Willow Pass Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, California.
- Location
- 3318 Willow Pass Road, Concord, California 94519
- CMS Provider Number
- 055241
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Willow Pass Healthcare Center during CMS and state inspections, most recent first.
A cognitively intact resident with a BIMS score of 15/15 was verbally abused by a CNA in the TV dining area after the resident asked the CNA to help another resident who was crying out. The CNA, who had a known history of a loud voice and prior counseling about professionalism, responded in a rude, loud, and angry tone, used profanity, and engaged in a shouting exchange with the resident, requiring staff to intervene. Witnesses, including another CNA and the SSD, reported hearing loud yelling and profanities, and observed the resident crying, visibly upset, and trembling from anger afterward. Documentation by nursing and social services reflected the resident’s report that the CNA’s tone was rude and loud and not an acceptable way to speak to him, in violation of the facility’s abuse prevention policy that guarantees residents freedom from verbal and mental abuse by staff.
A CNA engaged in a loud verbal altercation with a cognitively intact resident in a TV dining area after the resident requested help for another resident who was crying out. The CNA and the resident yelled and exchanged profanities, and the resident was later noted to be trembling from anger. Despite the incident and prior counseling of the CNA about professionalism and voice volume, staffing records showed the CNA continued providing direct care to nine residents for the remainder of his shift. The ADM, acting as Abuse Coordinator, acknowledged that facility policy required immediate removal of an employee suspected of abuse from the care or vicinity of residents, but this did not occur in this case.
A cognitively intact resident with right knee pain purchased a new pair of shoes for a CNA after noticing the CNA’s swollen feet and being told the CNA had arthritis. The CNA accepted the shoes for personal use and later gave the resident twenty dollars, stating she did not see anything wrong with accepting the gift. The Administrator and DON were unaware of this transaction, and facility policy stated that abuse and financial abuse would not be tolerated, indicating a failure to prevent financial exploitation of the resident’s resources.
A resident with intact cognition and a history of skin cancer had not received a shower for over a month despite being scheduled for twice-weekly showers, and the ADL care plan did not address the resident’s repeated refusals to shower or include interventions as required by facility policy. The DON confirmed the resident refused showers and that the care plan had not been updated to reflect this ongoing issue. In addition, although IDT care plan conferences documented that the resident had discharge potential, no discharge care plan was developed upon admission, and the DON could not produce one, stating discharge planning was only discussed during conferences. The resident’s family member was not consistently invited to these conferences, contrary to the facility’s Care Planning and IDT policies requiring identification and care planning of all needs with measurable objectives and adequate interventions, and inclusion of the resident’s representative whenever possible.
A cognitively impaired resident, dependent on staff for hygiene and bathing, was repeatedly observed with facial hair despite having requested shaving and having it documented on multiple Shower Day Skin Inspection forms. A CNA stated that shaving should occur during scheduled showers but could not explain why it was not done for this resident. The DON reported that CNAs were expected to offer shaving with showers, obtain consent, and notify charge nurses of refusals, consistent with facility policy requiring regular showers and documentation, but the resident’s facial hair remained unaddressed over several shower days.
Two residents, one male and one female, were assigned to rooms sharing a single bathroom without a lock, leading both to feel uncomfortable and lacking privacy. Both residents were able to express their concerns, and the DON acknowledged the privacy risk and the need for a lock to prevent abuse. The facility's policy required person-centered care, but this was not maintained in the shared bathroom arrangement.
The facility did not maintain required records for quarterly fire sprinkler system inspections and testing, as only one quarter's documentation was available and the Maintenance Director confirmed inspections were done in-house without a vendor. This deficiency affected all residents in the facility.
Fire extinguishers in two areas were found obstructed by carts, including a metal cart in the kitchen and a medical cart near a resident room. The Maintenance Director indicated these obstructions were due to ongoing activities, and the facility handles extinguisher inspections internally without vendor support. These issues affected a significant portion of residents and did not meet NFPA 10 requirements for accessibility and visibility.
Surveyors identified that the facility did not maintain required inspection and maintenance records for kitchen equipment, including missing annual inspection records, and incomplete semiannual maintenance and cleaning records for the kitchen suppression system and hood-exhaust. The Maintenance Director confirmed the absence of an annual inspection plan and was unable to provide all required documentation.
The facility did not maintain complete fire drill records for the AM shift in the fourth quarter, and was unable to provide the missing documentation when requested. Additionally, surveyors observed improper use of extension cords and daisy-chained power strips in multiple areas, with staff confirming these were used due to a lack of available outlets and to power specific equipment.
The facility did not maintain complete fire drill records, specifically missing documentation for the AM shift during a quarter, and was unable to provide the required records when requested by surveyors. This deficiency affected all residents in the facility.
The facility failed to maintain a safe and comfortable room temperature for two residents during a heat wave, with temperatures reaching 84°F. Despite ongoing repairs, the air conditioning system remained faulty, causing discomfort for a resident with COPD and another with dementia. The facility lacked documentation of air filter replacements and preventative maintenance, contrary to its policy.
A resident with dementia and mobility issues fell and fractured their hip due to inadequate supervision in an LTC facility. The resident attempted to use an out-of-order bathroom and was found in the hallway without a walker. Despite being at high risk for falls, the resident was not properly monitored, resulting in a fall and subsequent surgery for a hip fracture.
A resident with dementia and mobility issues fell while searching for a bathroom because her room's toilet was out of order. The CNA found the bathroom out of order and no bedside commode available. The Maintenance Supervisor confirmed the issue was not logged, and the DON stated a commode should have been provided.
The facility failed to protect a resident from verbal and physical abuse by another resident, resulting in a skin tear. The incident occurred in the courtyard without staff presence, and the injured resident's care plan was not updated to address the incident or injury. The aggressor had a history of behavioral problems, and the facility's abuse prevention policy was not effectively implemented.
Verbal Abuse of Cognitively Intact Resident by CNA in Common Area
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a CNA used profanity, raised his voice, and yelled at the resident in the TV dining area after the resident requested help for another resident who was crying out. The involved resident had an admission date of 2/10/26 and an MDS dated 3/6/26 showing intact cognition, clear communication, and full understanding, with a BIMS score of 15/15. On Super Bowl Sunday, while in the TV dining room, the resident observed another resident crying out for help and called out to a CNA for assistance. The resident reported that the CNA responded in a rude tone, saying, “We got a problem?” in a loud and angry manner, and that other staff had to remove the CNA from the room. The resident stated that the CNA’s tone was “pissed and loud,” that people should not talk to residents that way, and that the CNA should have been fired. In interviews, the CNA acknowledged that he had previously been counseled about professionalism and his loud voice, and admitted that during the 2/8/26 incident he raised his voice at the resident instead of “swallowing his pride.” The DSD confirmed that the CNA had a loud voice that some residents did not like and that loud talking by direct care staff could make residents feel hurt or scared, and stated the CNA had been spoken to before about his loud voice. Another resident described the CNA as sometimes “obnoxious.” The Social Services Director reported hearing a commotion, then observing the CNA and the resident yelling and shouting at each other and exchanging profanities, with the CNA appearing “hot headed,” and documented the verbal altercation in the progress notes. A witness statement and interview from another CNA indicated she heard loud screaming, was told the CNA was “fighting with a resident,” and then saw both the CNA and the resident arguing, with the resident crying and visibly upset afterward. A nurse’s progress note documented that the resident perceived the CNA’s tone as rude and loud and stated, “That’s not the way they can talk to me.” The facility’s abuse prevention policy stated that each resident has the right to be free from verbal, sexual, physical, and mental abuse and must not be subjected to abuse by anyone, including facility staff.
Failure to Remove CNA From Resident Care After Verbal Altercation
Penalty
Summary
The deficiency involves the facility’s failure to remove a CNA from resident care areas after he engaged in a verbal altercation with a resident. On the date of the incident, Resident 1, who had an intact mental status with a BIMS score of 15 and was able to clearly express ideas and understand others, was in the TV dining room when another resident (Resident 2) began crying out for help. Resident 1 asked CNA 1, who was sitting in the room, to help Resident 2. According to Resident 1, CNA 1 responded in a rude tone, asking, “We got a problem?” and used a loud, angry tone. Social Services Director 1 reported hearing a commotion and, upon entering the TV room, observed Resident 1 and CNA 1 yelling and shouting at each other and exchanging profanities, with CNA 1 described as hot headed. SSD 1 documented in the progress notes that Resident 1 had a verbal altercation with CNA 1, and she noted that Resident 1 was trembling from anger after the incident. CNA 1 acknowledged that he raised his voice at Resident 1 during the incident and stated he had previously been counseled about being professional and lowering his voice with residents. The DON confirmed that CNA 1 had a generally loud voice and had been told in the past to treat residents with respect. Despite the altercation occurring around midday, staffing records and the CNA’s timecard showed that CNA 1 continued working his full shift from approximately 7:00 a.m. to 3:30 p.m., providing direct care to nine assigned residents for more than three hours after the incident. The Administrator, who served as the Abuse Coordinator, stated that if the incident occurred around noon, CNA 1 should have been sent home immediately and suspended during the investigation, and that the facility’s abuse prevention policy required immediate removal of an employee suspected of abuse from the care or vicinity of the resident. The failure to remove CNA 1 from resident care areas after the altercation constituted the cited deficiency.
Failure to Prevent Financial Exploitation by CNA
Penalty
Summary
The facility failed to prevent financial exploitation of a resident when a CNA accepted a new pair of shoes that the resident purchased for the CNA’s personal use. The resident had been admitted with a diagnosis that included right knee pain, and the MDS assessment showed a BIMS score of 15, indicating intact cognitive status with the ability to recall the correct year, month, and day of the week. According to the CNA, the resident noticed the CNA’s swollen feet, inquired about the condition, and was told the CNA had arthritis. The resident then bought a new pair of shoes and gave them to the CNA, who accepted them and later gave the resident twenty dollars for the shoes. During an interview, the CNA stated she did not see anything wrong with accepting the shoes from the resident. The Administrator and DON reported they were not aware that the CNA had received shoes purchased by the resident and stated the facility did not expect the CNA to receive shoes from the resident for personal use. Review of the facility’s Abuse Prevention policy, dated 9/1/2008, indicated that abuse, neglect, abandonment, isolation, and financial abuse would not be tolerated at any time. Despite this policy, the CNA’s acceptance of the shoes constituted exploitation, as the resident’s belongings or money were used for the CNA’s personal gain.
Failure to Care Plan for Shower Refusals and Discharge Needs
Penalty
Summary
Surveyors identified a deficiency in care planning related to a cognitively intact resident admitted with malignant neoplasm of the skin. The resident’s Minimum Data Set (MDS) showed a BIMS score of 15, indicating intact mental status, with clear speech and ability to understand and be understood. The resident reported during interview that he had not showered for some time and that he sometimes refused showers. Review of the shower record from 2/10/26 to 3/11/26 showed the resident had not received a shower for more than a month, despite being scheduled for showers twice weekly. The ADL care plan did not address the resident’s ongoing refusal to shower, and the DON acknowledged that the facility’s expectation was that the care plan be updated with the refusal and appropriate interventions. This was inconsistent with the facility’s “Shower for Residents” policy, which required that continual refusal to shower/bathe trigger social services involvement and care plan interventions to remedy the situation. Surveyors also found that the Interdisciplinary Team (IDT) did not develop a care plan addressing the resident’s discharge plan upon admission. Although the MDS indicated no discharge plan, care plan conference documentation on multiple dates reflected that the resident had discharge potential. The DON was unable to provide a discharge care plan for the resident and stated that discharge planning was addressed during care conferences rather than through a written care plan initiated on admission. Additionally, care plan conference records showed that the resident’s family member was not invited to participate, and the DON confirmed that the family member was not consistently invited. These findings were not in accordance with the facility’s Care Planning policy, which required that all resident care needs be identified through continuous assessments and care planned with measurable objectives and adequate interventions, and with the facility’s Care Planning-IDT process that included the resident and family/representative whenever possible.
Failure to Provide Assisted Grooming and Shaving With Scheduled Showers
Penalty
Summary
Surveyors identified that a resident who was cognitively impaired and dependent on staff for toileting, hygiene, and bathing was not provided grooming services to maintain personal hygiene. The resident had been admitted with a hip fracture and had a BIMS score of 03, indicating impaired mental status and inability to recall the correct year, month, and day of the week. The resident’s MDS documented that she required maximal assistance with showering/bathing and assistance of two or more helpers with toileting and hygiene. During observation, the resident was seen sitting in a wheelchair next to her bed with visible facial hair around her chin. The resident stated she had previously asked staff for a shave and that she wanted to be shaved. CNA 1 reported that residents’ facial hair was supposed to be shaved during scheduled showers but could not explain why this resident had not been shaved. Review of the resident’s Shower Day Skin Inspection forms on multiple dates showed that the resident had facial hair documented on each occasion, indicating the condition was ongoing. The DON stated that the facility’s expectation was that CNAs offer shaving with scheduled showers after obtaining consent, and that refusals should be reported to the charge nurse and documented. The facility’s shower policy required showers at least twice weekly, documentation of showers on the ADL flow sheet, and involvement of nursing and social services if residents continually refused bathing, with care plan interventions to address the situation. Despite these expectations and policies, the resident’s facial hair remained unshaven over multiple shower days.
Failure to Provide Privacy and Safety in Shared Resident Bathroom
Penalty
Summary
The facility failed to provide a safe, private, and homelike environment for two residents by assigning them to rooms that shared a single bathroom without a lock, resulting in both male and female residents having to share the same bathroom. During observation and interviews, a female resident expressed feeling unsafe due to sharing the bathroom with a male resident and noted the absence of a lock on the bathroom door. The male resident also reported discomfort with the arrangement and stated that there should be a lock for privacy. Both residents were cognitively able to express their needs and concerns, and their Minimum Data Set (MDS) assessments indicated they required only minimal assistance with toileting and ambulation. The shared bathroom was located between the two residents' rooms, and the lack of a lock required the male resident to signal when the bathroom was in use to avoid accidental entry. The Director of Nursing acknowledged that female and male residents should not be sharing bathrooms and recognized the lack of privacy as a risk, further stating that a bathroom lock was necessary to prevent abuse. The facility's policy emphasized providing person-centered care that respects residents' comfort, independence, and personal preferences, which was not upheld in this situation.
Failure to Maintain and Document Quarterly Sprinkler System Inspections
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25 requirements. During a record review and interview with the Maintenance Director, it was found that the facility could not provide records of quarterly sprinkler inspections and testing for the first, second, and fourth quarters of the year. Only the third quarter inspection record was available. The Maintenance Director stated that the inspections and testing are performed in-house and that no external vendor had been used for these services. This deficiency affected all 77 residents across three smoke compartments. The lack of required documentation for quarterly inspections and testing was identified during the survey, and the absence of these records could result in a malfunctioning fire sprinkler system in the event of a fire. The findings were based solely on the review of records and staff interview, with no mention of any specific incidents involving residents at the time of the deficiency.
Plan Of Correction
Corrective Action Facility renewed the contract with the sprinkler company. Moving forward, the facility will make sure that sprinkler inspections are done by a professional company on a quarterly basis. Maintenance director will make sure that there will be no quarterly missing inspections. He will make sure that it is done by a contracted professional vendor. Identify other residents. All other residents have the potential to be affected by this deficient practice, so the facility will ensure that fire sprinklers are inspected on a quarterly basis by a professional vendor. Maintenance director and administrator made a walk-through and made sure that this deficiency is not affecting any other areas of the facility. Systemic Changes As a systemic change, the facility will add a quarterly sprinkler inspection into the safety committee action list. Team members will monitor and also check the maintenance records for compliance. Any discrepancy will be brought to the maintenance director and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction was completed on 04/18/2025.
Obstructed Fire Extinguishers Compromise Safety Compliance
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, as evidenced by observations during a facility tour. Specifically, fire extinguishers were found to be obstructed in two separate locations. In the kitchen, a K fire extinguisher was blocked by a metal cart approximately three feet high and one inch away from the extinguisher. The Maintenance Director stated that the cart was placed there temporarily during dishwashing activities. In another instance, a fire extinguisher next to Room 133 was obstructed by a four-foot-high medical cart, which was about three inches away from the extinguisher. The Maintenance Director explained that the cart was being used to charge a computer. These obstructions affected 54 of 77 residents in two of three smoke compartments. The facility conducts fire extinguisher inspections in-house and has not had a vendor perform inspections or testing. The observed obstructions could result in a delay in accessing a fire extinguisher in the event of a fire, as the extinguishers were not readily accessible or visible as required by NFPA 10.
Plan Of Correction
Corrective Action Maintenance director immediately removed the obstruction (metal cart) in front of the fire extinguisher. The Dietary manager will do an in-service to the kitchen team regarding the importance of keeping the fire extinguister area clean and easily accessible. Maintenance director pulled the med cart away from the fire extinguisher immediately. DSD will in-service the nursing team regarding the importance of keeping the fire extinguishers area clear and accessible all the time. Identify Other Residents Facility will ensure that no other residents are affected by this deficient practice by ensuring that fire extinguishers in the facility are not obstructed by anything. K 353 Maintenance director in conjunction with dietary manager periodically checks the fire extinguisher in the kitchen to ensure that it is not obstructed by any equipment. Maintenance director will make sure that this deficiency is not affected in any other area by checking all other fire extinguishers at the facility. Systemic changes As a systemic change, safety committee members check the fire extinguishers at the facility randomly to ensure that there are no impediments in front of any fire extinguishers. Monitoring Process Administrator and maintenance supervisor will monitor for compliance on a quarterly basis. QA Process This plan of correction is integrated into the facility's monthly QA process. POC will review for the completeness and effectiveness. Completion Date This plan of correction will be completed on 04/18/2025.
Failure to Maintain Kitchen Equipment Inspection and Maintenance Records
Penalty
Summary
Surveyors found that the facility failed to maintain required inspection and maintenance records for its kitchen cooking equipment. During a tour and record review, it was observed that the facility could not provide annual inspection records for the kitchen equipment, and the Maintenance Director confirmed that there was no annual inspection plan in place. The Maintenance Director stated that equipment was only checked by a vendor when it broke down, rather than being inspected regularly as required. Additionally, the facility was unable to provide one of two required semiannual maintenance records for the kitchen suppression system and one of two required semiannual kitchen hood-exhaust cleaning records. Although one record for each was provided, the other records were not located, and the facility did not submit the missing documentation by the deadline given by surveyors. These deficiencies affected 17 of 77 residents in one of three smoke compartments.
Plan Of Correction
Corrective Actions Facility will make sure that all cooking equipment is maintained as required. Facility contacted the company to come for the semi-annual kitchen suppression system service and semi-annual kitchen hood cleaning system. Facility will contact a qualified company to inspect the kitchen equipment annually. Maintenance director will make sure that he is organized and keeping all maintenance records for kitchen equipment regularly and ready for an inspection. Identify other residents. Other residents may have the potential to be affected by this deficient practice, so maintenance supervisor along with dietary supervisor will make sure that all kitchen equipment is serviced, and preventive maintenance is done regularly. Administrator and maintenance director will walk through in the building to ensure that this deficient practice is not affecting any other areas. Systemic Changes As a result of systemic change, the maintenance director, dietary manager, and administrator will meet monthly to ensure that there is no kitchen equipment inspection due at that time. Facility will keep a special binder to keep all the maintenance records for the kitchen equipment. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction completed on 04/18/2025.
Incomplete Fire Drill Records and Improper Use of Electrical Equipment
Penalty
Summary
The facility failed to maintain complete fire drill records, as evidenced by the absence of documentation for fire drills conducted during the AM shift in the fourth quarter of 2024. During a record review and interview, the Administrator was unable to provide the required fire drill records and could not locate them in the designated binders. The facility was given an opportunity to submit the missing records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. Additionally, the facility did not maintain electrical equipment in accordance with regulatory requirements. Observations revealed the use of extension cords and daisy-chained power strips in several areas, including the Main Entrance, Kaiser Room, and Dietary Supervisor's Office. Specifically, extension cords were used to power a wander guard detector and a portable air conditioning unit, while a power strip was found powering another power strip for computers and monitors. The Maintenance Director confirmed these setups were due to insufficient outlets and the need to power specific equipment.
Plan Of Correction
Systemic Changes As a new system, the safety committee monthly meeting will review the documentation to ensure the plan of correction is sustained and completed. Any discrepancy will be addressed to the maintenance supervisor and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025. Corrective Action Maintenance director removed the yellow extension cord at the main entrance. Wander guard system is directly connected to the main power. Facility immediately removed the power strip from the kaiser room. The maintenance director will make sure that all electrical equipment is connected directly to the power outlet in the wall. Maintenance director and dietary manager removed the extension cord from the dietary manager's office and the portable air conditioner connected directly to the wall outlet. Identify other residents Maintenance director will do walk through the facility to make sure that this deficiency is not repeating in any other rooms. Any similar violations will be corrected immediately. Safety committee members will assist the maintenance director to identify any similar violations at the facility. Systemic Changes As a systemic change, the DSD and maintenance director will conduct an in-service to housekeeping and maintenance staff to re-educate them about the importance of not having any extension cords in the rooms & hallway. Housekeeping will assist and report to the maintenance director if they see any similar violations anywhere in the facility, and maintenance will correct it immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025.
Incomplete Fire Drill Records
Penalty
Summary
The facility failed to maintain complete fire drill records as required by NFPA 101. During a record review and interview with the Administrator, it was found that fire drill documentation for the AM shift during the fourth quarter of 2024 (October, November, December) was missing. The Administrator was unable to provide these records when requested and stated that it was unusual for them not to be in the binders. The facility was given an opportunity to submit the missing fire drill records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. No additional information about the medical history or condition of the residents at the time of the deficiency was provided in the report.
Plan Of Correction
Corrective Action Facility will ensure that fire drills are conducted each quarter each shift. The Director of Staff Development and Maintenance Supervisor is on board with the new plans. Facility already contacted the vendor and explained to them the importance of fire drills in each quarter. Facility got the copies of the missing fire drills conducted from the vendor. Please see attached. Facility will make sure that disaster drill is not mingled with the quarterly fire drills. Identify Other Residents Facility will ensure that other residents in the facility are not affected by this deficiency. As a new plan, there will be a new schedule for the fire drills for the whole year to make sure each quarter, each shift are covered, and with the new documentation sheet, it will be clearly documented. Disaster drills will be separated from the fire drill.
Failure to Maintain Safe Room Temperature During Heat Wave
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature level in the rooms of two residents during a heat wave, with room temperatures recorded at 84 degrees Fahrenheit. Resident 1, who has chronic obstructive pulmonary disease and intact mental status, reported discomfort due to the heat despite using a fan. Similarly, Resident 3, who has dementia and impaired mental status, also expressed discomfort with the room temperature. Both residents experienced fluctuating room temperatures, with no cool air flow from the vents, indicating a malfunctioning air conditioning system. The Maintenance Supervisor (MS) and Administrator acknowledged the issue, noting that the air conditioning unit had been faulty for weeks and repairs were ongoing. However, they were unable to provide records of air filter replacements or preventative maintenance for the air conditioning units. The facility's policy requires maintenance services to ensure all equipment is operable and safe, but the lack of documentation and unresolved air conditioning issues suggest a failure to adhere to these standards.
Failure to Supervise Resident Leads to Hip Fracture
Penalty
Summary
The facility failed to adequately supervise a resident with a history of falls, resulting in the resident sustaining a left hip fracture. The resident, who was admitted with dementia, muscle weakness, and mobility issues, required supervision during activities of daily living. Despite these needs, the resident was left unsupervised and attempted to use a bathroom that was out of order, leading to a fall in the hallway. The resident's care plan indicated a high risk for falls, and staff were instructed to anticipate and meet the resident's needs promptly, which was not adhered to in this instance. On the day of the incident, a Certified Nursing Assistant observed the resident walking in the hallway without a walker and expressed a need to use the bathroom. The CNA's back was turned when the resident fell, indicating a lack of supervision. Subsequently, the resident was found in distress with a deformed left hip and severe pain, necessitating emergency medical attention and transfer to an acute care hospital. The resident underwent surgery for a hip fracture, highlighting the facility's failure to provide adequate supervision and prevent accidents for a high-risk resident.
Resident Falls Due to Nonfunctional Bathroom
Penalty
Summary
The facility failed to provide a functioning toilet for a resident, leading to a potential fall incident. The resident, who was admitted with dementia, muscle weakness, and mobility issues, had a bathroom that was out of order. The resident's Annual Minimum Data Set (MDS) assessment indicated occasional bladder incontinence and a moderately impaired mental status. On the day of the incident, the resident attempted to find an alternate bathroom due to the nonfunctional toilet in her room, which resulted in a fall in the hallway. The Certified Nursing Assistant (CNA) observed the resident walking in the hall without a walker and expressed the need for a bathroom. The CNA confirmed the bathroom was out of order and noted the absence of a bedside commode. While the CNA was looking for an alternate bathroom, the resident fell. The Maintenance Supervisor later confirmed the bathroom issue was not logged, and the Director of Nursing stated that a bedside commode should have been provided, and staff should have been more attentive to the resident's needs.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse when another resident yelled and punched him in the face, resulting in a skin tear. The incident occurred in the courtyard, where there was no staff presence to intervene. The injured resident expressed increased anger and fear for his safety following the altercation. The facility's records indicated that the injured resident had no history of physical or verbal behavioral symptoms, while the aggressor had a documented history of behavioral problems, including previous altercations with other residents. During the incident, the aggressor became angry after being called a derogatory name by the injured resident and responded by hitting him. The facility's interdisciplinary team notes and interviews with staff confirmed that the altercation was not witnessed by staff, and the injured resident's care plan was not updated to address the incident or the injury sustained. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of staff oversight in the courtyard and the failure to revise the care plan to address the resident's injury and safety concerns.
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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