13/2026 contained no documentation of the concerns or any follow-up. In interviews, the dialysis social worker reported that the resident stated no one from the facility had addressed her concerns, and the resident confirmed that no one had followed up as of 1/13/2026. The SSD stated she had no documented grievances for this resident, did not document verbal concerns because there were too many residents, did not initiate grievance forms unless specifically requested, and could not recall the issues brought to her attention, resulting in no grievance resolution being provided to the resident.
Failure to Identify, Investigate, Report, and Protect After Allegation of Rough Handling During Care
Penalty
Summary
The deficiency involves the facility’s failure to identify, investigate, report, and implement protective measures in response to an allegation of abuse, as required by its Abuse Prohibition Policy and Procedures. The policy stated that staff must identify events that may constitute abuse, immediately remove the alleged perpetrator from duty pending investigation, initiate an investigation within two hours, protect patients during the investigation, and report allegations of abuse to appropriate agencies within specified time frames. Despite these requirements, when a family member reported that a CNA had handled a resident roughly during incontinence care and requested that the CNA not be reassigned, the facility did not treat this as a potential abuse allegation and did not follow the policy’s mandated steps. The resident involved had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, as well as essential hypertension, and was documented as cognitively intact with capacity to understand and make decisions. Staffing records showed that the CNA in question was assigned to the resident on consecutive shifts. A change in condition evaluation documented that the resident claimed the CNA was rough while turning him, and that the supervisor was made aware and the CNA was reassigned for the remainder of that shift. However, there was no indication that the incident was reported to the Administrator or DON as the abuse coordinator, and no immediate investigation or protective measures consistent with the abuse policy were initiated at that time. Interviews further substantiated the allegation and the facility’s failure to act in accordance with its policy. The family member reported that the resident said the CNA hurt his left arm and that a roommate, who was alert, confirmed hearing the resident scream during care. The resident later stated that the CNA pulled him by his left arm, causing pain, and that he screamed but the CNA did not stop or respond. The roommate reported hearing the resident say “you hurt me” while the CNA continued care and appeared to be in a hurry. Despite the family member’s request that the CNA not be reassigned, staffing records and interviews confirmed that the CNA was again assigned to the resident on a subsequent night shift, and the Administrator stated she was not informed of the complaint and that the CNA should not have been reassigned pending investigation. The CNA reported that no one interviewed her or explained why she had been reassigned on the day of the complaint, further demonstrating that no timely investigation or protective process was initiated as required by the facility’s abuse policy.
Failure to Timely Report Alleged Abuse and Prevent Reassignment of Accused CNA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse and to protect a resident from further contact with the alleged perpetrator, as required by its Abuse Prohibition Policy and Procedures. The policy, dated 2/23/2021, required that upon receiving information about suspected or alleged abuse, the designee report the allegation to CDPH, local law enforcement, the Ombudsman, and other required agencies within two hours, initiate an investigation within two hours, document witness interviews, and protect patients from further harm during the investigation. On 1/11/2026 at 10:00 AM, a cognitively intact resident with hemiplegia and hemiparesis following a cerebral infarction, and the resident’s family member, reported to an LVN that a CNA had been rough while turning the resident and had hurt the resident. The LVN documented the complaint in a Change in Condition Evaluation and reassigned the CNA for the remainder of that shift but did not report the allegation to the DON or Administrator, assuming the RN on duty would do so. As a result, the Administrator, who is the facility’s abuse coordinator, was not informed and no required external reports were made within the mandated two-hour timeframe. The resident’s admission and assessment records showed that the resident had the capacity to understand and make decisions and was cognitively intact. The family member stated that the resident’s roommate, who was alert, confirmed hearing the resident scream while the CNA was changing the resident’s briefs. The family member reported the incident to the LVN and RN and specifically requested that the CNA not be assigned to the resident again. Despite this, staffing assignment sheets showed that the same CNA was again assigned to the resident on the night shift of 1/12/2026. The family member later reported that when she arrived the next morning, the resident stated no one had checked on or changed him during the night, and the family member found the resident’s diaper soaking wet; the resident identified the assigned CNA as the same CNA previously reported for rough handling. The Administrator confirmed she was unaware of the initial complaint and stated that, had she been informed, she would have initiated the abuse investigation and reporting process as outlined in the facility’s policy.
Failure to Control Visitor-Introduced Substances and Supervise High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to a resident with a known history of substance abuse and prior fentanyl overdose. The resident was admitted with psychoactive substance abuse and paraplegia, required assistance with ADLs and transfers, and had care plans and policies in place related to substance use disorder, smoking, visitation, and comprehensive care planning. Despite these, the facility did not consistently assess, monitor, or document signs and symptoms of substance use or abuse as required by the resident’s care plans and the facility’s policies. Staff documented that a family member frequently stayed overnight in the resident’s room and engaged in unspecified suspicious behavior that led to police notification, but there was no documented investigation, IDT follow‑up, or reassessment of the resident for substance use or abuse after this event. The facility also failed to adequately address multiple specific incidents involving contraband substances and unsafe smoking. On one occasion, an LVN observed the resident vaping a substance that smelled like marijuana in his room, with his roommate coughing from the smoke. The resident was later found in possession of vape pens, a marijuana “live resin” vape, and non‑prescribed Blue Chew erectile enhancement pills, which were confiscated. Progress notes and interviews show that although these items were removed and a care plan was created to monitor for changes related to non‑prescribed medications, there was no documented ongoing monitoring for substance use, suspicious behaviors, or adverse effects, and the physician was not informed of these incidents. Staff also documented complaints of the resident’s room smelling like marijuana when the resident was with a visitor, but there is no evidence that the substance abuse care plans were revised with new interventions in response. The facility further failed to enforce its smoking and visitation policies and to implement increased supervision despite repeated incidents involving the same visitor. A smoking evaluation documented that the resident was not allowed to smoke due to being under the legal smoking age and unable to safely hold a cigarette, yet a restorative nursing attendant later observed the same family member placing an unknown smoking material in the resident’s mouth outside the front of the facility. Staff and the administrator approached and educated the resident, and an NP ordered close monitoring for changes in level of consciousness, but there is no documentation of reassessment for substance use or abuse or of specific supervision of visits. Subsequently, the same family member visited again; staff entered the resident’s room, noted smells of smoke, marijuana, and alcohol, and found the resident vomiting, foaming at the mouth, and unable to hold his head up. The visitor admitted providing alcohol, and hospital records confirmed acute alcohol intoxication. After the resident’s return, visitor logs show that the same family member continued to visit without documented restrictions or supervised access, and interviews confirm that staff were not instructed to monitor or supervise visits or to watch for specific substance‑related behaviors, despite the resident’s history and prior documented incidents.
Failure to Provide Ordered Electric Wheelchair and Medically Related Social Services
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services, specifically an ordered electric wheelchair, to a paraplegic resident. The facility’s policy on Social Services, dated September 2021, stated that medically related social services are provided to maintain or improve each resident’s ability to meet everyday physical needs, including equipment for ambulation. Resident 1, originally admitted in November 2023 and later readmitted, had diagnoses including paraplegia and psychoactive substance abuse. A Minimum Data Set dated October 10, 2025, documented intact cognition and memory, with the resident requiring partial to total assistance for activities of daily living and being dependent for transfers and toileting. On July 14, 2025, the physician ordered an electric wheelchair for the resident and directed the facility’s case manager to request authorization. However, there was no documentation or endorsement of follow-up on this order. During an interdisciplinary care conference on September 26, 2025, attended by the resident’s family member, Social Services staff, the Director of Rehabilitation, and the Director of Staffing and Development, the team determined that providing an electric wheelchair was not appropriate at that time. Their rationale was the resident’s history of substance use disorder, prior fentanyl use, and recent contraband incidents involving marijuana vape products and non-prescribed supplements, and they believed access to an electric wheelchair could increase the potential for self-harm related to drug-seeking behavior. The record also noted that the resident was using a manual wheelchair with staff and family assistance and could navigate the facility and go on outings with support. Interviews and observations showed that the resident could not independently and safely propel the manual wheelchair. The resident’s family member reported that the resident had requested an electric wheelchair since July 2025 and had not received it, and that the resident was experiencing isolation and loneliness. During observation in the resident’s room, the resident stated he could not safely wheel himself alone and felt his mobility and right to move freely were restricted; when attempting to propel the manual wheelchair in a straight line, he veered to the right and struck the bedside table and wall. A physical therapist confirmed the resident could not propel a manual wheelchair due to poor coordination. The current case manager stated she was unaware of the electric wheelchair order and that there was no documentation regarding the request. The Social Services Director stated she believed Social Services only arranged DME for residents being discharged and did not know what happened to the July 2025 order, while the DON stated Social Services was responsible for arranging DME for custodial residents. The Administrator acknowledged that there was no documented follow-up on the July 14, 2025 electric wheelchair order until the September 26, 2025 meeting and that the decision not to provide the electric wheelchair was based on concerns about the resident’s safety related to illegal substance use behaviors.
Failure to Maintain Resident Dignity During Care Procedure
Penalty
Summary
Certified Nursing Assistants (CNAs) 2 and 3 failed to treat a resident with respect and dignity during a fecal disimpaction procedure. The resident, who was cognitively intact but fully dependent on staff due to quadriplegia and had a history of anxiety and depression, was present in the room when CNAs 2 and 3 engaged in a personal conversation that included derogatory and inappropriate comments. Specifically, while Registered Nurse (RN) 1 left the room to retrieve lubricant, CNA 2 made a comment, "What if you spit on it?" in response to CNA 3's remark, "You can either hit it or quit it," both of which were made in the presence of the resident. The resident reported feeling uncomfortable and upset by these comments and responded by yelling at the staff. Facility policy and procedures reviewed indicated that residents are to be treated with dignity and respect at all times, and demeaning practices are prohibited. The resident's care plan specifically noted the need for staff to maintain the resident's dignity and comfort during incontinence care. Interviews with the CNAs confirmed the inappropriate conversation took place in the resident's presence, and the Director of Nursing acknowledged that such comments could be perceived as hurtful and offensive, potentially resulting in psychosocial harm.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement the care plan for a resident with a history of falls, specifically neglecting to ensure the placement of bolster pillows on the mattress while the resident was in bed. The resident, who had diagnoses including Parkinson's Disease with significant tremors and contractures, was dependent on staff for all activities of daily living and functional mobility. Despite being identified as at risk for falls and having experienced unwitnessed falls resulting in pain and hospital transfer, the care plan interventions such as attaching bolster pillows to the mattress and positioning the resident in the center of the bed were not carried out. Observations and interviews revealed that, following the resident's falls, the care plan was revised to include specific interventions like keeping a floor mat on the left side of the bed, moving the right side of the bed against the wall, and ensuring the bed was in the lowest position. However, during multiple observations, the resident was found in bed without the required bolster pillows, and staff confirmed that the bolsters were not present. Staff interviews indicated awareness of the resident's frequent involuntary movements and the need for bolsters to prevent sliding or falling, yet the intervention was not implemented. Further review and interviews with facility staff, including the Assistant Director of Nursing, revealed that the care plan was not updated promptly after the initial fall and that the recommended interventions were not consistently applied, particularly after the resident was transferred to a different room. The lack of communication and follow-through resulted in the omission of the bolster pillows, despite clear documentation and interdisciplinary team recommendations to use them as a preventive measure for recurrent falls.
Failure to Inform and Involve Responsible Party in Pressure Ulcer Care Planning
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident with a stage 4 pressure ulcer was properly informed and included in care planning meetings, as required by facility policy. The resident, who had severe cognitive impairment and lacked decision-making capacity, was admitted with significant medical conditions including a stage 4 sacral pressure ulcer, Type 2 Diabetes Mellitus, and a tracheostomy. Facility policies mandated that the RP be notified of the care plan and participate in the development and revision of the comprehensive care plan, especially for significant conditions such as pressure ulcers. Record reviews and interviews revealed that although the RP was listed as an attendee in care conference documentation, she was not actually present during the meetings. Instead, she was informed separately by phone after the meetings concluded, and the information provided was limited. The RP reported that she was only told that the wound had re-opened, without being informed of the wound's stage, measurements, or specific details. Facility staff confirmed that updates to the RP were not provided regularly or in sufficient detail, and that the RP was not given the opportunity to ask questions or participate meaningfully in the care planning process. Staff interviews further indicated that the RP was not informed about the staging or measurements of the wound, with some staff expressing that such details were withheld because they believed the RP would not understand or would ask more questions. The responsible party was not included in the interdisciplinary care conferences, contrary to facility policy and regulatory requirements, and was not kept fully informed about the resident's wound status or treatment plan. This resulted in the RP being unaware of the severity and progression of the resident's pressure ulcer.
Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
The facility failed to administer prescribed medications and treatments as ordered by the physician for a resident with multiple medical conditions, including epileptic seizures, a pressure ulcer, and chronic kidney disease. Specifically, the resident did not receive scheduled doses of nystatin cream for wound care, Zoryve foam for seborrheic dermatitis, and normal saline flushes for PICC line maintenance on several documented occasions. Review of the Treatment Administration Record (TAR) and IV Administration Record revealed multiple blank entries, indicating missed administrations of these medications and treatments. Interviews with nursing staff confirmed that the absence of documentation on the TAR and IV Administration Record meant the medications and treatments were not given. Both the Licensed Vocational Nurse and the Registered Nurse Supervisor acknowledged that the resident should have received these medications daily as ordered, and that the records should not have contained blank spaces. The staff also confirmed that the missed administrations were not documented as given or offered. The resident reported not receiving his prescribed creams and described feeling unwell as a result. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified, and for all administrations to be documented. The failure to follow physician orders and document medication and treatment administration resulted in the resident not receiving necessary care for his wounds and PICC line maintenance.
Failure to Maintain Consistent Documentation for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to maintain current, detailed, and consistent medical records for one resident who required turning and repositioning every two hours to prevent the worsening of a stage four pressure ulcer, as ordered by the physician. The facility's policy required documentation of the date and time care was given, the names and titles of staff involved, the position in which the resident was placed, reasons for changing position, resident participation, any problems or complaints, refusals and interventions, and the signature and title of the person recording the data. However, a review of the resident's records revealed multiple gaps in documentation by both CNAs and nurses over several days, with missing entries for required time slots and shifts. The resident involved had severe cognitive impairment, a history of a stage four pressure ulcer, Type 2 Diabetes Mellitus, and tracheostomy status, and was unable to make decisions or understand care instructions. Despite physician orders and facility policy, staff failed to consistently document turning and repositioning in both the bedside folder and the computer system. During an interview, the RNS confirmed that if documentation was missing, it indicated the resident was not turned or repositioned as required. These documentation lapses were observed over a period of several days, affecting the resident's prescribed wound care regimen.
Failure to Post Accurate and Current Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that accurate and current nurse staffing data, including the total number and actual hours worked by licensed (RNs, LVNs) and unlicensed (CNAs) nursing staff, were posted daily at the beginning of each shift as required. Observations revealed that the posted staffing document in the facility's front lobby was outdated by five days and only displayed projected staffing hours rather than the actual hours worked for each shift. The document did not meet the facility's policy, which requires posting the actual time worked for each category and type of nursing staff within two hours of the beginning of each shift. Interviews with the Administrator confirmed that the Director of Staff Development, who was responsible for updating and posting the staffing data, had been on leave, and no other staff member was assigned to this responsibility. The Administrator acknowledged not noticing the outdated posting and had created a document showing only projected staffing hours, not actual hours worked. This resulted in the facility not maintaining compliance with its own policy and regulatory requirements for daily nurse staffing postings.
Failure to Ensure Timely Response and Respectful Communication for Residents
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect in two separate instances involving two residents. In the first case, a cognitively intact resident who was physically dependent on staff for all activities of daily living (ADLs) was observed waiting at least 19 minutes for assistance after activating the call light. During this period, staff were seen at the Nurses' Station while the call light remained illuminated and audible. The resident reported frequent delays in staff response, sometimes waiting up to an hour, and often had to rely on his roommate to seek help. Interviews with staff revealed confusion and lack of accountability regarding who was responsible for responding to the call light, with some staff assuming others would respond. The facility's policy required timely response to call lights, but this was not followed, resulting in unmet needs and compromised the resident's dignity and safety. In the second instance, another resident reported that a CNA used derogatory language, calling him a "stupid old man" after he requested hot water. The resident stated that when he confronted the CNA, the CNA responded, "I don't care." The resident felt disrespected and neglected, and subsequently noticed that the CNA no longer acknowledged or assisted him during assigned shifts. The incident was reported to a nurse, and the resident provided a description of the CNA involved. Documentation and interviews confirmed that the resident felt a change in the CNA's behavior towards him after the incident, leading to further feelings of neglect. Both cases were substantiated through interviews, observations, and record reviews. The facility's policies on answering call lights and treating residents with dignity and respect were not adhered to, resulting in residents experiencing delays in care and disrespectful communication. The deficiencies were directly observed and corroborated by resident statements, staff interviews, and review of facility records.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited inappropriate physical contact with other residents. The care plan did not specify the exact behaviors to be monitored during one-to-one supervision, nor did it provide clear, resident-centered interventions or define the duration and criteria for discontinuing the supervision. The lack of specificity in the care plan was confirmed during interviews with nursing staff and the Assistant Director of Nursing, who acknowledged that the care plan's directive to monitor for episodes of inappropriate touching was vague and not tailored to the resident's actual behaviors. Observations and interviews revealed that the one-to-one supervision outlined in the care plan was not consistently implemented. On multiple occasions, the resident was observed without a staff member providing the required one-to-one supervision. Staff interviews indicated that the assigned sitter was sometimes absent, and coverage was not always provided as required by the care plan. One staff member admitted to monitoring the resident from the hallway while performing other duties, rather than providing continuous, direct supervision as specified. The resident involved had a history of cognitive impairment and required moderate assistance with activities of daily living. The care plan was initiated after incidents of inappropriate touching were reported by another resident, who described multiple episodes of unwanted physical contact. Despite the care plan and orders for one-to-one monitoring, facility staff failed to ensure that supervision was maintained at all times, and the care plan lacked the necessary detail to guide staff in effectively monitoring and addressing the resident's behaviors.
Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide adequate pain management for a resident following a fall that resulted in a right ankle fracture. Despite the resident's ongoing complaints of pain, especially during physical therapy and ambulation, there was a lack of consistent and thorough pain assessment, documentation, and follow-up. The facility's policy required assessment of pain type, frequency, intensity, and duration, as well as re-evaluation of interventions, but these steps were not consistently performed. Documentation often showed zero pain levels and no administration of pain medication, even when physical therapy notes and staff interviews indicated the resident was experiencing pain and refusing to ambulate due to discomfort. There were multiple instances where the resident's pain was not communicated to the nurse practitioner or physician, despite persistent complaints and refusal to participate in therapy. Physical therapy and CNA staff noted the resident's pain and functional decline, but this information was not always relayed to licensed nursing staff or documented in the medical record. Additionally, when pain medication was administered, there was insufficient documentation of pain reassessment to determine the effectiveness of the intervention, as required by facility policy. The lack of communication and documentation led to poor pain control and a decline in the resident's mobility. Interviews with staff confirmed that pain complaints were sometimes forgotten or not reported due to workload, and that there was a lack of awareness regarding the resident's physical restrictions and pain status. The resident's medical history included a right ankle fracture and fluctuating cognitive capacity, which further complicated assessment and management. The failure to accurately assess, document, and communicate the resident's pain, as well as to notify the appropriate medical providers, resulted in inadequate pain management and contributed to the resident's refusal to ambulate and functional decline.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents, staff members, or incidents were detailed in the report, and there were no direct observations of infection events or outcomes related to this deficiency. The deficiency is based solely on the facility's failure to have the required infection prevention and control program in place.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Ensure Proper Medication Administration and Monitoring
Penalty
Summary
A deficiency was identified when a resident's prescribed medications were found unadministered in a medication cup on the bedside table, despite being documented as given in the Medication Administration Record (MAR). Observation revealed that the medications, which included Vitamin C, Aspirin, Iron, Gabapentin, a multivitamin with minerals, and Zinc, remained untouched over 90 minutes after the time they were recorded as administered. The resident, who was cognitively intact and alert, stated she had not taken the medications because she was sleeping. The nurse responsible acknowledged placing the medications at the bedside and leaving the room, and confirmed that medications should be administered in the nurse's presence to ensure proper administration and prevent errors. The resident had a history of missed and incorrect medication administration, as documented in multiple care plans addressing missed doses and wrong medications given, with interventions to monitor for adverse effects and notify the medical doctor. Facility policy requires that medications be administered safely and timely, with the MAR only to be initialed after the medication is given. The observed practice of leaving medications unattended and documenting them as administered did not align with facility policy and created a risk for medication errors.
Failure to Maintain Clean and Clutter-Free Resident Room
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment in one resident's room, resulting in the accumulation of trash, debris, and clutter. During an observation, the resident's room was found to have a used meal tray cover, empty boxes, used plastic bottles, empty drink cartons, and used eating utensils scattered across the floor and bedside table. The resident reported that the clutter and trash had been present for approximately two weeks and that the room was consistently cluttered. The facility's policy requires a clean, sanitary, and orderly environment, and the resident's care plan specifically included maintaining a clutter-free environment to reduce fall risk. The resident involved had diagnoses of urinary tract infection and chronic obstructive pulmonary disease and was fully alert with no cognitive impairment, as indicated by recent assessments. The Assistant Director of Nursing confirmed that housekeeping is responsible for cleaning resident rooms twice daily and that nursing staff are expected to contact housekeeping as needed. The ADON also noted that the resident frequently orders and stores items in the room, contributing to the clutter. The failure to maintain cleanliness and orderliness in the resident's room was not in accordance with facility policy and the resident's care plan.
Failure to Ensure Proper Sling Use and Supervision During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents who required mechanical lift transfers were provided with the correct size sling and adequate supervision, resulting in accidents and potential hazards. In one incident, two CNAs used a small sling instead of the required extra-large full body sling to transfer a resident with hemiplegia and other mobility impairments. Despite the resident expressing concern that the sling was too tight, the CNAs proceeded with the transfer, during which the resident slipped out of the sling, fell, and sustained a large hematoma on the back of the head, as well as nausea and vomiting. The resident was transferred to the hospital for evaluation and treatment following the fall. The investigation revealed that the CNAs involved were not aware of the different sling sizes and had not received specific training or competency evaluation regarding the selection and use of the correct sling size for mechanical lift transfers. Interviews with staff, including laundry and housekeeping personnel, indicated a general lack of knowledge about sling sizing, with slings being distributed without regard to size or resident-specific needs. The facility's competency checklist for mechanical lift use did not include assessment of sling size or review of resident assessments for recommended sling size based on weight. In a separate incident, a CNA transferred another resident, who was dependent for all transfers and required a mechanical lift with a medium-sized sling, without the required assistance of a second staff member. The CNA acknowledged being aware of the two-person policy but proceeded alone because other staff were busy. This action was observed by the ADON, who confirmed it was against facility policy and placed the resident at risk for falls and injury. The facility's policy and the manufacturer's instructions both required proper sling sizing and two-person assistance for safe mechanical lift transfers, but these protocols were not consistently followed.
Failure to Ensure Timely Pain Medication Refill and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident with chronic pain syndrome, quadriplegia, depression, anxiety, left hip osteoarthritis, and opioid dependence. The resident was prescribed a fentanyl transdermal patch to be applied every 72 hours for chronic pain, as well as oxycodone as needed for moderate to severe pain. The facility did not ensure that the required medication order refill form for the fentanyl patch was signed by the physician in a timely manner, resulting in the resident missing two scheduled doses of the fentanyl patch. Documentation shows that the facility ran out of the fentanyl patch, and there was a delay in following up with the physician and pharmacy to secure the necessary authorization and delivery of the medication. During the period when the fentanyl patch was unavailable, the resident reported experiencing severe pain and repeatedly requested the medication from nursing staff. Despite the resident's complaints, documentation in the SBAR Summary for Providers indicated that the resident was not experiencing pain, which contradicted the resident's own statements and the observations of a CNA who noted the resident was always in pain. The resident's care plan required staff to monitor for pain, assess pain characteristics, utilize a pain scale, and medicate as ordered, but these interventions were not consistently implemented during the period when the fentanyl patch was missed. Interviews with facility staff revealed a lack of communication and follow-up regarding the missing medication. Nurses did not endorse the need to follow up on the fentanyl patch order to subsequent shifts, and there was no documented evidence of timely follow-up with the physician or pharmacy after the initial missed dose. The facility's policies required medications to be ordered in advance and pain management to be consistent with professional standards and the resident's care plan, but these procedures were not followed, resulting in unrelieved pain for the resident until the fentanyl patch was reapplied several days later.
Failure to Ensure CNA Competency in Mechanical Lift Sling Selection Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that five certified nurse assistants (CNAs) were trained and competent in the use of the mechanical lift device, specifically in selecting and using the correct sling size for residents, as required by facility policy and the manufacturer's instructions. This deficiency was identified through observation, interviews, and record review, which revealed that CNAs were not provided with adequate in-service training or competency assessments regarding the different sling sizes and their appropriate use based on resident assessments and weight. Instead, CNAs learned to use the mechanical lift and slings informally from coworkers, and there was a widespread lack of awareness among staff, including laundry and maintenance personnel, about the existence of different sling sizes and their significance. As a result of this lack of training and competency, two CNAs used a small sling instead of the required full body, extra-large sling to transfer a resident with significant mobility impairments, including hemiplegia, hemiparesis, muscle weakness, and contractures. During the transfer, the resident slipped out of the incorrectly sized sling and fell, sustaining a large hematoma on the back of the head, pain, and nausea/vomiting, which necessitated transfer to an acute care hospital for evaluation and treatment. The incident was documented in the resident's progress notes, care conference records, and hospital emergency department records, all of which confirmed the use of the wrong sling size and the resulting injury. Further investigation revealed that the facility's competency checklists for mechanical lift use did not include assessment or demonstration of selecting the correct sling size and capacity for residents. Interviews with CNAs, laundry staff, and the maintenance director confirmed that staff were unaware of the different sling sizes and had not received training on this aspect of resident care. The Director of Staff Development also acknowledged that no training or skills competencies had been conducted on sling size selection for the mechanical lift, and the Director of Nursing confirmed that the competency checklist was incomplete in this regard.
Failure to Develop and Implement Comprehensive Care Plans for Mechanical Lift Transfers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents who required the use of a mechanical lift for transfers. For the first resident, who had a history of hemiplegia, hemiparesis, muscle weakness, contractures, and osteoarthritis, the assessment indicated a need for a total lift with a full body, extra-large sling. However, there was no documented care plan addressing the use of the mechanical lift or specifying the appropriate sling size. This omission led to an incident where two CNAs used an incorrect, smaller sling, resulting in the resident slipping out of the sling and falling, causing a head injury. Interviews with the CNAs revealed they were not trained on sling sizes or proper use, and the care plan did not provide guidance on these critical details. For the second resident, who was dependent for all transfers due to quadriplegia and multiple contractures, the assessment indicated the need for a total lift with a full body, medium-size sling and two-person assistance. Despite this, there was no care plan developed or implemented to address the use of the mechanical lift for this resident. During an observation, a CNA was seen transferring the resident alone with the mechanical lift, contrary to facility policy and the resident's needs. The CNA acknowledged awareness of the two-person requirement but proceeded alone due to other staff being busy, placing the resident at risk. Both cases demonstrated a lack of individualized, comprehensive care planning in accordance with resident assessments, facility policy, and manufacturer instructions. The absence of clear, documented care plans specifying the correct equipment and procedures for mechanical lift transfers contributed to unsafe practices, including the use of incorrect sling sizes and insufficient staff assistance during transfers. These deficiencies were confirmed through record reviews, staff interviews, and direct observation.
Failure to Administer and Accurately Document Potassium Chloride as Ordered
Penalty
Summary
The facility failed to ensure that Potassium Chloride (KCL) was administered to a resident as ordered by the physician and in accordance with facility policy. The resident, who had a history of seizure and paraplegia, was readmitted with a low potassium level and had a physician's order for daily KCL administration. The Medication Administration Record (MAR) indicated that KCL was given daily over a five-day period, but a physical count of the medication packets revealed that three doses were not administered as documented. Interviews with nursing staff and review of the medication cart confirmed that there were more KCL packets remaining than should have been if the medication had been administered as recorded. The resident and a family member both reported that the resident did not receive KCL on certain days, with the family member observing and questioning the lack of administration. The charge nurse initially stated that KCL was not available, but later administered a dose after repeated inquiries from the family. Further review by the pharmacist and the Director of Nursing corroborated the discrepancy between the number of KCL packets delivered, the number remaining, and the MAR documentation. The facility's policy required accurate documentation and timely administration of medications, but the nurses documented administration of KCL even when it was not given, resulting in a failure to meet the resident's pharmaceutical needs as ordered.
Failure to Discard and Account for Medications After Resident Expiration
Penalty
Summary
The facility failed to properly store and discard medications belonging to a resident who had expired. During an observation in the medication room, a locked black box labeled with the resident's name was found on the top shelf of a storage cabinet. The registered nurse present was unaware of the box's existence, did not know the code to open it, and could not identify the medications inside. There was no record of the drug contents in the box, and it was unclear whether any controlled substances were present. The director of nursing confirmed that the facility did not have a specific policy for handling medications of residents who had expired and acknowledged that the medications should have been discarded to prevent diversion or misuse. The facility's policy stated that discontinued, outdated, or deteriorated medications should be returned or destroyed per pharmacy instructions, but this was not followed in this case. The resident involved had a history of sepsis, type 2 diabetes mellitus, end stage renal disease, and anemia, and had expired prior to the discovery of the medications.
Failure to Maintain Accurate Inventory of Resident's Personal Effects
Penalty
Summary
The facility failed to maintain a complete and accurate Inventory of Personal Effects for a resident, as required by its own policy and accepted professional standards. Upon admission, the resident's inventory form did not include all personal belongings, specifically omitting the resident's car and car keys, and the form was not signed by the resident. The omission was confirmed during a review of the resident's records, which showed that the inventory was signed only by a registered nurse, who could not recall why the resident had not signed the form or why the car and keys were not listed. The facility's policy requires that all items brought into the facility be listed and that the inventory form be signed by both the resident (or representative) and an employee. The deficiency came to light following an incident in which smoke was observed coming from a car parked in the facility's lot, later identified as belonging to the resident in question. The car had been parked at the facility for an extended period, had previously been vandalized, and was ultimately towed by police for an arson investigation. Interviews with facility staff and the resident's family member revealed that the car had been present for years, had been moved within the parking lot, and had suffered damage, but was never reported or properly documented as the resident's property in facility records. Further review of the resident's transfer documentation to a hospital showed that personal belongings were not listed at the time of transfer. The facility's interim administrator acknowledged that the lack of a complete and signed inventory made it difficult to monitor or verify the resident's belongings. The facility's policy and procedure on personal property explicitly require listing all items and obtaining the necessary signatures, which was not followed in this case.
Abandoned Resident Vehicle Left in Disrepair Leads to Fire Hazard
Penalty
Summary
Facility staff failed to maintain a safe and comfortable environment for residents, staff, and visitors by allowing an abandoned car, belonging to a resident, to remain unattended in the facility's parking lot for approximately two years. The car was in a state of disrepair, with flat tires, a broken window, and filled with trash and debris. Multiple staff members, including the Maintenance Manager, Housekeeping Manager, Dietary Supervisor, and Social Worker, observed the car in this condition but did not report it to facility management or take action to have it removed. The Maintenance Manager did not consider the abandoned car as trash or debris, despite facility policy requiring the grounds to be kept free from hazards. On 5/13/2025, the abandoned car caught fire, producing significant smoke and requiring intervention from facility staff, police, and the fire department. The fire was extinguished without reported injuries, but the incident placed 159 residents, staff, and visitors at risk of injury from burns due to the fire hazard. The police determined the fire was an act of arson and towed the vehicle for investigation. Interviews revealed that staff and a family member had been aware of the car's deteriorated and vandalized condition for an extended period but did not escalate the issue. The resident who owned the car had a history of cerebral vascular accident with right-sided hemiplegia and was noted to have moderately impaired cognition on the most recent assessment. At the time of the incident, the resident was not present in the facility, having been transferred to an acute hospital. The car and its keys were not listed in the resident's inventory of personal effects, and there was no documentation of the car being reported as abandoned. Facility policy required maintenance of the grounds in a safe and operable manner, but this was not followed in the case of the abandoned vehicle.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, revise, and implement individualized comprehensive care plans for multiple residents, as required by policy and regulation. For one resident with chronic obstructive pulmonary disease (COPD) and a history of heart failure, morbid obesity, and diabetes, the care plan did not include specific goals or interventions for the management of respiratory care and oxygen therapy, despite a physician's order for oxygen and the resident being observed receiving oxygen. Documentation was inconsistent, with no evidence in the Medication Administration Record or progress notes that oxygen was administered as ordered, and the care plan lacked measurable objectives or timetables for monitoring the resident's respiratory status. Staff interviews confirmed that the care plan was not updated to reflect the resident's current needs, and the facility's own policies regarding care plan development and revision were not followed. Additionally, the same resident was readmitted with a reddish/purplish discoloration and hematoma to the right trunk area, but the care plan did not address this new skin issue. There was conflicting documentation between the body check and the readmission skin assessment regarding the presence of skin issues, and no care plan or interventions were developed for the hematoma. Staff acknowledged that the lack of a care plan for this condition meant there was no ongoing assessment or monitoring, which could lead to further complications. The facility's policy required care plans to be updated with new or changed conditions, but this was not done in this case. Another resident with a history of hemiplegia, functional quadriplegia, and high risk for skin breakdown was found to have a reopened Stage 3 pressure injury and moisture-associated skin damage (MASD). The care plan did not include individualized interventions for the new MASD, and staff failed to provide timely incontinence care and repositioning as required. Observations showed the resident remained in the same position for extended periods, and staff interviews confirmed that care was not provided every two hours as indicated in the care plan and facility policy. The lack of updated care plans and failure to implement required interventions contributed to the risk of worsening skin conditions for this resident.
Failure to Provide Pressure Ulcer Prevention and Skin Integrity Management
Penalty
Summary
The facility failed to provide appropriate care and services for the prevention and management of skin breakdown for two residents at risk for skin integrity issues. For one resident with a history of hemiplegia, hemiparesis, functional quadriplegia, and diabetes, the care plan required frequent incontinence checks and changes, as well as turning and repositioning every two hours due to severe risk for pressure injuries and the presence of a Stage 3 pressure ulcer and moisture-associated skin damage (MASD). Observations and staff interviews revealed that this resident was left lying on his back for over six hours without being repositioned or having incontinence care provided as required. Staff confirmed that the resident was not checked or changed according to the care plan and facility policy, and the necessary interventions were not implemented consistently throughout the observed period. Another resident, who was readmitted with morbid obesity, diabetes, and a history of falls, was found to have a palm-sized reddish/purplish discoloration/hematoma on the right trunk area upon readmission. Documentation and interviews indicated that the initial body check did not identify any skin issues, while a subsequent skin assessment noted multiple skin concerns, revealing inconsistencies in documentation. The care plan for this resident did not include any goals or interventions for the management or monitoring of the hematoma and skin discoloration. Staff interviews confirmed that no care plan or interventions were developed or implemented for this issue, and there was no ongoing assessment or reassessment of the affected area. Facility policies required individualized care plans, regular skin assessments, and timely interventions for residents at risk of skin breakdown. However, the facility did not follow these policies for either resident, as evidenced by the lack of timely incontinence care, repositioning, and the absence of care planning and monitoring for new or existing skin conditions. These failures were confirmed through direct observation, record review, and staff interviews.
Failure to Implement Enhanced Barrier Precautions for Resident with ESBL
Penalty
Summary
The facility failed to implement its infection prevention and control program (IPCP) for a resident diagnosed with Extended Spectrum Beta Lactamase (ESBL) resistance in the urine. Despite a physician's order for Enhanced Barrier Precautions (EBP) and a care plan specifying the need for meticulous handwashing and proper use of personal protective equipment (PPE), staff were not informed or reminded of the required precautions. There was no EBP signage or PPE cart placed at or inside the resident's room, and staff were unaware of the need for EBP for this resident. Direct observations revealed that a Licensed Vocational Nurse (LVN) administered medication to the resident without wearing gloves or a gown, and a Certified Nurse Assistant (CNA) provided incontinence care without an isolation gown. Both staff members stated they were not aware that the resident required EBP, and noted the absence of signage and PPE carts that would typically indicate such precautions. Review of facility policies confirmed that EBP should be communicated to staff and PPE made available near or outside the resident's room for high-contact care activities. Interviews with staff, including the Assistant Director of Nursing (ADON), confirmed that the required EBP was not in place for the resident. The facility's own policies and procedures, as well as the resident's care plan and physician's orders, were not followed, resulting in a failure to implement necessary infection control measures for a resident with a multidrug-resistant organism. This lapse was identified through observation, interview, and record review.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident who reported being punched on the leg by an unnamed nurse. The resident, who had a history of infection of amputation stumps, anxiety disorder, and transient cerebral ischemic attack, was cognitively intact and dependent on staff for several activities of daily living. On the date of the incident, the resident informed a Licensed Vocational Nurse (LVN) that a nurse had punched him. The LVN documented the allegation in a Change of Condition (COC) form but did not notify the California Department of Public Health (CDPH), the Ombudsman, or local law enforcement within the required two-hour timeframe as outlined in the facility's policy and procedure. The Interim Director of Nursing (IDON) later discovered the abuse allegation during a review of nursing notes two days after the incident and subsequently reported it to the appropriate authorities. The facility's policy clearly states that any suspicion or allegation of abuse must be reported immediately to the administrator and to state agencies, the Ombudsman, and law enforcement within two hours. However, this protocol was not followed, resulting in a delay in reporting and investigation of the abuse allegation.
Failure to Prevent Accident and Assess Resident After Fall
Penalty
Summary
The facility failed to prevent an accident hazard and provide adequate supervision as required by policy and the resident's care plan. A resident with a history of falls, morbid obesity, and type 2 diabetes was being transferred from bed to wheelchair when the wheelchair brakes were not properly locked, causing the wheelchair to move and the resident to slip onto the floor. The resident required substantial assistance for transfers and had impaired balance, as documented in the care plan and assessments. The incident was not documented in the medical record, and there was no evidence of a fall being recorded for the resident on the date in question. Following the fall, certified nursing assistants (CNAs) moved the resident back to bed without a licensed nurse assessment, contrary to facility protocol. One CNA reported the fall to an LVN, who did not assess the resident or initiate a change of condition report, and instead directed the CNAs to return the resident to bed. The interim director of nursing and administrator were unaware of the incident until days later, and no investigation or required notifications were initiated at the time of the fall. The facility's policy required evaluation and documentation of all falls, which was not followed in this case.
Failure to Provide and Document Appropriate Respiratory Care for a Resident with COPD
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with its own policies, procedures, and standards of practice for a resident diagnosed with COPD and congestive heart failure. The resident was admitted and readmitted with these diagnoses, and the Minimum Data Set indicated intact cognition and no documented shortness of breath or respiratory treatments, including oxygen therapy. However, the Medication Administration Record did not show evidence that the resident received oxygen as needed over several days, despite a physician's order for oxygen therapy at 2L/min via nasal cannula as needed for COPD. This order lacked specific parameters for when to initiate, adjust, or discontinue oxygen therapy. Documentation was inconsistent and incomplete regarding the administration of oxygen. The Weights and Vitals Summary showed multiple instances where the resident was on oxygen, but the amount delivered was not specified. Nursing staff interviews confirmed that there was no documentation in the MAR or progress notes about when oxygen was started, the reason for its use, the resident's response, or when it was discontinued. There was also no evidence that the physician was notified about the resident's need for oxygen or that assessments were performed to determine the effectiveness or necessity of the therapy. The resident's care plan did not include specific goals or interventions related to respiratory care or oxygen therapy, despite the resident receiving oxygen. Facility policies required ongoing evaluation, documentation, and individualized care planning for residents with COPD, but these were not followed. Both the Registered Nurse Supervisor and the Interim Director of Nursing acknowledged the lack of adherence to facility policies and the absence of a resident-centered care plan for oxygen therapy, as well as insufficient documentation and communication with the physician.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with a complex medical history, including chronic pain syndrome, osteoarthritis, sciatica, recent fractures, and a recent surgery to the left leg, was readmitted to the facility following a hospital stay. Upon readmission, the resident's pain management orders from the hospital, which included acetaminophen-hydrocodone for moderate and severe pain, were not continued. Instead, the only pain medication available was acetaminophen, which was insufficient for the resident's reported pain levels. The resident repeatedly verbalized severe pain and expressed that the acetaminophen was not effective, but no stronger pain medication was provided until the following day. Facility staff failed to adequately assess, treat, and document the resident's pain in accordance with the facility's pain management policy. Multiple staff members, including a treatment nurse and an LVN, did not assess the resident's pain level during care interactions, despite clear verbal and non-verbal indications of severe pain. The resident reported a pain level of 10 out of 10 and described significant distress, including sleeplessness and feelings of hopelessness, yet staff did not promptly notify the physician or obtain appropriate pain management orders in a timely manner. Documentation showed that the resident's care plan included interventions to anticipate and respond to pain, but these were not effectively implemented. The medication administration record did not reflect appropriate pain medications for moderate or severe pain until after a significant delay. The deficiency resulted from the facility's failure to identify, assess, and manage the resident's pain as required by policy, leading to prolonged and unrelieved pain for the resident.
Failure to Supervise Smoking and Prevent Smoking-Related Hazards
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for residents who smoke, resulting in multiple deficiencies related to smoking safety. Several residents who required supervision with smoking, as indicated by their care plans and smoking assessments, were found to have unsupervised access to cigarettes and lighters. In one incident, a resident with a history of noncompliance with the smoking policy was able to smoke in bed, resulting in burned linens while three roommates were present in the room. The facility was unaware that this resident had retained smoking materials in his possession, and the incident required intervention by staff and notification of police. Other residents with documented needs for supervision were observed with cigarettes and lighters in their possession, both in their rooms and in the designated smoking patio. Despite care plans specifying that smoking materials should be kept at the nurses' station and that residents should be supervised while smoking, staff interviews revealed a lack of awareness regarding residents' possession of these items. Some staff members stated that residents are not allowed to have lighters due to fire and safety concerns, especially with the presence of oxygen in the facility, but acknowledged that some residents still retained these items. Additionally, the facility did not consistently conduct Interdisciplinary Team (IDT) meetings to assess the risks and benefits of smoking for all residents who smoke, as required by facility policy. Only a minority of residents who smoked had attended such meetings, and some residents did not have care plans addressing smoking safety. These failures resulted in unsafe conditions for residents, staff, and visitors, as evidenced by the smoking-related incident and the observed lapses in supervision and policy adherence.
Failure to Provide Behavioral Health Services for Resident with Alcohol Abuse
Penalty
Summary
The facility failed to ensure that a resident with a primary diagnosis of alcoholic cirrhosis received necessary behavioral health care and services as required. The Social Services Director (SSD) did not refer the resident to a psychiatrist or psychologist for appropriate counseling and behavioral services for alcoholism, despite the resident's agreement to such services as documented in a behavioral contract. The behavioral contract, signed by the resident, specified that the resident would be referred to psychiatric services and would participate in periodic checks of personal belongings, but there was no evidence that these interventions were implemented. Additionally, the facility's licensed nurses and SSD did not develop or implement person-centered care plans addressing the resident's behavioral health needs related to substance abuse. The care plans in the resident's record focused on other diagnoses and general behaviors but did not include interventions or goals specific to managing alcohol abuse, psychiatric referrals, or participation in support programs such as Alcoholics Anonymous. Observations of the resident's behavior, including going outside near a liquor store, were documented, but no corresponding behavioral health interventions or referrals were made. Interviews with facility staff confirmed that no care plan or behavioral health services were provided to address the resident's substance abuse issues, despite multiple opportunities and documented agreements to do so. The facility's policies required individualized care plans and behavioral management, but these were not followed in this case, resulting in a lack of appropriate treatment and services for the resident's psychosocial adjustment difficulties.
Failure to Ensure Continuity of Diabetic Care and Emergency Response
Penalty
Summary
A facility failed to provide appropriate treatment and care for a resident with a diagnosis of Diabetes Mellitus (DM) and a history of hypoglycemia, resulting in a series of critical lapses in care. Upon the resident's readmission from an acute hospital, the admitting RN did not review or verify all discharge orders, including those for blood sugar (BS) monitoring and insulin administration, with the attending physician or nurse practitioner. The licensed staff did not review the resident's medical history of DM and prior hypoglycemic episodes, nor did they ensure continuity of diabetic care by implementing necessary BS monitoring as previously ordered. As a result, the resident's care plan for DM was not implemented, and there was no monitoring for hypoglycemia or hyperglycemia for several days after readmission. Further, the facility failed to clarify or obtain necessary physician orders for BS monitoring and insulin administration upon readmission, despite the resident's recent hospitalization for hypoglycemia. An LVN entered an order for routine insulin injection without prior physician authorization, and another LVN administered insulin without checking the resident's BS beforehand, contrary to the care plan and facility policy. When the resident experienced a significant change in condition, including an altered level of consciousness and a critically low BS of 27, the nursing staff did not perform adequate assessment or promptly notify the physician or nurse practitioner. There was also a delay in calling 911 emergency services, despite clear indications of a medical emergency. These failures led to the resident experiencing severe hypoglycemia, altered mental status, and hypotension, necessitating emergency transfer to an acute hospital, where the resident was admitted to the ICU and subsequently died. The deficiency was identified as Immediate Jeopardy by the California Department of Public Health due to the facility's failure to ensure appropriate admission orders and continuity of care for diabetes management, resulting in actual harm to the resident.
Removal Plan
- The admitting licensed nurse was provided a one-to-one re-education and training by the vice president of education on receiving diabetic treatment and services, in accordance with professional standards of practice, have care plan, and physician orders for the management of hypoglycemia.
- Admitting licensed nurse will be provided re-education and training by the vice president of education on received diabetic treatment and services, in accordance with professional standards of practice, have care plan, and physician orders for the management of DM and hypoglycemia prior to her next scheduled work.
- The interim director of nursing was provided by the vice president of education with training on care plan for DM and review the resident's records to ensure the care plan is being followed, in accordance with the Director of Nursing's job description.
- The Interdisciplinary Team was also provided education and training by the vice president of education regarding reviewing the residents plan of care upon admission/readmission, change of condition and as needed.
- The Medical Director was informed by the administrator regarding the IJ findings for further corrective actions and recommendations.
- Diabetic residents had their care plan reviewed. Eighteen residents care plans were revised and 20 new care plans were initiated by the interim Director of Nursing or designees, to reflect blood glucose monitoring check order and current diabetic management protocol of hypoglycemia and hyperglycemia.
- The interim Director of Nursing initiated education to licensed nursing staff on all shift on diabetic management with emphasis on the following: Ensure diabetic residents upon admission/re-admission have blood sugar monitoring as ordered.
- Ensure diabetic residents have parameters for low and high BS and has order to give when below/high BS parameters.
- Ensure physicians are notified when resident's blood sugar falls below the parameters as specified by Physician.
- Licensed Nurses that are newly hired, on vacation, on leave, part time, or on call and registry staff will be given inservice by the Interim DON or designee prior to the start of their shift or hired.
- The facility's policies and procedures regarding Diabetic Management of residents was reviewed.
- The Interim Director of Nursing or designee audited new admission and current residents with diagnosis of Diabetes for diabetic management and ensure appropriate interventions are in place and care planned. Facility created an audit tool for residents with diagnosis of Diabetes for diabetic management.
- New hires will receive education on Diabetic Management, and resident safety by the Interim Director of Nursing or designee.
- Registry staff will be provided with accelerated orientation that includes checking of blood glucose levels and care plan initiation on residents upon admission/re-admission and as needed.
- A Quality Assurance Performance Improvement Performance Improvement Project will be implemented to review and interpret all audit findings pertaining to the new admission and current residents with diabetes by the IDT during clinical meetings and RN Supervisor on weekends.
- The Interim DON and or designee will continue to review QAPI plan to address, monitor progress and address missed opportunities by conducting root cause analysis and continuous quality improvement with collaboration with attending physician's medical director, pharmacy consultant and company management clinical resource.
- New admissions/re-admissions will be reviewed during clinical meeting by the IDT headed by the Interim DON and RN Supervisor on weekends to ensure that all admitted resident with Diabetes diagnosis, treatment and services with accordance with professional standard of practice which include diabetic management protocol for hypoglycemia and hyperglycemia, monitoring of blood glucose as ordered and care plan.
- The RN Supervisor on weekends will review all admissions/re-admissions to ensure compliance with Diabetes treatment and services with accordance with professional standard of practice which include diabetic management protocol for hypoglycemia and hyperglycemia, monitoring of blood glucose as ordered and care plan.
- The RN Supervisor during the shift will be notified by the Charge Nurse for any change of condition for coordination of care.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in two separate incidents of harm. One resident, who required moderate assistance with activities of daily living and had diagnoses including heart failure and mobility issues, was struck on the left elbow with a metal bar removed from another resident's wheelchair after a verbal altercation. This resident experienced bruising, redness, and emotional distress following the incident. Despite the resident reporting a prior incident where water was thrown at them by the same aggressor, no effective intervention was implemented to prevent further abuse, and the two residents continued to share a room until the physical assault occurred. Following the first incident, the aggressive resident was moved to share a room with another resident who was legally blind and had multiple impairments, including dementia and muscle weakness. Five days after this room change, the aggressive resident struck the blind resident on the face with a radio, causing a laceration and redness. Staff interviews revealed that concerns about the aggressor's behavior were reported, but there was no evidence of a thorough assessment of roommate compatibility or adequate supervision to prevent further incidents. Staff also failed to recognize or act upon warning signs, such as verbal aggression and agitation, prior to the physical assault. The facility's policies required immediate reporting and intervention in cases of suspected abuse, including separating residents involved in altercations and providing adequate supervision when risk was identified. However, the report documents that staff did not consistently follow these procedures. There was a lack of proper investigation into the initial incident, and staff did not escalate or act upon reports of aggressive behavior. The failure to assess roommate compatibility and to intervene after reports of verbal aggression directly contributed to the subsequent physical abuse and injury of a vulnerable, blind resident.
Failure to Conduct Thorough Investigation of Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an alleged physical altercation between two residents, as required by its Abuse Prohibition Policy and Procedure. After one resident reported being struck on the left elbow by another resident using a wheelchair armrest, staff did not obtain separate, accurate statements from both residents involved. Instead, a nurse copied and pasted the same statement for both residents, despite one resident denying the incident. There was no evidence that staff interviewed witnesses or conducted a comprehensive investigation into the circumstances of the altercation. The records show that the resident who reported being hit had a history of heart failure, gait abnormalities, and required assistance with daily activities, while the other resident had paraplegia and was independent in wheelchair mobility. The incident was reported to staff, and the residents were separated, but documentation of the investigation was incomplete. The facility did not document any further assessment or investigation into why the altercation occurred or whether there were underlying behavioral issues that could lead to further incidents. Interviews with staff and the administrator confirmed that the required investigative steps, such as obtaining individual statements and thoroughly documenting the investigation, were not followed. The administrator was unable to provide additional documentation to demonstrate a thorough investigation. The facility's policy required causative factors to be investigated within two hours and for the investigation to be thoroughly documented, but these steps were not completed, resulting in an incomplete investigation of the alleged abuse.
Delayed Referral and Removal of Gastrostomy Tube
Penalty
Summary
Facility staff failed to ensure timely removal of a resident's gastrostomy tube (GT) as ordered by the physician. The resident, who had a history of acute respiratory failure and type 2 diabetes, was transitioned to an oral diet, and GT feedings were discontinued. Despite a physician's order for GT removal and an attempt by a physician assistant (PA) to remove the tube, the removal was unsuccessful due to severe resistance. The PA documented the failed attempt and recommended referral to a gastrointestinal (GI) specialist, notifying the charge nurse and registered nurse supervisor. Following the PA's recommendation, facility staff did not promptly initiate a referral to a GI specialist. There was no evidence in the resident's chart that the referral was made until over a month later, despite a second recommendation from a nurse practitioner. The resident's appointment with a GI specialist was not scheduled until more than two months after the initial recommendation. During this period, the GT was not being flushed, and the resident reported that the tube had been inactive for several weeks. Interviews with facility staff, including the interim director of nursing, confirmed that licensed nurses did not follow up on the PA's recommendation or notify the attending physician about the failed removal. Facility policy required prompt reporting of complications and adherence to best practices in enteral feeding, but these procedures were not followed. This resulted in the resident's unused GT remaining in place for an extended period, with the potential for complications.
Failure to Provide Timely and Documented Dialysis Care
Penalty
Summary
Facility staff failed to provide safe and appropriate dialysis care for a resident with a history of renal failure and type 2 diabetes mellitus, who required hemodialysis three times a week. The facility did not ensure that staff completed post-hemodialysis treatment status documentation in accordance with its own policy and procedure on dialysis care. Specifically, the resident's Hemodialysis Communication Records for multiple dates lacked documentation of vital signs, dialysis site status, monitoring for post-dialysis complications, and the licensed nurse's signature. Nursing Progress Notes also failed to record the times the resident left for and returned from dialysis appointments, as well as the resident's status upon return. The facility did not assist the resident to be ready for scheduled hemodialysis treatments at the designated pick-up time of 12:30 PM on Mondays, Wednesdays, and Fridays. Interviews with the dialysis center secretary and the resident revealed that the resident was frequently not prepared on time, causing delays in transportation and late arrivals at the dialysis center. As a result, the resident's dialysis sessions often started later than scheduled, sometimes as late as 3 PM to 4 PM, and finished in the evening. On one occasion, the resident was not picked up from the dialysis center until after 10:30 PM due to these delays. The facility's own staff, including the interim director of nursing and social worker, acknowledged that the resident was not consistently ready for transportation at the scheduled time, contributing to the delays. The facility's policy required nursing staff to communicate vital information to the dialysis provider and maintain thorough documentation, but these requirements were not met. The lack of timely preparation and incomplete documentation resulted in frequent delays in the resident's dialysis treatment sessions.
Failure to Accurately Document Resident Weight
Penalty
Summary
The facility failed to maintain accurate documentation of a resident's weight in accordance with accepted professional standards and practices. Specifically, there were significant discrepancies in the recorded weights for a resident with diagnoses of renal failure and diabetes mellitus. On one occasion, the resident's weight was documented as 169.4 lbs. post-dialysis, while a subsequent record indicated a weight of 116.4 lbs., representing a 53 lb. difference. These weights were copied from the Hemodialysis Communication Record without reweighing the resident, as confirmed by staff interviews and record reviews. The resident's weight was not accurately recorded on multiple occasions, and staff responsible for weighing residents, including the Rehab Nursing Assistant and Certified Nurse Assistants, did not reweigh the resident to verify the accuracy of the recorded weights. The Registered Dietitian also relied on the incorrect weight from the Hemodialysis Communication Record without requesting a reweigh or reporting the discrepancy to nursing staff. During an in-person evaluation, the RD did not recommend a reweigh despite the significant weight loss noted in the records. The Interim Director of Nursing acknowledged that the weights were not recorded accurately and that staff should not have copied weights from other records. Facility policy required accurate and timely documentation of weights, including obtaining a baseline weight upon admission and weekly weights thereafter. The failure to follow these procedures resulted in inaccurate documentation of the resident's weight, which was not identified or corrected by nursing or dietary staff.
Failure to Implement Infection Control Program for Scabies
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program to prevent and control the spread of scabies among residents. Resident 1 was diagnosed with scabies on 3/6/25, but the facility did not implement the dermatology orders to apply Permethrin 5% topical cream promptly. The medication was not available, and there was a lack of follow-up to ensure the order was relayed and executed. Additionally, Resident 1 was not placed on contact isolation until 3/10/25, four days after the diagnosis, increasing the risk of transmission. Resident 2, who was Resident 1's roommate, was not placed under contact isolation as per physician orders and was transferred to another room with three new roommates on 3/10/25. This transfer occurred without proper monitoring and tracking for scabies exposure, and there was no surveillance tracking for Residents 3, 4, and 5 or other potentially exposed residents and staff. The facility's infection preventionist did not adequately assess, implement, monitor, and manage the infection prevention and control program when Resident 1 was diagnosed with scabies. The facility's infection prevention and control program was not effectively managed, as evidenced by incomplete documentation and lack of follow-up on infectious cases. The infection preventionist was not familiar with specific tasks and did not spend sufficient time on infection prevention duties. The facility's policy and procedure for infection prevention and control were not followed, leading to potential transmission of communicable diseases and infections among residents, staff, and visitors.
Failure to Maintain Hazard-Free Environment and Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to provide a hazard-free environment and adequate supervision for three residents at high risk for falls, resulting in multiple incidents and injuries. For one resident with a history of falls, muscle weakness, and dementia, the care plan was not updated after repeated falls, and interventions were not adjusted in a timely manner. Despite several falls, including one that resulted in a non-displaced acute fracture of the left ankle, the interdisciplinary team did not consistently conduct post-fall meetings or root cause analyses, and staff did not closely monitor the resident after each incident. Family members and staff interviews confirmed that safety measures such as floor mats were often not in place, and the care plan was not individualized or updated to reflect new interventions. Another resident, who was independent with transfers and ambulation but had a history of falls and muscle weakness, slipped on Nystatin powder left on the floor after staff applied it for a skin condition. The resident sustained a left proximal humerus fracture. The care plan for this resident was left blank after the fall, and the root cause analysis conducted by the interdisciplinary team did not accurately identify the environmental hazard. The resident reported that the call light was not answered promptly after the fall, and staff interviews confirmed that the care plan did not address the risk of slipping on powder, nor was the resident included in the post-fall conference. A third resident, with severe cognitive impairment and a risk of falls due to confusion and abnormal gait, was found crawling on the floor on multiple occasions. The care plan interventions were limited to verbal reminders and ensuring the call light was within reach, but staff were not adequately informed of the resident's fall risk. On one occasion, a CNA left the resident unattended after refusing care, unaware of the resident's need for frequent supervision. Staff interviews revealed a lack of communication regarding the resident's fall risk and the need for increased monitoring, despite repeated incidents of the resident being found on the floor.
Failure to Prevent and Manage UTIs and Catheter-Related Complications
Penalty
Summary
The facility failed to provide appropriate care and services to prevent new and recurrent urinary tract infections (UTIs), infection, blockage, or bleeding for five sampled residents. For one resident with an indwelling catheter, there was a significant delay in notifying the primary physician of critical laboratory values, including a high white blood cell count and low blood glucose, with follow-up occurring approximately 14.5 hours after the lab reported the results. Licensed nurses did not consistently assess or document daily nursing assessments related to the resident's indwelling catheter and urine output characteristics over a ten-day period. Additionally, when the resident became increasingly lethargic and unresponsive, staff failed to monitor and document vital signs, changes in mental status, and food intake, and did not immediately notify the physician of the resident's worsening condition. Other residents with suprapubic or indwelling catheters and a history of recurrent UTIs were not consistently kept clean and dry when incontinent of urine and stool. Documentation and interviews revealed that incontinence care was sometimes delayed due to staffing shortages, and records of care were incomplete, making it unclear whether timely care was provided. For these residents, there was also a lack of care plans to monitor or prevent the recurrence of UTIs, and no additional infection prevention measures were implemented beyond routine care, even after multiple UTIs and hospitalizations. The facility also failed to assess and monitor for signs and symptoms of UTI, such as sediment, blood in the urine, back or flank pain, and fever, as ordered by physicians for residents with catheters. Observations and interviews indicated that staff did not consistently follow protocols for monitoring, documentation, and physician notification in the event of significant changes in condition. Facility policies required prompt reporting of critical lab results and significant changes in resident status, as well as thorough documentation, but these were not followed, resulting in delayed care and hospital transfers for affected residents.
Failure to Provide Adequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for four residents. One resident, who was admitted without any skin breakdown, developed a Stage 2 coccyx pressure ulcer that progressed to Stage 3, and also developed a left heel vascular ulcer during their stay. Documentation revealed that the resident was dependent for activities of daily living, always incontinent, and at risk for pressure ulcers, but there was no consistent documentation of skin assessments or evidence that turning, repositioning, and incontinence care were performed as required. Interviews with nursing staff indicated that the resident was likely not repositioned every two hours and briefs were not changed frequently, resulting in prolonged exposure to moisture and soiling, which contributed to the worsening of the pressure ulcer. Two other residents with a history of healed pressure ulcers were not provided with proper maintenance and monitoring of their low air loss (LAL) mattresses. The LAL mattresses were not set according to the residents' weights and were not checked every shift for proper setting, connection, and functioning as ordered by the physician. Documentation was missing for multiple shifts, and observations confirmed that the mattress settings did not match the residents' weights. Staff interviews confirmed the importance of these interventions to prevent recurrence or worsening of pressure ulcers, but the required checks and documentation were not consistently performed. Another resident with a Stage 4 pressure ulcer did not have weekly wound assessments documented in the nursing progress notes or interdisciplinary team reports after a certain date. Additionally, the facility failed to obtain records from the wound specialist regarding the resident's wound condition and treatment recommendations. Staff interviews confirmed that weekly wound assessments and communication with the wound specialist were not maintained, resulting in a lack of information about the wound's condition and the effectiveness of the treatment plan. The facility's own policy required regular skin inspections, documentation, and ongoing monitoring, which were not followed in these cases.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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