Santa Monica Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1320 20th Street, Santa Monica, California 90404
- CMS Provider Number
- 055540
- Inspections on file
- 35
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Santa Monica Health Care Center during CMS and state inspections, most recent first.
The facility failed to follow its care plan conference policy by not holding IDT meetings with resident and/or representative participation for three cognitively intact residents who required moderate to total assistance with ADLs and had diagnoses such as afib, PVD, chronic respiratory failure, acute kidney failure, BPH, and muscle weakness. For each resident, record review showed no admission IDT care conference or documented discussion of the plan of care, despite the facility’s policy requiring the IDT, together with the resident or surrogate, to develop a plan of care based on the comprehensive assessment and to encourage their participation. Staff interviews, including with the MDS nurse, interim SSD, and DON, confirmed that these conferences were not conducted or documented as required.
A resident with a history of aggressive and unpredictable behavior did not receive necessary behavioral health care and services, as outlined in their care plan, leading to a physical altercation that caused harm to another resident. Despite staff awareness of the resident's behavioral issues and the implementation of a 1:1 sitter for safety within the facility, the resident was allowed to go out on pass without supervision, and repeatedly declined psychological services.
A resident with a history of diabetes, COPD, and hypertension, who was full code, became unresponsive and was not breathing. During CPR, an LVN used a non-rebreather mask instead of an Ambu bag, which is not appropriate for non-breathing individuals. Staff interviews and facility policy confirmed that a bag valve mask should have been used to provide positive pressure ventilation.
A resident with diabetes, receiving insulin and tube feeding, was admitted without a physician order for blood glucose monitoring. Despite a care plan identifying the risk for unstable blood glucose, nursing staff did not obtain necessary orders or check blood sugar during an acute change in condition, contrary to facility policy. The resident became unresponsive and died, with staff interviews confirming that required monitoring protocols were not followed.
A resident with diabetes and chronic kidney disease experienced erratic blood sugar levels that were not reported to the physician, despite facility policy requiring such notification. The resident was found unresponsive with hypoglycemia and required emergency intervention and hospitalization. Staff interviews revealed a lack of communication regarding blood sugar trends and meal intake, contributing to the incident.
Surveyors identified multiple failures in food storage and sanitation, including missing refrigerator temperature logs, absence of a thermometer, expired food in storage, lack of documentation for ice scoop cleaning, and staff food stored with resident food. These deficiencies were confirmed by the RD and were not in accordance with facility policy.
The facility did not submit MDS assessments to CMS within the required 14-day period after completion for three residents with complex medical needs, including cognitive impairment and chronic conditions. The MDSN confirmed the late submissions, and the DON acknowledged the regulatory requirement for timely reporting of assessment data.
A resident admitted with muscle wasting, difficulty walking, and hypertension was assessed as incontinent of bowel and bladder, but no care plan was initiated to address these needs. Staff interviews and record reviews confirmed the absence of a care plan, which was not in accordance with facility policy requiring comprehensive care planning for identified needs.
A resident with severe cognitive impairment and multiple diagnoses did not have an individualized care plan addressing dementia, despite requiring substantial assistance with ADLs. The DON confirmed that such care plans are necessary and acknowledged the omission, which was not in line with facility policy requiring the IDT to create resident-centered plans for those with dementia.
A resident with severe cognitive impairment and multiple medical conditions was found to have oxygen tubing in use beyond the facility's required seven-day change interval. The DON confirmed the tubing had not been changed as per infection control policy, which mandates weekly replacement of respiratory equipment.
The facility failed to inform three residents about the State Long-Term Care Ombudsman program, as confirmed by interviews and record reviews. Despite policies stating residents should be notified upon admission and during resident council meetings, the residents were unaware of the program and how to contact the Ombudsman.
The facility failed to follow standardized recipes and diet textures, resulting in residents on mechanical soft and finely chopped diets receiving incorrect portion sizes and food textures. This included serving 4 ounces of chicken instead of 5 ounces, regular parsley rice instead of pureed rice, and long strips of bell pepper garnish, which could pose a choking hazard.
The facility failed to ensure safe and sanitary food storage and preparation practices, including improper storage of cooked and raw foods, inadequate handwashing by kitchen staff, unsanitary ice machine maintenance, and improper labeling and monitoring of resident food brought from outside. These deficiencies could lead to harmful bacteria growth and cross-contamination.
A facility failed to maintain a resident's dignity during feeding when a CNA was observed standing over a resident while assisting with breakfast. The resident, who had multiple medical conditions and was capable of making decisions, was not treated in accordance with the facility's policy requiring staff to be at eye level during feeding.
The facility failed to promptly and thoroughly investigate the loss of personal belongings for a resident who reported missing clothes and shoes after being moved to another room. Despite informing staff, no follow-up communication was made, and documentation lacked proper details and timestamps.
The facility failed to document that Advance Directive information was discussed and provided to two residents, potentially violating their rights to be fully informed about their options for advance directives. The Social Worker admitted there was no documentation, and the Director of Nursing was unaware of the missing forms.
A resident was using a low air loss mattress (LALM) without a physician's order, set at an incorrect weight. The resident had multiple diagnoses, and the absence of a physician's order for the LALM was confirmed by the Treatment Nurse and Director of Nurses, highlighting a failure to follow facility policy.
A resident with a history of a left femur fracture and other conditions experienced severe pain that was not adequately managed by the facility. Despite frequent complaints and requests for stronger pain relief, the facility did not promptly notify the MD or adjust the pain management plan, resulting in the resident suffering from severe pain levels of 7 to 8 out of 10. The facility's pain management policy was not followed, leading to prolonged and severe pain for the resident.
Failure to Conduct IDT Care Plan Conferences With Resident Participation
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy and procedure for conducting care plan conferences and involving residents and/or their representatives in the development of person-centered plans of care. For Resident 1, who was admitted with atrial fibrillation, peripheral vascular disease, and an anxiety disorder, the Minimum Data Set (MDS) showed intact cognitive skills for daily decision-making and a need for moderate assistance with ADLs. However, review of the medical record as of 1/23/2026 showed no documentation of an Interdisciplinary Team (IDT) meeting or care plan conference upon admission. Resident 1’s care coordinator reported visiting the facility to inquire about the resident’s plan of care and goals, but no staff could provide a care plan or related documentation, and attempts to obtain information from social services were unsuccessful. For Resident 3, admitted with chronic respiratory failure, acute kidney failure, and muscle weakness, the MDS indicated intact cognitive skills for daily decisions and total dependence on staff for ADLs. A review of this resident’s medical record as of 1/23/2026 similarly revealed no IDT meeting or care plan conference upon admission. During an interview and record review, the MDS nurse confirmed that there was no IDT care conference completed and no discussion documented regarding Resident 3’s plan of care. For Resident 4, admitted with benign prostatic hyperplasia, atrial fibrillation, and muscle weakness, the MDS showed intact cognitive skills for daily decisions and a need for maximal to total assistance with ADLs. As with the other residents, review of the medical record as of 1/23/2026 showed no IDT meeting or care plan conference upon admission. The MDS nurse confirmed that no IDT care conference or discussion of the plan of care had been completed for this resident. The DON and interim Social Services Director both stated that, per facility practice and policy, an IDT care conference including the resident and/or resident representative should be held upon admission to discuss the plan of care, services, and discharge planning. The facility’s written policy, “Care Plan Conference,” requires the IDT, in conjunction with the resident or representative, to develop the plan of care based on the comprehensive assessment and to hold care plan conferences within specified timeframes, encouraging resident and representative participation, which did not occur for these residents.
Failure to Provide Necessary Behavioral Health Services Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as part of their comprehensive assessment, resulting in a physical altercation that caused harm to another resident. The resident in question was admitted with several medical diagnoses, including autoimmune thyroiditis, hyperlipidemia, gastroesophageal reflux disease, muscle weakness, and unsteadiness on feet. Despite being cognitively intact and not requiring mobility devices, the resident exhibited aggressive and unpredictable behavior, as documented in care plans and staff interviews. The care plan for verbal and physical aggression included referral to a psychologist or psychiatrist, but psychology notes indicated the resident repeatedly declined to be seen. Staff interviews revealed that the resident often became agitated, frustrated, and aggressive when things did not go their way, leading to concerns about potential harm to themselves and others. Nursing staff and supervisors described the resident as not getting along with roommates, yelling at staff, and requiring a 1:1 sitter for safety due to aggressive behavior. The need for a sitter was specifically to protect other residents and staff from potential physical altercations, as the resident was considered unpredictable and prone to anger. Despite these interventions, the facility allowed the resident to go out on pass without a sitter, with the DON stating that the facility's responsibility was limited to the resident's behavior inside the facility. The facility's policy on safety supervision emphasized individualized, resident-centered approaches based on assessed needs and identified hazards, but the implementation did not address the resident's behavioral health needs adequately, as evidenced by the incident and ongoing behavioral concerns.
Failure to Use Appropriate Oxygen Delivery Device During CPR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use the appropriate oxygen delivery device during cardiopulmonary resuscitation (CPR) for a resident who was unresponsive, had no pulse, and was not breathing. Instead of using a bag valve mask (Ambu bag) to provide positive pressure ventilation, the LVN placed the resident on a non-rebreather mask at 10 liters of oxygen. The non-rebreather mask is not designed for use on individuals who are not breathing, as it cannot deliver oxygen without the patient’s own respiratory effort and may obstruct the airway. The resident involved had a medical history including diabetes mellitus, chronic obstructive pulmonary disease, and hypertension, and was admitted to the facility with a full code status, as indicated by the Physician Orders for Life-Sustaining Treatment (POLST). On the day of the incident, the resident was observed having convulsions, became unresponsive, and was found to have no pulse and was not breathing. CPR was initiated, but the LVN used a non-rebreather mask rather than the Ambu bag, contrary to facility policy and standard emergency procedures. Emergency medical services (EMS) were called and arrived shortly after, but the resident was pronounced dead. Interviews with facility staff, including the LVN involved, the Director of Nursing (DON), and other nurses, confirmed that the correct procedure during CPR for a non-breathing resident is to use an Ambu bag to provide positive pressure ventilation. The facility’s policies and national guidelines also specify the use of a bag valve mask in such situations. The use of a non-rebreather mask on a non-breathing resident was acknowledged by staff as inappropriate and potentially obstructive to oxygen delivery.
Failure to Monitor Blood Glucose in Diabetic Resident on Insulin
Penalty
Summary
The facility failed to implement a system to ensure blood glucose monitoring for a resident with diabetes who was receiving insulin and tube feeding. Upon admission, the resident had a diagnosis of diabetes mellitus and was prescribed Lantus insulin twice daily, but there was no physician order for blood sugar monitoring, despite the resident's care plan identifying a risk for unstable blood glucose levels. The resident's hospital discharge records also did not include blood sugar monitoring orders, and this omission was not addressed by the facility's licensed nursing staff. On the morning of the incident, a licensed vocational nurse observed the resident experiencing convulsions, body shaking, and unresponsiveness, with no pulse or breathing. Despite the resident's diabetic status and the acute change in condition, the nurse did not check the resident's blood glucose level, stating uncertainty about the need to do so. Cardiopulmonary resuscitation was initiated, and emergency services were called, but the resident was pronounced dead shortly after. The facility's policy required blood glucose checks for diabetic residents on insulin, especially during changes in condition or when unresponsive, but this protocol was not followed. Interviews with facility staff, including the DON and the medical director, confirmed that blood glucose monitoring is standard practice for diabetic residents on insulin, particularly when there is a change in condition. The facility's own policies and procedures outlined the necessity of obtaining physician orders for blood glucose monitoring upon admission and during episodes of unresponsiveness. However, these procedures were not adhered to, resulting in the failure to monitor and respond appropriately to the resident's diabetic condition.
Failure to Notify Physician of Erratic Blood Sugar Levels Resulting in Hypoglycemic Event
Penalty
Summary
The facility failed to notify the physician of a resident's fluctuating blood sugar (BS) levels, which were not reported despite being erratic and outside the normal range. The resident, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease, and dysphagia, was admitted with specific dietary and insulin orders. The resident's blood sugar levels ranged from 83 to 328 mg/dL, but these variations were not communicated to the medical doctor as required by facility policy. On the day of the incident, the resident was found unresponsive with a blood sugar reading of 43 mg/dL, indicating hypoglycemia with altered mental status. Emergency interventions were initiated, including administration of glucagon and transfer to a general acute care hospital. Interviews with staff revealed that the licensed nurse did not notify the physician about the erratic blood sugar levels, believing the levels were at baseline, and failed to consider trends across all shifts. The director of nursing acknowledged that the physician should have been informed to adjust insulin dosages and prevent such episodes. Further review showed that the registered dietician had not reviewed the resident's blood sugar levels or meal intake, despite the resident's reduced food consumption, which could contribute to hypoglycemia. The facility's policy required notification of the physician and resident representative when significant changes in condition occurred, but this procedure was not followed, resulting in the resident experiencing a hypoglycemic event requiring hospitalization.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as evidenced by several observations and interviews. There were no temperature logs for two refrigerators, and one refrigerator lacked a thermometer, making it impossible to verify that perishable foods were stored at safe temperatures. Additionally, a container of black beans was found in the refrigerator past its use-by date, and the ice machine scoop did not have a cleaning log to document when it was last sanitized. Staff food items were also found stored in a refrigerator designated for residents, contrary to facility policy. These deficiencies were confirmed through interviews with the Registered Dietician, who acknowledged the lack of documentation and the presence of expired food and staff items in resident storage areas. The facility's policies require proper food storage, temperature monitoring, and separation of staff and resident food to prevent contamination, but these procedures were not followed. All 56 residents who received food from the kitchen were potentially affected by these lapses.
Failure to Timely Submit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure timely electronic submission of Minimum Data Set (MDS) assessments to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day period after completion. Specifically, for three sampled residents with significant medical conditions such as cerebral infarction, hypertension, dementia, anxiety, atrial fibrillation, chronic kidney disease, and altered mental status, the MDS assessments were completed but not transmitted to the system within the regulatory timeframe. The MDS Nurse confirmed that the assessments for these residents were completed on specific dates but were not submitted until several weeks later, exceeding the 14-day requirement. Record reviews and staff interviews revealed that the MDS assessments for these residents, who required varying levels of staff assistance with activities of daily living and were cognitively impaired, were not submitted as per CMS regulations. The DON acknowledged the requirement for timely submission and the importance of notifying CMS of any changes in resident care. The deficiency was further supported by reference to the CMS Resident Assessment Instrument (RAI) Manual, which outlines the 14-day submission requirement for MDS data.
Failure to Initiate Care Plan for Incontinence Upon Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with multiple diagnoses, including muscle wasting, difficulty walking, and hypertension. Upon admission, assessments documented that the resident was incontinent of both bowel and bladder, with inadequate control and frequent episodes of incontinence. Despite these findings, there was no care plan initiated to address the resident's incontinence, as confirmed by both record review and staff interviews. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the absence of a care plan meant that staff did not have documented goals or interventions to guide care for the resident's incontinence. The facility's policy required a comprehensive care plan to be developed for each resident, including measurable objectives and timetables to address identified needs. The lack of a care plan for incontinence was identified during the survey and was not in accordance with the facility's established procedures.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident diagnosed with dementia. Record review showed that the resident was admitted with multiple diagnoses, including dementia, hypertension, and acute kidney failure. The Minimum Data Set assessment indicated the resident had severe cognitive impairment and required substantial to maximal assistance with most activities of daily living, such as eating, hygiene, and dressing. Despite these needs, there was no care plan addressing the resident's dementia diagnosis. During an interview, the DON confirmed that care plans are required for all residents, especially for those with high-risk diagnoses like dementia, to guide staff in providing appropriate interventions. The DON acknowledged that the absence of a dementia-specific care plan could result in staff not knowing the necessary interventions for the resident. Review of the facility's policy indicated that the interdisciplinary team is responsible for creating a resident-centered care plan for individuals with confirmed dementia, but this was not done for the resident in question.
Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures for one resident by not ensuring that oxygen tubing was changed every seven days as required. During a record review, it was found that a resident with severe cognitive impairment and dependence on activities of daily living was receiving oxygen via nasal cannula, and the tubing in use was dated beyond the seven-day change interval. The Director of Nursing confirmed that the tubing had not been changed according to policy and acknowledged the requirement for weekly changes. The resident's medical history included depression, hypertension, and atrial fibrillation, and a physician's order was in place for oxygen administration as needed to maintain oxygen saturation above 92%. Facility policy specified that respiratory equipment such as cannulas and humidifiers should be changed every seven days or when visibly contaminated. The failure to follow this schedule was observed during a concurrent observation and interview, and the facility's policy was confirmed through record review.
Failure to Inform Residents About Ombudsman Program
Penalty
Summary
The facility failed to provide information about the State Long-Term Care Ombudsman to three of four sampled residents. Resident 15, 45, and 53, who were alert and oriented, stated during a Resident Council Meeting that they were not aware of the Ombudsman program or how to contact the Ombudsman's office. This deficiency was identified through interviews and record reviews, which revealed that these residents had not been adequately informed about the Ombudsman program despite the facility's policy stating that residents should be notified upon admission and during resident council meetings. Interviews with the Social Service Director, Activities Assistant, and Director of Nursing confirmed that the responsibility for informing residents about the Ombudsman program was not consistently executed. The Social Service Director stated that residents were notified upon admission and during resident council meetings, while the Director of Nursing indicated that the Activities Director was responsible for informing residents about the Ombudsman. However, the residents' lack of awareness indicated a failure in the communication process, leading to the deficiency noted in the report.
Failure to Follow Standardized Recipes and Diet Textures
Penalty
Summary
The facility failed to ensure the standardized recipes for the lunch menu were followed on 3/26/2024. Specifically, the cook used a smaller scoop size to serve chicken Dijon, resulting in 16 residents on mechanical soft and finely chopped diets receiving 4 ounces of chicken instead of the prescribed 5 ounces. Additionally, 13 residents on finely chopped diets received regular parsley rice instead of pureed parsley rice as required by the menu. The cook admitted to making a mistake with the scoop sizes and not noticing the menu's requirement for pureed rice, which could lead to residents feeling hungry and potentially choking on improperly prepared food. Furthermore, the cook added long strips of sliced red bell pepper as a garnish for residents on mechanical soft diets, which was not in accordance with the mechanical soft diet policy. Nine out of 16 residents on mechanical soft and finely chopped diets received these long strips, which could pose a choking hazard. The kitchen supervisor and registered dietitian confirmed that the bell peppers should have been chopped into smaller pieces. The facility's policies and procedures, as well as the menu and diet spreadsheet, clearly indicated the correct portion sizes and food textures that were not adhered to during this meal service.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices. Cooked eggs were stored on the same shelf and on top of cartons of raw liquid eggs, and a large piece of raw pork loin was stored on top of imitation crab meat. The cook acknowledged that the refrigerator space was small, leading to improper storage and potential cross-contamination. Additionally, a kitchen staff member did not wash their hands properly before handling clean dishes, using a bucket of soapy water instead of the designated handwashing sink, which could lead to the transfer of germs from dirty to clean dishes. The ice machine in the kitchen was not maintained in a sanitary manner, with red color residue observed inside the ice storage bin. The kitchen supervisor and maintenance supervisor confirmed that the residue was likely from juice spills, as the ice storage bin was kept open while filling beverage containers. The facility's policy required the ice machine to be kept closed when not in use, but this was not followed, leading to potential contamination. Food brought in by residents or their families was not properly labeled or dated, and the resident food refrigerator was not monitored for temperature. Expired and moldy food was found in the refrigerator, and the maintenance staff admitted that they were not allowed to discard food per the facility's policy. The director of staff development and the maintenance supervisor acknowledged that the refrigerator had not been cleaned and that the food was not safe for residents due to the lack of proper labeling and monitoring.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced a resident's dignity, respect, and individuality for one of four sampled residents. On 3/26/2024 at 8 AM, a Certified Nursing Assistant (CNA) was observed standing over Resident 208 while assisting the resident during breakfast. This action did not align with the facility's policy, which requires staff to be at eye level with residents while feeding them to ensure dignity and respect. Resident 208, who was admitted with medical diagnoses including hyperlipidemia, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease, acute pulmonary edema, and a left femur fracture, was capable of understanding and making decisions. During an interview, the CNA acknowledged the mistake and the Director of Nursing confirmed that staff must be at eye level with residents while feeding them. The facility's policy on assisting residents to eat also supports this requirement.
Failure to Investigate Lost Belongings Promptly
Penalty
Summary
The facility failed to promptly and thoroughly investigate the loss of personal belongings for Resident 27. Resident 27, who was cognitively intact and required maximal assistance with activities of daily living, reported missing two bags of clothes, including five pairs of pants, five shirts, and one pair of orthopedic shoes, after being moved to another room. Despite informing facility staff about the missing items, no follow-up communication was made with Resident 27 regarding the investigation or resolution of the issue. Interviews with the Social Worker and Administrator revealed that the information about the missing property was noted, and a decision was made to replace the lost items. However, the facility's documentation, including the Inventory of Personal Effects list and the Grievance/Complaint Report, lacked proper details and timestamps. The facility's policies on misappropriation of resident property and grievance resolution were not adhered to, resulting in a delay in addressing Resident 27's concerns and replacing the lost belongings.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to document that Advance Directive information was discussed and provided to two residents, Resident 8 and Resident 22. Resident 8, who was admitted with multiple diagnoses including bilateral knee osteoarthritis, anxiety disorder, and major depressive disorder, was found to be moderately cognitively impaired and required maximal assistance with personal hygiene. During an interview, the Social Worker (SW) admitted that there was no documentation in Resident 8's medical record regarding the acknowledgment of advance directives. Similarly, Resident 22, who was admitted with conditions such as orthostatic hypotension, anemia, and COPD, was cognitively intact but also lacked documentation of having received information about advance directives. The SW confirmed that although information was provided, there were no notes or documentation to support this claim for either resident. The Director of Nursing (DON) was unaware of the missing advance directive acknowledgment forms for Residents 8 and 22. The facility's policy, dated 8/16/2021, mandates that residents or their representatives be provided with written information regarding advance directives upon admission and that this be documented in the resident's clinical record. The failure to document these discussions and provide written information as required by the facility's policy potentially violated the residents' rights to be fully informed about their options for advance directives.
Failure to Obtain Physician's Order for Low Air Loss Mattress
Penalty
Summary
The facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident, which is designed to distribute body weight and help prevent skin breakdown. The resident, who was admitted with multiple diagnoses including cellulitis, tremor, depression, hypothyroidism, hyperlipidemia, manic episode, anxiety disorder, obstructive sleep apnea, and hypertension, was observed using the LALM set at 320 pounds, despite weighing only 187 pounds. The Treatment Nurse confirmed the absence of a physician's order for the LALM and stated the need to call the physician to obtain one. The Director of Nurses also acknowledged the importance of having a physician's order to ensure appropriate treatment for the resident. The facility's policy and procedures require physician orders to provide clear direction in the care of residents. This deficiency had the potential to result in inappropriate care and treatment for the resident, as the LALM was being used without proper authorization and at an incorrect setting for the resident's weight.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, resulting in severe pain. The resident, who was cognitively intact and had a history of a left femur fracture, seizures, anxiety disorder, depression, and hypertension, reported that the pain medications administered did not relieve their pain for more than three hours. Despite the resident's continual complaints and requests for stronger pain relief, the facility did not notify the MD promptly or adjust the pain management plan accordingly. The resident's pain levels were consistently reported between 7 to 8 out of 10, indicating severe pain, yet the care plan only addressed mild pain interventions and did not include strategies for managing severe pain. Interviews with staff revealed that the resident frequently complained of pain and sometimes refused the offered medications, stating they were ineffective. The certified nursing assistant and licensed vocational nurse both reported the resident's ongoing pain to the RN supervisor, who then contacted the MD. Initially, the MD was reluctant to increase or change the pain medication without identifying the underlying cause of the pain but eventually ordered the pain medication to be administered every four hours instead of every six hours and requested further tests to determine the cause of the pain. The facility's policy on pain management emphasized the need for regular pain screening, evaluation, and care management, including notifying a physician and administering therapeutic interventions as ordered. However, the facility did not adhere to these procedures, resulting in the resident experiencing prolonged and severe pain without adequate intervention or timely communication with the MD to adjust the pain management plan.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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