Sharon Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 8167 West Third St., Los Angeles, California 90048
- CMS Provider Number
- 055755
- Inspections on file
- 94
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Sharon Care Center during CMS and state inspections, most recent first.
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Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site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.
A resident with heart failure and pleural effusion, who was alert and cognitively intact, consented twice to receive influenza and PNA vaccines and had active MD orders for both. Facility records and CAIR showed the last flu and PNA vaccines were given years earlier, and there was no documentation that the ordered vaccines were administered or that the resident refused them in accordance with facility P&P requiring annual flu vaccination and routine PNA vaccination. The IPN reported the resident refused when re-offered and that vaccines were readily available from the pharmacy, while the DON acknowledged the vaccines should have been given promptly after consent.
A resident with severe cognitive impairment and documented lack of decision-making capacity was admitted with multiple diagnoses, including benign neoplasm of the meninges, altered mental status, and adult failure to thrive. The facility’s IPN stated that policy requires a signed consent from the resident or representative before administering vaccines such as influenza, pneumonia, and COVID, to confirm education on risks and benefits. However, there was no documented evidence that the resident’s representative was provided or signed any immunization consent, despite facility IPCP policies specifying procedures for obtaining direct and proxy consent for vaccinations.
A resident with muscle wasting, lack of coordination, and ESRD had multiple assessments showing bilateral leg weakness, dependence for sit-to-stand and bed-to-chair transfers, and a need for a total (Hoyer) lift with two-person assist. Despite this, staff routinely transferred the resident with one-person assist using a gait belt, and the resident was not on fall precautions. The care plan was not updated after a prior fall or after readmission assessments to reflect the need for a Hoyer lift and two-person assistance, and on one occasion the resident sustained an assisted fall during a wheelchair-to-bed transfer performed by a CNA using a gait belt alone.
A resident with Parkinson’s disease and other conditions was receiving Mirtazapine 15 mg for depression, and their MDS documented frequent depressive symptoms, yet depression was not coded as an active diagnosis and no depression-related care plan was in place. During interviews, an LVN, the DON, and the MDS nurse confirmed that the depression diagnosis from the hospital and continued psychotropic order were not reflected in the MDS or care plan, and the IDT conference notes did not document a medication review, contrary to the facility’s psychotropic medication policy requiring documented indication and evaluation on admission or readmission.
A resident admitted with type 2 DM and a history of MI had an active DM diagnosis documented on the MDS, but no corresponding diabetes care plan was developed when the diagnosis triggered in the assessment system, contrary to facility policy requiring individualized care plans with measurable objectives and timetables. During surveyor review with the DON and MDS nurse, no care plan appeared when searching under "Diabetes Mellitus," and a diabetes care plan dated the day before the interview was found only when searching under "diabetes." The DON admitted she created this plan after overhearing the surveyor request it and that it was incomplete, and the MDS nurse confirmed there was no explanation for the earlier omission and that, without a diabetes care plan, the resident’s care would be incomplete.
A resident with dementia, rheumatoid arthritis, anemia, and HTN, who required partial to moderate assistance with ADLs and had a family member as DPOA, did not receive timely access to requested medical records through the resident representative. The facility’s policy required access to personal and medical records within 24 hours and copies within two business days of a request, but the Medical Records Director delayed processing a mailed request until returning from vacation, and records were not provided until many days later. The Facility Administrator confirmed that the delay occurred because the facility waited for corporate office clearance, and although a medical records consultant was available when the MRD was off, that consultant was responsible for many other facilities, resulting in the resident representative being denied timely access to the records as required by policy.
A resident with epilepsy, a femur fracture, ESRD, and a three-year history of left ear hearing loss did not have a comprehensive care plan addressing the hearing deficit. An MDS documented adequate hearing, while an ENT consult noted chronic hearing loss, wax removal, and recommended follow-up. The resident later voiced concern about persistent hearing loss and lack of further interventions. Review by the MDS nurse and DON confirmed there were no care plan problems, goals, monitoring parameters, or orders related to hearing loss, despite facility policy requiring individualized care plans for all identified problems.
A resident with multiple medical conditions and at risk for malnutrition experienced significant unplanned weight loss after the facility failed to follow physician orders for a Restorative Nursing Aide (RNA) feeding program at both breakfast and lunch. Instead, only breakfast was covered by RNAs, while lunch was handled by CNAs, contrary to the care plan and physician orders. Staff interviews and documentation confirmed the deviation from prescribed care, resulting in continued poor oral intake and weight loss.
A resident with a fractured arm and other medical conditions experienced ongoing pain despite receiving Oxycodone-Acetaminophen every six hours. The resident repeatedly requested more frequent pain medication, but staff did not notify the physician or adjust the medication schedule as required by the care plan and facility policy, resulting in unmanaged pain and discomfort.
A resident with non-Hodgkin lymphoma and requiring assistance with ADLs did not have transportation arranged in advance for a scheduled chemotherapy appointment. Staff only became aware of the oversight on the morning of the appointment after the resident reminded them, leading to a last-minute call for backup transportation. Facility policy requires transportation to be scheduled promptly after appointments are set, but this was not followed.
A resident with diabetes and hyperglycemia was found with prescription triamcinolone ointment at bedside, which was applied by CNAs at the resident's request without a formal assessment or physician order for self-administration. Interviews revealed that staff did not confirm the appropriateness of this practice with licensed nurses, and facility policy requires only licensed personnel to administer medications.
A resident with muscle weakness and chronic kidney disease, who required substantial assistance and was able to communicate her needs, was not provided with warm water to make tea during meals as documented in her food preferences. Staff were aware of her preference, but the omission of a tea bag on the tray led to the CNA not providing hot water, resulting in the resident's preference not being honored and causing frustration.
A resident's room was found to have scattered chipped paint on the wall, which made the resident feel upset and did not meet the facility's standards for a homelike environment. Staff, including an LVN and the Maintenance Director, acknowledged the issue and stated it should have been addressed, as facility policy requires maintaining a clean and comfortable setting.
A resident with multiple medical and mental health diagnoses, who was identified as having difficulty hearing, did not have a comprehensive care plan developed to address their communication needs. Staff and social services confirmed the resident's hearing challenges, but no interventions or individualized strategies were documented or implemented, contrary to facility policy.
Three residents did not receive proper pressure ulcer prevention due to staff failing to ensure low air loss mattresses were functioning and set according to physician orders. One resident's mattress was leaking air and taped, while two others had mattresses set at incorrect weight levels, contrary to their care plans and orders. Nursing staff confirmed these issues could compromise skin integrity and wound healing.
Two residents were placed at risk of falls and injury when an extension cord was taped from a bathroom outlet, running under a door and across the floor to a bed, in violation of the facility's electrical safety policy. Both the Maintenance Director and DON acknowledged the setup was unsafe and could cause tripping.
A resident with an indwelling catheter and multiple medical conditions was observed to have a large amount of sediment in the catheter tubing on multiple occasions. Despite a physician order to change the catheter for excessive sedimentation and staff awareness of the need to notify the physician, no notification was made and the catheter was not changed as ordered.
A resident with a gastrostomy tube had a feeding tube syringe that was not labeled or dated, as required by facility policy. Nursing staff confirmed that syringes should be dated and changed daily, but this was not done, making it unclear when the syringe was last replaced.
A resident with end stage renal disease and an AV shunt did not have the required emergency kit at the bedside to manage potential bleeding, despite physician orders and facility policy. Nursing staff and the DON confirmed the absence of the kit and its importance for immediate response to dialysis-related emergencies.
CNAs applied a prescription ointment to a resident without a physician's order or proper authorization, contrary to facility policy. The resident, who required assistance with personal care, directed the CNAs to apply the medication, and staff did so without consulting a licensed nurse or confirming an order. Facility policy restricts medication administration to licensed personnel, and this protocol was not followed.
Two residents were found to have medications left unsecured at their bedside, including a topical cream and oral tablets. Nursing staff acknowledged that medications should not be left with residents and confirmed this was not in line with facility policy, which requires all drugs and biologicals to be stored securely in locked compartments.
Surveyors found that food items, including sandwiches and butter cups, were not labeled or dated as required, and expired items were not discarded. Additionally, the dishwashing machine did not have the correct sanitizer concentration, as confirmed by staff and test strips. These deficiencies were observed during interviews and record reviews, and were not in accordance with facility policies.
A urinal containing urine was found on a bedside table next to a resident's food and drinks. The resident had impaired cognition and required assistance with daily activities, including eating. An LVN and the DON confirmed that this practice was not safe and did not comply with the facility's infection prevention and control policy, which requires maintaining a sanitary environment.
A resident with significant physical limitations was unable to signal for assistance because the call light in their room was not working. Staff confirmed the malfunction, and there was uncertainty about how often maintenance checks were performed. Facility policy required the call system to be functional and regularly maintained, but the issue was not identified or corrected before it was observed.
Fourteen resident rooms were found to be below the required 80 square feet per resident for multiple occupancy, with measurements confirming insufficient space. Staff and residents did not report issues with care or mobility in these rooms, and a waiver had been requested for the affected rooms, but the deficiency was cited due to noncompliance with federal space requirements.
A facility failed to ensure a resident's PRN psychotropic medication, Seroquel, had a 14-day administration limit, as required by policy. The resident, with schizophrenia and major depressive disorder, was prescribed Seroquel without the necessary stop date, increasing the risk to their mental well-being. The facility's Psychiatrist did not order the medication, and the Director of Nursing and Pharmacy Consultant acknowledged the oversight.
A facility failed to complete a PASRR Level II assessment for a resident with schizophrenia, major depressive disorder, and metabolic encephalopathy. The PASARR Level I was incomplete, missing a critical question about suspected mental illness, which should have triggered further evaluation. The resident exhibited cognitive impairment and behavioral issues, yet the necessary assessment and support from the Department of Mental Health were not provided. Staff interviews confirmed the oversight.
A resident with mental illness experienced significant behavioral changes, including verbal aggression and agitation, but the facility failed to notify the physician as required by policy. This oversight led to the resident's hospitalization and a psychiatric hold. Staff interviews confirmed the lack of physician notification, despite the facility's policy mandating it for significant condition changes.
A resident with schizophrenia and major depressive disorder experienced behavioral changes, including verbal aggression and agitation, which were not addressed in their care plan. The facility failed to update the care plan with specific interventions for the resident's antipsychotic medication, Seroquel, following changes in the resident's condition. This oversight led to the escalation of behaviors and the resident's subsequent admission to a General Acute Care Hospital.
A facility failed to develop and implement a comprehensive care plan for a resident admitted with a left fibula fracture and osteoporosis. Despite the need for pain management and fracture care, no baseline care plan was initiated or implemented. The Director of Nursing confirmed the absence of care plans, which should have been developed within 48 hours of admission according to facility policies.
A facility failed to assess and monitor a resident's left lower leg splint, risking complications like skin breakdown. The resident, admitted with a fibula fracture and osteoporosis, was at risk for pressure ulcers. Despite this, no documentation of splint assessment was found over several weeks, as confirmed by the DON, violating the facility's Skin Integrity Management policy.
A facility failed to provide adequate nursing staff, resulting in a resident waiting over three hours for incontinence care and two residents missing scheduled showers. The DON acknowledged the delay was unacceptable, and CNAs cited high workloads as the reason for unmet care needs. Facility policies on maintaining ADLs were not followed, impacting residents' hygiene and well-being.
A resident with a history of hemorrhagic disorder experienced a critically low platelet count, but the LTC facility failed to notify the physician immediately or take emergency action. Despite the critical nature of the lab results, staff followed non-emergency procedures, delaying the resident's transfer to a hospital. The resident was eventually transferred but died seven days later.
The facility failed to ensure cleanliness and proper maintenance of dinnerware and water pitchers. Observations revealed cloudy glasses, stained mugs, and worn coffee pots, with CNAs expressing concerns about cleanliness. Additionally, water pitchers were not replaced timely, with some residents lacking pitchers at their bedside. The facility's policy on cleaning and sanitizing was not followed.
The facility failed to provide two residents with their preferred fresh fruits, offering only canned fruits instead. Despite dietary requirements and preferences, the Dietary Manager cited budget and seasonal issues for the lack of fresh fruit, contrary to the facility's policy on food preferences.
A facility failed to create a comprehensive care plan for a resident with bipolar disorder and prescribed Risperidone. The care plan lacked goals, interventions, or monitoring, despite the resident's symptoms of depression and mood swings. Staff interviews revealed the care plan was not completed, and the resident had not been seen by a psychiatrist since admission, contrary to facility policy.
A facility failed to conduct a required yearly performance evaluation for an LVN, hired on 9/22/22, as per their policy. The DON and ADM confirmed the absence of the evaluation, which should have been completed 90 days post-hire and annually. This oversight was acknowledged as a risk to resident safety.
The facility failed to maintain a yearly skills competency checklist for a CNA, hired on 3/12/24, as required by policy. The Administrator confirmed the absence of the checklist, and the DON acknowledged the oversight, emphasizing the importance of documentation to ensure competency. The facility's policy mandates competency evaluations upon hire and annually.
A resident was prescribed Risperidone for bipolar disorder without documented consent, as required by facility policy. Despite being alert and oriented, the resident's chart lacked a signed consent form. Interviews revealed that the admitting nurse was responsible for obtaining consent, but this was not done. The psychiatrist was also not informed of the resident's admission, contributing to the oversight.
Two residents were involved in a verbal altercation where one attempted to strike the other. The facility failed to report the incident to authorities or conduct an investigation, as required by their abuse policy. Additionally, the residents were not separated in a timely manner, with one resident being moved 11 days later.
A resident with visual impairment was mistakenly taken to a skilled nursing facility instead of an ophthalmologist appointment due to an identification error. Despite being accompanied by a CNA and carrying an envelope with his name, the transportation driver took him to the wrong location, causing the resident to miss his appointment and experience distress.
A resident with severe cognitive impairment fell during the night shift, but the LTC facility failed to assess or document the incident immediately. The LVN was informed hours later and notified the NP, but the physician was not contacted right after the fall. The facility did not adhere to its fall management policy, which requires immediate injury observation, neurological evaluation, documentation, and physician notification.
A facility failed to conduct a quarterly Braden scale assessment for a resident with pressure ulcers, who was at severe risk of developing further ulcers. The resident had multiple health issues, including altered mental status and immobility, and was readmitted with unstageable pressure-induced tissue damage. Despite these conditions, the required assessment was not completed, which is crucial for informing staff about the necessary care to prevent worsening of the resident's wounds.
A resident at severe risk for pressure ulcers did not receive adequate care planning, leading to deficiencies in their treatment. The care plan for the resident's sacral coccyx ulcer was not updated when reclassified to Stage IV, and the plan for a heel wound was incomplete. Additionally, no care plan was developed for a new PVD wound. Interviews with staff highlighted the lack of comprehensive interventions, contrary to facility policy.
A CNA in an LTC facility used a derogatory term towards a resident during an altercation over socks, witnessed by another resident and an RN. The resident had mildly impaired cognition and had been feeling depressed. The facility's policy prohibits such language, but the CNA's communication was ineffective, increasing the risk of verbal abuse.
A resident with multiple health conditions experienced seven instances of G-tube dislodgment without an initial care plan or timely revisions. The facility also failed to conduct timely interdisciplinary team meetings following these incidents, contrary to its policies.
A resident was incorrectly billed for a single room while another resident was on bed hold in the same room. The facility's records showed no agreement for the single room, and the resident was not liable for the charges. The DON confirmed the resident was in a semi-private room during the relevant period.
A resident experienced a significant delay in the implementation of a Registered Dietician's recommendations to change their G-tube feeding formula, resulting in a 4% weight loss over 51 days. The resident, with multiple health conditions and dependent on staff for daily activities, did not receive the recommended change from Jevity 1.2 cal/ml to Glucerna 1.5 cal/ml at a higher rate until much later, despite facility policy allowing for such dietary orders to be delegated.
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 Implement Flu and Pneumococcal Vaccination Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to influenza and pneumococcal immunizations for one resident. The resident was admitted with diagnoses including a left radius fracture, heart failure, and pleural effusion, and was documented as alert and oriented with intact cognition for daily decision-making. On two separate vaccine consent forms, the resident consented to receive both influenza and pneumococcal (PNA) vaccines. The resident’s Order Summary Reports contained physician orders for a yearly Fluzone influenza vaccine and a Pneumococcal 13 vaccine, both to be given intramuscularly as needed for vaccination. The facility’s policies, reviewed on 12/18/2025, required that influenza vaccines be offered annually between October 1 and March 31 and that all residents be offered pneumococcal vaccines. Record review and interviews showed that, despite the resident’s consent and existing physician orders, there was no documentation that the influenza or pneumococcal vaccines were administered or refused in accordance with facility policy and current standards of practice. The California Immunization Registry (CAIR) indicated the resident’s last influenza vaccine was received in 2024 and the last pneumococcal vaccine in 2014, with recommendations for additional doses of both vaccines. The Infection Preventionist Nurse stated that the facility could obtain flu and PNA vaccines from the pharmacy without issues and reported that the resident refused the vaccines on one date when they were re-offered, but this refusal was not supported by documentation of administration or refusal consistent with the policies. The DON acknowledged that the resident should have received the flu and PNA vaccines as soon as consent was obtained and that the resident was at risk for flu and PNA infections.
Failure to Obtain Immunization Consent for Resident Lacking Decision-Making Capacity
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy and procedures related to immunization consent for one resident. Resident 4 was admitted with diagnoses including benign neoplasm of the meninges, altered mental status, and adult failure to thrive. A history and physical dated 6/17/2025 documented that the resident did not have the capacity to understand and make decisions, and a Minimum Data Set dated 12/24/2025 indicated severe cognitive impairment. The same MDS showed the resident mostly required supervision or touching assistance for ADLs such as oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, and putting on/taking off footwear. During an interview, the Infection Prevention Nurse stated that before administering vaccinations such as influenza, COVID, or pneumonia, a resident or their representative must sign a consent form to indicate they have been educated on the benefits and risks. The IPN confirmed there was no documented evidence that the resident’s representative had been given the consent. Review of the facility’s Infection Prevention and Control Program policy, last reviewed on 12/18/2025, showed that the program included immunization policies and procedures, including obtaining direct and proxy consent and specifying how often this should occur. The lack of documented consent for influenza, pneumonia, and COVID vaccinations for Resident 4, who lacked decision-making capacity, constituted a failure to follow the facility’s infection control policies and procedures.
Failure to Update Fall Risk and Transfer Care Plan Leading to Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s fall risk and transfer care plan to reflect current assessments and needs. The resident was admitted with diagnoses including muscle wasting and atrophy, lack of coordination, and end-stage renal disease. A care plan dated 11/12/2025 identified a deficit in activities of daily living and required two staff for transfers using a Hoyer lift with a medium sling. A Lift Transfer Reposition assessment dated 1/22/2026 documented that the resident could not transfer independently or with supervision without a device, was unable to bear at least 50% weight on one or both legs, and required a total (Hoyer) lift with a medium sling. Nursing documentation on the same date noted bilateral leg weakness and fall risk factors, including a history of falls within six months. A subsequent MDS dated 1/29/2026 indicated the resident was alert and oriented with good recall, and was dependent for sit-to-stand and chair/bed-to-chair transfers, requiring assistance of two or more helpers. A physical therapy note dated 1/31/2026 also documented that the resident was dependent with 100% assist or two or more helpers for sit-to-stand and chair/bed-to-chair transfers. However, a Restorative Nursing Weekly/Monthly Progress Report dated 2/24/2026 stated the resident’s function was improving and that the resident could sit and stand with one-person assist using a gait belt. Despite the earlier assessments indicating dependence and need for a total lift, the care plan in effect on 2/26/2026 still listed the resident as at risk for falls/injury due to impaired mobility with interventions including two-person transfers using a Hoyer lift, and this intervention was not created until 2/27/2026, after the assisted fall. On 2/26/2026, the resident experienced an assisted fall while being transferred from a wheelchair to a bed by a CNA using a gait belt with one-person assist. The CNA reported that this one-person gait belt transfer was the usual practice, that the resident was not on fall precautions, and that she was only aware of the second fall. The LVN also stated the resident was a one-person transfer with a gait belt and not on fall precautions. The DON later acknowledged that the Lift Transfer Reposition assessment on readmission indicated the need for a total Hoyer lift and that this status should have been updated in the care plan at admission/readmission, and also stated that the care plan had not been updated after a prior fall on 12/23/2025. Facility policies required that comprehensive care plans be developed within seven days of the comprehensive assessment and be reviewed and revised as the resident’s condition changed, including after significant changes and at least quarterly, but the resident’s fall risk and transfer care plan was not updated to reflect current assessments and prior falls before the assisted fall occurred.
Failure to Accurately Code Depression and Care Plan for Psychotropic Use on MDS
Penalty
Summary
Surveyors identified that the facility failed to ensure an accurate MDS assessment and related care planning for a resident with a documented diagnosis of depression. The resident was admitted with Parkinson’s disease, muscle weakness, and difficulty walking, and had an active order for Mirtazapine 15 mg for depression manifested by overconcern with health issues. The resident’s MDS indicated they felt little interest or pleasure in doing things and felt down, depressed, or hopeless half or more of the days, but depression was not coded as an active diagnosis on the MDS. During interview and record review, an LVN confirmed there was no care plan addressing depression and that the diagnosis of depression was not triggered on the MDS, despite the resident receiving a medication ordered for depression. Further review with the DON and MDS nurse showed that the resident had received a depression diagnosis from the hospital and that a psychiatrist at the GACH had continued the Mirtazapine upon readmission. The MDS nurse stated that once the order was entered into the electronic chart, there was no alert to trigger the depression diagnosis in the MDS. Review of the IDT care conference documentation showed no recorded review of medications, and the DON and MDS nurse confirmed there was no care plan documented for depression or for the use of Mirtazapine. The DON and MDS nurse stated that without a care plan, something could be missed, and that the care plan is the comprehensive plan of care for the resident. The facility’s psychotropic medication use policy required that residents not receive psychotropic medications without a clinically indicated, documented condition and that the IDT evaluate and document the resident’s underlying condition and medications on admission or readmission, which was not reflected in the records reviewed for this resident.
Failure to Develop Comprehensive Diabetes Care Plan for a Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing diabetes mellitus for a resident admitted with type 2 DM and a history of myocardial infarction. The admission record showed the resident was admitted with type 2 DM, and the MDS dated 12/31/2025 documented the resident as alert, oriented, with good recall, and with an active diagnosis of diabetes. Facility policy required that areas of concern triggered during the resident assessment be evaluated and incorporated into an individualized comprehensive care plan with measurable objectives and timetables to meet medical, physical, mental, and psychosocial needs. Despite the diabetes diagnosis being triggered in the MDS, there was no corresponding diabetes care plan in place for this resident. During an interview and concurrent record review with the DON and the MDS nurse on 1/21/2026, the surveyor requested the resident’s diabetes care plan. Initial review of the Care Plan Report under "Diabetes Mellitus" showed no care plan. When the MDS nurse searched under "diabetes," a care plan was visible, but it was dated 1/20/2026 and had been created by the DON after she overheard the surveyor ask for the resident’s diabetes care plan. The DON acknowledged that the diabetes care plan she created was incomplete. The MDS nurse stated there was no indication why the care plan had not been developed when type 2 DM was triggered in the MDS and confirmed that care plans are the comprehensive plan of care for the resident and that, without the diabetes care plan, the resident’s care would be incomplete.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its own policy and procedure for providing timely access to a resident’s medical records when a resident representative requested records for one of the sampled residents. The resident, admitted with rheumatoid arthritis, anemia, HTN, and later documented with dementia without behavioral disturbance, required partial to moderate assistance with ADLs and had a family member designated as DPOA for medical decisions. The facility’s policy, revised in late 2025, stated that residents have the right to access their personal and medical records within 24 hours (excluding weekends and holidays) of a request and to obtain copies within two business days of an oral or written request. The policy also allowed a legal representative to grant others access to the resident’s records through a written request specifying what information should be released and to whom. The Medical Records Director reported that the facility received a written medical records request from the resident’s representative by mail on 12/31/2025. However, the MRD did not begin processing the request until returning from vacation on 1/5/2026 and ultimately provided the records to the resident’s representative on 1/12/2026. The MRD stated that records are typically provided within two business days after corporate office review and approval. The Facility Administrator confirmed that the records were not released within the two-day timeframe specified in the facility’s policy because the facility was waiting for clearance from the corporate office. The FA also stated that a medical records consultant was available when the MRD was off, but that consultant was responsible for 60 other facilities. As a result, the resident’s representative was denied timely access to the requested medical records in accordance with the facility’s own policy.
Failure to Develop Comprehensive Care Plan for Resident’s Hearing Loss
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s left ear hearing loss. The resident was admitted with diagnoses including epilepsy, a femur fracture, and end stage renal disease, and an MDS assessment dated 10/25/2025 documented that the resident had adequate hearing and cognitive skills for daily decision making, with varying levels of assistance needed for ADLs. An ENT consult dated 12/25/2025 documented a three-year history of hearing loss, wax removal, patient education, and a recommendation for follow-up in six months or more. Despite this documented history and evaluation, the resident’s medical record contained no care plan problem, goals, monitoring parameters, comfort measures, or physician notification requirements related to hearing loss. During an observation and interview, the resident, seated in bed, expressed concern about ongoing hearing loss in the left ear and reported having received treatment once at the facility, but questioned whether additional interventions would be offered since the hearing loss persisted and had begun prior to admission. The MDS nurse confirmed that a review of the record revealed no care plan, orders, or guidance to address the resident’s hearing loss, and stated that the resident should have a care plan for each current diagnosis and problem. The DON similarly stated that a comprehensive care plan should have been initiated for the resident’s hearing loss to guide nurses in monitoring for worsening hearing, communicating effectively with the resident, and notifying the provider if the problem worsened. The facility’s policy required the interdisciplinary team to develop an individualized comprehensive care plan for each identified problem area within seven days of completing the comprehensive MDS and to update it with significant changes or at least quarterly, which was not done for this resident’s hearing loss.
Failure to Implement RNA Feeding Program as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to implement physician orders for a Restorative Nursing Aide (RNA) feeding program for both breakfast and lunch for a resident at risk for dehydration and malnutrition. The resident, who had multiple diagnoses including chronic kidney disease, Alzheimer's disease, anemia, myelodysplastic syndrome, and muscle wasting, experienced significant unplanned weight loss over a three-month period. The resident's care plan and physician orders specifically required RNA assistance with feeding at both breakfast and lunch to address poor oral intake and nutritional risk. Despite these orders, observations and interviews revealed that the RNA feeding program was only provided at breakfast, with Certified Nursing Assistants (CNAs) feeding the resident at lunch instead of RNAs. Staff interviews confirmed that RNAs were not assigned to feed the resident during lunch, and that this practice was not in accordance with the physician's orders or the resident's care plan. Documentation from multiple care conferences and progress notes indicated ongoing poor oral intake and continued weight loss, but did not address whether the RNA feeding program was being fully implemented as ordered. The facility's own policies required that physician orders be accurately transcribed and implemented, and that restorative nursing services be individualized and resident-centered as outlined in the care plan. However, the failure to provide RNA feeding at both prescribed meals resulted in the resident experiencing a 9.4% weight loss over three months, with weights dropping from 82.8 lbs to 75 lbs. Staff acknowledged that not following the physician orders could negatively affect the resident's nutritional status.
Failure to Notify Physician and Adjust Pain Management for Resident
Penalty
Summary
A deficiency occurred when the facility failed to manage pain effectively for a resident with a recent fall and a fractured left arm, as well as other medical conditions including heart failure and hypertension. The resident was prescribed Oxycodone-Acetaminophen 10-325 mg every six hours for moderate to severe pain. Despite this, the resident repeatedly reported that the pain medication wore off after three to four hours and requested more frequent dosing for better pain relief. Staff interviews confirmed that the resident consistently complained of pain and requested medication before the scheduled time, but the physician was not notified of the ongoing pain or the resident's request for a change in medication timing. The care plan for the resident included monitoring the effectiveness of pain interventions and notifying the physician if pain was not controlled. However, the assigned LVN did not report the resident's continued pain or request for more frequent medication to facility leadership or the physician, despite being instructed to do so by the RN and DON. The facility's pain management policy required documentation of the effectiveness of PRN medications and physician notification if pain was not managed, but these steps were not followed, resulting in the resident remaining uncomfortable and waiting for the next scheduled dose while in pain.
Failure to Arrange Timely Transportation for Chemotherapy Appointment
Penalty
Summary
The facility failed to arrange transportation for a resident's scheduled chemotherapy appointment, as required by physician orders and facility policy. The resident, who was admitted with diagnoses including non-Hodgkin lymphoma, a left fibula fracture, and a history of falls, was cognitively intact but required moderate to maximum assistance with activities of daily living. The resident's chart indicated a chemotherapy appointment was scheduled, but on the morning of the appointment, staff discovered that transportation had not been arranged in advance. The resident had to remind staff about the appointment, prompting a last-minute call to the facility's backup transportation service. Interviews with facility staff, including the Registered Nurse Supervisor, Facility Administrator, and Director of Nursing, confirmed that transportation arrangements were not made until the day of the appointment, contrary to facility policy which requires transportation to be scheduled as soon as possible after an appointment is set. The facility's policy and procedures specify that the Social Services Department is responsible for organizing transportation in collaboration with the resident's family representative. The failure to arrange timely transportation could have resulted in the resident missing the chemotherapy treatment.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility failed to assess and ensure that a resident had an order to self-administer a prescribed medication. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hyperglycemia, was found to have two tubes of prescription triamcinolone acetonide ointment at her bedside. The resident reported that certified nursing assistants (CNAs) would apply the ointment to her buttocks daily or upon her request, and that the medication was prescribed by her outside physician. The Minimum Data Set indicated the resident had intact cognition and required some assistance with personal care tasks. During interviews, a CNA stated she applied the ointment to multiple areas as directed by the resident, believing it was approved, but did not confirm with a charge nurse. The CNA acknowledged that only licensed nurses should administer medications. An LVN explained that a formal assessment and physician order are required before a resident can self-administer medications, and that leaving medication at the bedside could result in improper use. The Director of Nursing confirmed that medication should not be left at the bedside without an order, as this could be dangerous. Facility policy indicated only licensed personnel may administer medications.
Failure to Honor Resident's Beverage Preference During Meals
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident with warm water to make tea during meals, despite the resident's documented preference for tea at breakfast, lunch, and dinner. The resident, who had muscle weakness, lack of coordination, and chronic kidney disease, required substantial assistance with daily activities and was able to communicate her needs. The Food Preference Interview and dietary records clearly indicated the resident's desire for tea with each meal. However, during an observation, the resident's breakfast tray did not include a tea bag or hot water, and the resident expressed frustration at having to repeatedly request hot water for tea, despite staff being aware of her preference. A Certified Nursing Assistant (CNA) confirmed that she did not provide hot water because the tea bag was missing from the tray, even though she knew the resident regularly wanted tea. The Dietary Manager also acknowledged the resident's preference for tea and stated that CNAs were responsible for providing hot water when trays arrived. Facility policy required that residents' food preferences be honored and reflected on their tray cards, but this was not followed in this instance, resulting in the resident's preference not being honored and causing her frustration.
Failure to Maintain Homelike Environment Due to Chipped Paint
Penalty
Summary
A deficiency was identified when a resident's room was observed to have scattered chipped paint on the wall, which detracted from a homelike environment. The resident, who had been admitted with diagnoses including muscle weakness, lack of coordination, and chronic kidney disease, was assessed as usually able to understand and communicate needs, though unable to make medical decisions. The resident required substantial assistance with daily activities such as showering, dressing, and toileting hygiene. During an interview, the resident expressed feeling upset about the chipped paint in the room. Staff interviews confirmed the presence of chipped paint, with an LVN stating that the issue should be addressed immediately and acknowledging that the condition of the wall was unacceptable and could negatively impact the resident's sense of a homelike environment. The Maintenance Director reported that the chipped paint was brought to his attention recently but indicated that such damage likely did not occur suddenly. Facility policy requires the maintenance department to keep the building in good repair and to provide a safe, clean, and comfortable environment, which was not met in this instance.
Failure to Develop Care Plan for Resident with Hearing Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident who was identified as having difficulty hearing. The resident, admitted with diagnoses including anxiety disorder, major depressive disorder, and atherosclerotic heart disease, was noted in the admission record and history and physical to lack capacity for decision-making. The Minimum Data Set assessment indicated the resident was usually understood by others and required partial to moderate assistance with activities of daily living. However, during observations and interviews, it was consistently noted by staff and social services that the resident had trouble hearing during conversations. Despite these findings, there was no care plan in place to address the resident's hearing impairment. Staff interviews confirmed that interventions such as communication boards, amplified hearing devices, or modified communication techniques had not been documented or implemented. The facility's own policy required the development of a comprehensive care plan with measurable objectives and timetables for each resident, but this was not followed in the case of this resident, resulting in a failure to meet the resident's communication needs.
Failure to Ensure Proper Functioning and Settings of Pressure-Relieving Mattresses
Penalty
Summary
The facility failed to provide necessary treatment and services to minimize the risk of development of pressure injuries for three residents by not ensuring the proper functioning and correct settings of low air loss mattresses (LALMs) as ordered by physicians. For one resident with a history of cerebral infarction and contractures, the LALM was observed to be leaking air and held together with tape, making a loud hissing noise. A nurse confirmed the mattress was not functioning properly, which could prevent adequate pressure relief as required by the resident's care plan and physician orders. Another resident, admitted with an ulcer and open wound of the left lower leg, had a physician order for the LALM to be set at 120 lbs., while the resident's actual weight was 103.5 lbs. However, the LALM was observed to be set at 355 lbs., significantly higher than both the resident's weight and the ordered setting. A registered nurse confirmed that this incorrect setting could add pressure to the resident's back, potentially worsening their skin condition, and the DON stated that such a setting would prevent proper healing. A third resident, with diagnoses including COPD, gastrotomy, and dysphagia, was ordered a LALM with a Level 2 setting for wound prevention, which the DON clarified was intended for residents weighing 120 lbs. The resident's current weight was 82.3 lbs., indicating a mismatch between the mattress setting and the resident's needs. The facility's policy required continuous monitoring and adjustment of interventions to prevent pressure ulcers, but these actions were not consistently implemented for the residents involved.
Unsafe Placement of Extension Cord Creates Fall Hazard
Penalty
Summary
The facility failed to provide a safe environment for two residents by allowing an electrical extension cord to be placed in a walk area shared by both individuals. One resident, admitted with multiple diagnoses including acute kidney failure, muscle weakness, and a history of falls, required assistance with mobility and was identified as being at risk for falls. The care plan for this resident included interventions such as providing verbal cues for safety, repositioning items within the visual field, and educating on safe techniques to prevent falls. The second resident, also cognitively intact, required assistance with personal hygiene and dressing. During observations, an orange extension cord was found taped from a bathroom outlet, running under the bathroom door and across the floor to another resident's bed. Both the Maintenance Director and the DON acknowledged that the placement of the extension cord was unsafe and could cause residents to trip and fall. The facility's policy on electrical safety specified that extension cords should not be placed where they could cause trips or falls, but this policy was not followed, resulting in a hazardous environment for the residents.
Failure to Notify Physician of Catheter Sediment
Penalty
Summary
Facility staff failed to provide necessary care and treatment for a resident with an indwelling catheter by not notifying the physician when sediment was observed in the catheter tubing. The resident had a physician order in place to change the catheter for excessive sedimentation, and both LVN and RN staff acknowledged the presence of sediment and the requirement to report such findings to the physician. Despite this, the physician was not notified, and the catheter was not changed as ordered. The resident involved had multiple diagnoses, including osteomyelitis, diabetes mellitus, and benign prostatic hyperplasia, and required substantial assistance with activities of daily living. Observations on consecutive days confirmed a large amount of sediment in the catheter. Facility policy required notification of the physician for changes in condition, but this protocol was not followed in this instance.
Failure to Label and Date Feeding Tube Syringe
Penalty
Summary
A deficiency was identified when a feeding tube syringe used for a resident with a gastrostomy tube was found to be neither labeled nor dated. The resident, who had diagnoses including chronic obstructive pulmonary disease, gastrostomy, and dysphagia, was dependent on staff for all activities of daily living and received nutrition via a feeding tube. Observation in the resident's room revealed that the syringe used for tube feeding was not marked with a date or label, contrary to facility policy. During an interview and record review, a registered nurse confirmed that the feeding tube syringe should be dated, timed, and changed daily, as per facility policy. The nurse acknowledged that without proper labeling, staff would not be able to determine when the syringe was last changed, which could place the resident at risk for infection. The facility's policy on enteral feeding specified that syringes must be changed daily, and this procedure was not followed in this instance.
Failure to Provide Required Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to provide necessary emergency equipment and supplies at the bedside for a resident receiving hemodialysis, as required by professional standards and the facility's own policy. The resident, who had end stage renal disease and was dependent on renal dialysis, did not have an emergency kit containing clean gauze, a tourniquet, and tape at the bedside to manage potential bleeding from an AV shunt. This was confirmed during observations and interviews with nursing staff, who acknowledged the absence of the kit and its importance in managing emergencies such as bleeding from the AV fistula. Record review showed that the resident had active physician orders to monitor the AV shunt site for signs of infection, edema, and bleeding, and to apply pressure and notify medical staff if bleeding occurred. Despite these orders and the facility's policy requiring staff to be trained and prepared for dialysis-related emergencies, the necessary emergency kit was not present at the resident's bedside. Interviews with nursing staff and the DON confirmed that the kit should have been available and that its absence could delay emergency care.
Unlicensed Staff Applied Prescription Medication Without Physician Order
Penalty
Summary
Certified Nursing Assistants (CNAs), including CNA 4, applied triamcinolone acetonide ointment 0.1%, a prescription medication, to a resident without a physician's order and in violation of the facility's Administering Medications policy. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hyperglycemia, had intact cognition and required varying levels of assistance with personal care. The resident reported that CNAs would apply the ointment to her buttocks daily or upon request, and CNA 4 confirmed applying the ointment to multiple areas as directed by the resident, without consulting a licensed nurse or verifying a physician's order. Record review and staff interviews revealed that the resident did not have a current order for the medication, nor was there documentation of a self-administration evaluation or care plan. The facility's policy specified that only licensed or permitted personnel may administer medications. Both CNA 4 and a registered nurse acknowledged that CNAs are not authorized to administer prescription medications, and doing so could potentially cause harm. The deficiency was identified through observation, interview, and record review.
Failure to Securely Store Medications at Bedside
Penalty
Summary
The facility failed to properly store medications for two residents in accordance with its Storage of Medications policy and procedure. For one resident with a diagnosis of cerebral infarction and intact cognition, Preparation H cream was found on the bedside table next to food during an observation. The registered nurse confirmed that medication should not be left at the bedside, as it is not safe and could be misused. The Director of Nursing also stated that medications must be stored securely and not left accessible to residents. For another resident with diagnoses including depressive disorder, epilepsy, and rotator cuff tear, two tablets were observed in a medicine cup on the bedside table. The licensed vocational nurse admitted to leaving the medication at the bedside every night, acknowledging that this practice was not appropriate and could allow the resident to hide or accumulate medication. A registered nurse confirmed that staff are required to ensure residents take their medication before leaving the room and that medications should not be left unattended. The facility's policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner in locked compartments.
Failure to Properly Label Food and Maintain Dishwashing Sanitizer Levels
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards for food service safety. Specifically, sandwiches in the kitchen refrigerator were found without labels or dates, and a bin of expired butter cups was not discarded. Staff interviews confirmed that the absence of labeling made it impossible to determine the age of the food, increasing the risk of serving expired items. Facility policy required all food to be labeled and dated, but this was not followed in these instances. Additionally, the facility did not ensure that the low temperature dishwashing machine had the appropriate concentration of sanitizer. During testing, the sanitizer test strip remained white instead of turning purple, indicating that the correct sanitizer concentration was not present. Staff acknowledged that proper sanitizer levels are necessary to ensure dishware is adequately disinfected. Facility policies required all dishware and utensils to be cleaned and sanitized after each use, but this standard was not met during the survey.
Failure to Maintain Infection Control by Storing Urinal Near Food
Penalty
Summary
A deficiency was identified when a urinal containing urine was observed on a bedside table next to a resident's food and drinks. The resident had a diagnosis of an unspecified mental disorder, moderately impaired cognition, and required varying levels of assistance for activities of daily living, including set up or clean up assistance for eating. The urinal's placement was confirmed during an observation and interview with an LVN, who acknowledged that this was not safe for infection control reasons. The facility's Infection Prevention and Control policy stated that a safe and sanitary environment must be maintained to prevent and manage the transmission of diseases and infections. During a review with the DON, it was confirmed that placing a urinal next to food is not in accordance with the facility's policy and could result in an unsafe and unsanitary environment. The deficiency was based on the failure to keep the urinal away from the resident's food, as required by the facility's infection control procedures.
Non-Functioning Call Light System in Resident Room
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the call light system in a resident's room was functioning properly. The resident, who had diagnoses including muscle weakness, lack of coordination, and chronic kidney disease, required substantial to maximal assistance from staff for showering, dressing, and toileting hygiene. During an observation, the resident pressed the call light, but it did not emit a sound or display a light outside the doorway, indicating it was not operational. Interviews with staff confirmed that the call light was not working, and there was uncertainty about the frequency of maintenance checks for the call light system. The facility's policies required that the call system remain functional at all times and be routinely maintained and tested by the maintenance department. The maintenance supervisor stated that call lights were checked weekly, but the non-functioning call light in the resident's room was not identified or addressed prior to the surveyor's observation. This failure had the potential to prevent the resident from being able to call for assistance when needed.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that 14 out of 33 resident rooms met the required minimum space of 80 square feet per resident in multiple occupancy rooms. Observations and measurements confirmed that several rooms, each housing three residents, were below the required 240 square feet total, with actual measurements ranging from 216 to 239.71 square feet. During facility tours, it was noted that the rooms were equipped with privacy curtains and allowed for direct corridor access, and staff reported no issues with space when providing care, including the use of wheelchairs and Hoyer lifts. Interviews with staff, including the Maintenance Director and a CNA, indicated that there had been no complaints from residents or staff regarding room size, and care activities such as transfers and wheelchair use were not hindered. A review of the facility's Client Accommodation Analysis and a letter from the Administrator confirmed the room sizes and noted that a waiver had been requested for these rooms. Despite the waiver request, the rooms did not meet the federal space requirements for multiple occupancy, resulting in a deficiency related to inadequate room size.
Failure to Implement 14-Day Limit on PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN psychotropic medication, Seroquel, had a documented 14-day limit for administration, as required by the facility's policy. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and agitation, was prescribed Seroquel 25 mg every 12 hours as needed without a 14-day stop. This prescription was later increased to 50 mg every six hours as needed, still without the required 14-day stop. The facility's Director of Nursing and the Pharmacy Consultant both acknowledged the absence of the 14-day stop, which is necessary to evaluate the medication's effectiveness. Interviews with the facility Psychiatrist revealed that she did not order the PRN Seroquel for agitation and suggested that the order might have originated from a General Acute Care Hospital. The facility's policy on psychotropic medication use mandates a 14-day limit on PRN orders unless a documented rationale for extension is provided. The lack of a 14-day stop on the resident's medication order increased the risk to the resident's mental and psychosocial well-being, as there was no mechanism to assess the ongoing need or effectiveness of the medication.
Failure to Complete PASRR Level II Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure proper assessment and documentation for a resident under the Preadmission Screening and Resident Review (PASARR) process. Specifically, the facility did not complete a PASRR Level II assessment for a resident diagnosed with schizophrenia, major depressive disorder, and metabolic encephalopathy. The PASARR Level I screening was incomplete, as a critical question regarding suspected mental illness was left unanswered, which should have triggered a Level II assessment. The resident exhibited moderate cognitive impairment and had a history of verbal aggression and mood disturbances, as documented in their care plan and Minimum Data Set (MDS). The care plan noted behaviors such as yelling at staff and becoming physical, which were related to cognitive loss and psychiatric disorders. Despite these documented behaviors and diagnoses, the necessary PASRR Level II assessment was not conducted, which would have provided additional support from the Department of Mental Health. Interviews with facility staff, including the Minimal Data Set Nurse (MDSN) and the Director of Nursing (DON), confirmed the oversight. The MDSN acknowledged that the PASRR Level II should have been completed due to the resident's schizophrenia diagnosis. The DON admitted that the incomplete PASARR Level I evaluation was inaccurate and that the facility should have rectified this to ensure appropriate care planning and support for the resident.
Failure to Notify Physician of Resident's Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician after a significant change in the condition of a resident with mental illness, leading to a deficiency. The resident, who had diagnoses including schizophrenia and major depressive disorder, exhibited increased behavioral symptoms and required hospitalization. The facility's policy mandates immediate notification of physicians in such cases, but this was not done. The resident's Minimum Data Set indicated moderate cognitive impairment and feelings of depression. On multiple occasions, the resident displayed behavioral changes, including verbal aggression and agitation, which were documented in the Situation Background Assessment and Recommendation (SBAR) forms. However, there was no evidence that the physician was informed about these changes, as confirmed by interviews with the Licensed Vocational Nurse and the Director of Nursing. The facility's policy requires informing the physician of significant changes in a resident's condition, but this was not adhered to. The resident's condition deteriorated, resulting in an emergency department visit and a psychiatric hold. The failure to notify the physician was acknowledged by the staff, highlighting a lapse in following the established protocol for handling changes in resident conditions.
Failure to Update Care Plan for Resident with Behavioral Changes
Penalty
Summary
The facility failed to update the care plan for a resident who was at risk for physical behavior towards others after experiencing a change of condition on two separate occasions. The resident, who had diagnoses including schizophrenia and major depressive disorder, exhibited verbal aggression and agitation, which were not adequately addressed in the care plan. Despite the resident's behavioral changes and requests for medication schedule adjustments, the care plan was not revised to reflect these changes or to include specific interventions for the antipsychotic medication, Seroquel, prescribed to the resident. The resident's care plan initially included general approaches for managing verbal behaviors and mood symptoms but lacked specific interventions tailored to the resident's needs and medication regimen. The care plan did not incorporate the necessary updates following the resident's change in condition, as indicated by the SBAR forms documenting the resident's agitation and verbal aggression. The facility's policy required care plans to be individualized and updated with measurable objectives and timetables, but this was not adhered to in the resident's case. Interviews with facility staff, including the MDS Nurse, LVN, and DON, confirmed that the care plan should have been updated to address the resident's behavioral changes and to include specific interventions for the medication. The failure to update the care plan resulted in the escalation of the resident's behaviors, ultimately leading to the resident's admission to a General Acute Care Hospital. The facility's policy emphasized the importance of ongoing assessments and revisions to care plans as residents' conditions change, which was not followed in this instance.
Failure to Implement Baseline Care Plan for Resident's Pain Management and Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with a fracture of the left fibula and osteoporosis. Despite the resident's need for pain management and care for the left lower leg fracture with a splint, no baseline care plan was initiated or implemented from the time of admission until the survey date. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of care plans for the resident's pain management and fracture care. The facility's policy and procedures require that a baseline care plan be developed within 48 hours of a resident's admission to ensure individualized care. Additionally, the facility's policies on pain management and skin integrity management emphasize the need for an interdisciplinary plan of care that addresses underlying causes of pain and includes both non-pharmacological and pharmacological approaches. The failure to adhere to these policies resulted in a deficiency that could negatively impact the resident's health and safety.
Failure to Monitor and Document Leg Splint Assessment
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's left lower leg splint, which was necessary to prevent complications such as skin breakdown and potentially compartment syndrome. The resident, who was admitted with a fracture of the left fibula and osteoporosis, was identified as being at risk for developing pressure ulcers. Despite this risk, there was no documentation of assessment and monitoring of the splint from February 9, 2025, to March 5, 2025. During an observation on March 5, 2025, the resident was seen with the left lower leg splint, and the Director of Nursing confirmed the lack of documentation regarding the splint's assessment and monitoring. The facility's policy on Skin Integrity Management required daily monitoring of wounds or dressings for complications, which was not adhered to in this case. This oversight in documentation and monitoring was verified by the Director of Nursing during an interview and record review.
Insufficient Staffing Leads to Delays in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in significant delays in care and unmet scheduled services. Resident 1, who was admitted with a fracture and osteoporosis, required moderate to maximal assistance for activities of daily living (ADLs) and experienced frequent episodes of incontinence. Despite these needs, Resident 1 reported waiting over three hours for incontinence care, which was confirmed by a Certified Nursing Assistant (CNA) who stated that the delay was due to being unable to assist sooner. The Director of Nursing (DON) acknowledged that such a delay was unacceptable. Additionally, the facility did not ensure that scheduled showers were provided to Residents 4 and 5. Resident 4, diagnosed with Parkinson's Disease, epilepsy, and dementia, required maximal assistance for ADLs and was scheduled for a shower every Wednesday. However, there was no documentation of a shower being provided, and a CNA admitted to being unable to shower Resident 4 due to time constraints and a high workload. Similarly, Resident 5, who had atrial fibrillation and required moderate assistance for ADLs, was also not showered as scheduled, with another CNA citing an excessive number of residents to care for as the reason. The facility's policies and procedures, which emphasize the importance of providing care to maintain or improve residents' ability to carry out ADLs, were not adhered to in these instances. The lack of sufficient staffing led to delays and omissions in basic care, such as incontinence management and scheduled showers, which are essential for maintaining residents' personal hygiene and overall well-being.
Failure to Act on Critical Lab Results
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary skills and knowledge to identify a change in condition for a resident with a critically low platelet count. The resident, who had a history of hemorrhagic disorder due to circulating oral anticoagulants, was admitted with a platelet count of 95,000 uL, which later dropped to 33,000 uL. Despite the critical nature of this lab result, the facility did not immediately inform the physician or take appropriate emergency action, resulting in a delay in transferring the resident to a General Acute Care Hospital (GACH) for treatment. Interviews with facility staff revealed a lack of understanding and adherence to emergency protocols. A Licensed Vocational Nurse (LVN) stated that in emergency situations, residents should be sent via 911, but admitted to following a supervisor's recommendation for non-emergency transport despite the resident's unstable condition. Another LVN indicated that they would wait for a supervisor's directive even in critical situations, such as cardiac arrest. The Director of Nursing (DON) acknowledged that the critical platelet count constituted a change in condition and that the physician should have been notified immediately, but this was not done. The facility's policy and procedure for lab and diagnostic test results required prompt physician notification for critical results, but this was not followed. The Medical Doctor (MD) involved was not aware of the second critical lab result until later and had ordered an emergency transfer via 911, which was not executed by the facility. The failure to act promptly on the critical lab results and the lack of proper communication and emergency response placed the resident at risk for spontaneous bleeding, which could result in death. The resident was eventually transferred to GACH but died seven days later.
Deficiency in Cleanliness and Maintenance of Dinnerware and Water Pitchers
Penalty
Summary
The facility failed to maintain cleanliness and proper condition of dinnerware and food service equipment, as observed during a survey. Clear plastic glasses were found to be cloudy with dishwasher cleaning buildup, and some plastic mugs were stained with coffee or tea. The Dietary Manager acknowledged that these items should have been replaced. Additionally, Certified Nursing Assistants (CNAs) expressed concerns about the cleanliness of residents' cups, noting milk residue and lipstick marks. They also reported that the thermoses and coffee pots were old and worn, with lids that did not stay on, posing a hazard when pouring hot beverages. Furthermore, the facility did not ensure timely replacement of residents' water pitchers for washing. During an observation, some residents were found without water pitchers at their bedside, and the pitchers present were yellow, indicating they had not been swapped out as required. The Dietary Manager confirmed that CNAs were responsible for changing the pitchers daily, and on the day of the interview, all pitchers should have been gray. The facility's policy stated that all dishware, serviceware, and utensils should be cleaned and sanitized after each use, which was not adhered to in these instances.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, resulting in them receiving canned fruits instead of the fresh fruits they preferred. Resident 2, who was admitted with conditions including hypertension, anemia, muscle weakness, and diabetes mellitus, was on a consistent carbohydrate diet with specific dietary requirements. Resident 3, admitted with chronic obstructive pulmonary disease, anemia, hemiplegia, hemiparesis, and muscle weakness, was on a regular diet with additional fortified foods. Both residents expressed during interviews that they were no longer receiving fresh fruits like bananas and grapes, which they had previously been provided. The Dietary Manager confirmed that fresh fruits were no longer available due to budget constraints and seasonal availability. The facility's policy on resident food preferences stated that meals should be consistent with residents' preferences, and if a preferred item was unavailable, a suitable substitute should be provided. However, this policy was not adhered to, as the residents were not given fresh fruits or suitable substitutes, leading to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plan for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with bipolar disorder and prescribed Risperidone, a psychotropic medication. The resident was admitted with multiple diagnoses, including bipolar disorder, but the care plan lacked goals, interventions, or monitoring for the disorder and the medication. The Minimum Data Set (MDS) indicated the resident experienced symptoms of depression and mood swings, yet these were not addressed in the care plan. Interviews with facility staff, including the MDS Nurse, Administrator, Psychiatrist, and Director of Nursing, revealed that the care plan was not completed, and the resident had not been seen by a psychiatrist since admission. The facility's policy required the Interdisciplinary Team to develop a comprehensive care plan with measurable objectives and timetables to meet the resident's needs. However, the admitting nurse did not initiate the necessary care plan, and the psychiatrist was not informed of the resident's admission. This oversight resulted in the absence of a care plan to monitor the effectiveness of interventions for the resident's bipolar disorder and psychotropic medication, increasing the risk of untreated adverse reactions.
Missing Performance Evaluation for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) had a yearly performance evaluation documented in their employee file. LVN 1 was hired on 9/22/22, and there was no performance evaluation completed since the date of hire. During an interview, the Director of Nursing (DON) stated that performance evaluations should be conducted 90 days after the start of employment and then annually. However, the DON could not explain why LVN 1's performance evaluation was missing. The Administrator (ADM) also confirmed the absence of the evaluation and agreed that it should have been performed. The facility's policy, dated 9/20, mandates performance evaluations at the end of a 90-day probationary period and annually thereafter. The lack of a performance evaluation for LVN 1 was acknowledged by the DON as creating a risk to resident safety.
Missing Skills Competency Checklist for CNA
Penalty
Summary
The facility failed to ensure that the employee file of one of two sampled Certified Nurse Assistants (CNA 2) contained a yearly skills competency checklist. CNA 2 was hired on 3/12/24, but the skills competency checklist was missing from their file. During an interview, the Administrator confirmed the absence of the checklist, and the Director of Nursing (DON) acknowledged that the skills competency should have been completed upon hire and annually. The DON emphasized that without written documentation, it is assumed that the competency was not completed. The facility's policy and procedure, dated 5/19, required competency evaluations upon hire, annually, and as necessary, to ensure nursing staff demonstrate the skills needed to care for residents.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 3, had a documented consent for psychotropic medications, specifically Risperidone, which was prescribed for bipolar disorder mood swings. The resident was admitted with diagnoses including Type II diabetes mellitus, bipolar disorder, and cellulitis. Despite being alert, oriented, and having good recall, the resident did not have a signed Psychotropic Medication Administration Disclosure for consent in their physical chart. This oversight was identified during a review of the resident's records and confirmed through interviews with facility staff. Interviews with the Medical Records Department, a Registered Nurse, and the Director of Nursing revealed that it was the responsibility of the admitting nurse to obtain consent for psychotropic medications within a day or two of admission. However, this was not done for Resident 3. The facility's policy indicated that informed consent should be obtained by the prescriber prior to the initiation of psychotropic medications, but this procedure was not followed. The psychiatrist, who visits the facility monthly, was not informed of the resident's admission, further contributing to the lack of consent documentation.
Failure to Report and Investigate Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse policy and procedures in handling an incident involving two residents, resulting in a deficiency. The incident involved a verbal altercation between two residents, where one resident attempted to strike the other. Despite the altercation, the facility did not report the incident to the state licensing/certification office, police, or ombudsman, nor did it conduct an investigation as required by their policy. Additionally, the residents were not separated in a timely manner, with one resident being moved to a different room 11 days after the incident. Resident 1, who was involved in the incident, was admitted to the facility with multiple diagnoses, including chronic obstructive pulmonary disease, pneumonia, and mild cognitive issues. The resident required assistance with daily activities such as eating, toileting, and personal hygiene. On the day of the incident, Resident 1 was involved in a shouting match with their roommate, Resident 7, who attempted to strike them. Despite the altercation, Resident 1 initially declined a room change, preferring to stay in their current room. Resident 7, the other party involved, had a history of moderate cognitive issues and required substantial assistance with daily activities. The resident also exhibited fluctuating behaviors of inattention. During the incident, Resident 7 was redirected after attempting to strike Resident 1 and was offered a room change, which they agreed to. However, the facility failed to follow through with the room change for Resident 7, and no investigation or reporting of the incident was conducted, contrary to the facility's abuse prohibition policy.
Resident Identification Error Leads to Missed Appointment
Penalty
Summary
The facility failed to ensure proper resident identification, resulting in a mix-up between two residents with the same first name. Resident 1, who had severe cognitive impairment and required substantial assistance, was scheduled for transfer to another skilled nursing facility (SNF). Meanwhile, Resident 2, who was legally blind and had moderately impaired cognitive function, was supposed to attend an ophthalmologist appointment. However, due to the identification error, Resident 2 was mistakenly taken to the SNF instead of the eye specialist. The incident occurred when a transportation driver arrived at the facility and incorrectly identified Resident 2 as the individual to be transferred to the SNF. Despite Resident 2 carrying an envelope with his name and being accompanied by a certified nursing assistant (CNA), the driver took him to the wrong location. This error led to Resident 2 missing his scheduled appointment with the ophthalmologist, causing him distress and requiring the appointment to be rescheduled. The facility's policy on resident identification, which includes a photo and/or wristband system, was not effectively implemented to prevent this mix-up.
Failure to Provide Immediate Care After Resident Fall
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident who experienced a fall. The resident, admitted with diagnoses including metabolic encephalopathy and generalized muscle weakness, fell during the night shift. Despite the fall occurring, there was no immediate assessment or documentation of the incident. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was found on the floor in a sitting position without pain or swelling, and denied hitting their head. However, the fall was not documented until later in the day, and the resident's physician was not notified immediately. Interviews with facility staff revealed that the licensed vocational nurse (LVN) was informed of the fall around noon, several hours after it occurred, and subsequently notified the nurse practitioner. The facility's policy and procedure for fall management, which requires immediate observation for injury, neurological evaluation, documentation, and notification of the physician and responsible party, was not followed. The director of nursing confirmed the lack of documentation and immediate notification, which are critical steps outlined in the facility's policies for managing falls and changes in resident condition.
Failure to Conduct Quarterly Braden Scale Assessment for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers was assessed quarterly using the Braden scale assessment, which is crucial for evaluating the risk of developing pressure ulcers. The resident, who was at risk of developing pressure ulcers according to their Minimum Data Set, was readmitted with several diagnoses, including altered mental status, hemiplegia, hemiparesis, muscle wasting, and a gastrostomy. Despite these conditions, the facility did not complete a Braden scale assessment for the resident on the required quarterly date. The resident's care plan, initiated after readmission, noted unstageable pressure-induced tissue damage on the sacral coccyx extending to the left buttock, with a goal for the wound to heal. However, the care plan lacked comprehensive interventions. A subsequent Braden scale assessment indicated the resident was at severe risk of developing pressure ulcers, with a score of 8, highlighting issues such as limited sensory perception, constant moisture, immobility, and friction problems. The Director of Nursing acknowledged the oversight in completing the Braden scale assessment, which is essential for informing staff about the necessary care to prevent the worsening of the resident's wounds.
Inadequate Care Planning for Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care for a resident at severe risk of developing pressure ulcers, leading to deficiencies in the resident's care plan. The resident, who was readmitted with multiple diagnoses including altered mental status and hemiplegia, had an unstageable pressure ulcer on the sacral coccyx and a right lateral heel vascular wound. The care plan for these wounds was not adequately developed or revised, lacking necessary interventions and updates when the sacral coccyx wound was reclassified as a Stage IV pressure ulcer. The care plan for the resident's sacral coccyx pressure ulcer did not include sufficient interventions, and the plan was not updated when the wound was reclassified from unstageable to Stage IV. Additionally, the care plan for the right lateral heel vascular wound was incomplete, listing only one intervention without further details. The facility also failed to develop a care plan for a new PVD wound on the resident's right lateral lower leg, which was identified during a skin check. Interviews with the Treatment Nurse and the Director of Nursing revealed that the care plans were lacking in substance and did not reflect the resident's current wound status. The facility's policies required comprehensive and individualized care plans, which were not adhered to in this case. The lack of proper care planning increased the risk of the resident's skin integrity worsening and hindered the healing process.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when a Certified Nurse Assistant (CNA) used a derogatory term in the presence of a resident. On the morning of August 12, 2024, CNA 1 was involved in an altercation with a resident over a pair of socks. During this interaction, the resident called CNA 1 a liar and used a derogatory term, to which CNA 1 responded by repeating the derogatory term as she left the room. This incident was witnessed by another resident and a Registered Nurse (RN), who confirmed hearing the exchange. The resident involved in the incident had a history of mildly impaired cognition and had been feeling down, depressed, or hopeless in the weeks leading up to the event. The facility's policy on abuse prohibition, which was reviewed by the Director of Nursing and the Administrator, clearly states that verbal abuse includes the use of disparaging and derogatory terms. Despite this policy, the CNA's communication with the resident was deemed ineffective and increased the risk of verbal abuse, as noted by the Administrator.
Failure to Develop and Revise Care Plan for G-tube Dislodgment
Penalty
Summary
The facility failed to ensure that a resident with a G-tube had an initial care plan developed for G-tube dislodgment and that it was revised after subsequent dislodgments to include new interventions. This oversight resulted in seven instances where the resident's G-tube was dislodged and required replacement. The resident, who was admitted with multiple diagnoses including hypertension, type two diabetes mellitus, heart failure, muscle weakness, dysphagia, and encephalopathy, experienced cognitive impairment and was dependent on staff for various activities of daily living. Despite these conditions, the facility did not have a care plan addressing the G-tube dislodgment until several months after the resident's admission. Additionally, the facility did not conduct interdisciplinary team (IDT) meetings in a timely manner following the G-tube dislodgments. The progress notes for the resident indicated no entries for IDT meeting notes regarding the G-tube dislodgment until several months after the initial incident. This lack of timely IDT meetings and care plan revisions was contrary to the facility's policy and procedures, which required care plans to be reviewed and revised by the interdisciplinary team after each assessment and as needed to reflect the response to care and changing needs and goals.
Resident Incorrectly Charged for Single Room
Penalty
Summary
The facility failed to ensure that a resident was not billed for a single room while another resident was on bed hold in the same room. This deficiency was identified during a review of the resident's admission record and financial statements. The resident, who was independent in decision-making and required assistance with certain activities of daily living, was charged for a single room despite the presence of another resident on bed hold in the room. The Business Office Assistant confirmed that there was no documentation of an agreement for the single room, and the resident was not liable for the charges. Further investigation by the Director of Nursing revealed that the facility's census records indicated the resident was in a semi-private room with another resident on bed hold during the relevant dates. The Director of Nursing confirmed that the resident should not have been charged for a single room under these circumstances. The lack of proper documentation and billing practices led to the resident being incorrectly charged for a single room they did not receive.
Delayed Implementation of Dietician's Recommendations for G-tube Feeding
Penalty
Summary
The facility failed to implement the recommendations made by the Registered Dietician (RD) during an interdisciplinary team meeting regarding a change in a resident's gastrostomy (G-tube) feeding formula. This oversight resulted in a delay of 51 days before the recommended change was made, during which time the resident experienced a weight loss of six pounds, equivalent to 4% of their body weight. The resident, who was admitted with multiple diagnoses including hypertension, type two diabetes mellitus, heart failure, muscle weakness, dysphagia, and encephalopathy, was dependent on staff for various activities of daily living. The deficiency was identified through interviews and record reviews, which revealed that the Director of Nursing (DON) acknowledged the failure to follow up on the RD's recommendations. The recommendations included changing the G-tube feeding formula from Jevity 1.2 cal/ml to Glucerna 1.5 cal/ml at a higher rate, which was not implemented until much later. The facility's policy indicated that dietary orders could be delegated to a qualified dietitian, but the necessary steps to obtain a physician's order for the change were not taken in a timely manner.
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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