Autumn Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Chico, California.
- Location
- 587 Rio Lindo Avenue, Chico, California 95926
- CMS Provider Number
- 056074
- Inspections on file
- 83
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Autumn Creek Post Acute during CMS and state inspections, most recent first.
A resident with significant mobility limitations and fear of falling required substantial assistance for transfers and could not ambulate safely. Despite documented concerns about the primary caregiver’s financial pressure, verbal abuse, and threats, and repeated cancellations or refusals of car-transfer training, the IDT proceeded toward discharge at the caregiver’s insistence without a complete, coordinated discharge plan. On the day of discharge, the caregiver rushed the process, did not wait for staff to complete discharge instructions or assist with the transfer, and attempted to move the resident from wheelchair to car without having accepted training, resulting in a fall in the parking lot. Staff, including the DON and DOR, later acknowledged that caregiver training had not been completed and that the discharge plan did not clearly define transport responsibilities.
The facility failed to follow its abuse reporting policy and state law when staff did not report separate allegations of verbal and medication-related abuse involving a resident within the required 2-hour timeframe. A CNA reported that the resident’s responsible party called the resident an addict and threatened to have pain meds discontinued, and the DOR separately observed the responsible party yelling at the resident by phone and heard the resident express fear that her pain meds would be discarded after discharge. The DOR relayed her concerns to the ADMIN, who chose to combine the distinct allegations into a single report and submitted the report late, and both the ADMIN and DOR later acknowledged they did not meet mandated reporter and policy requirements.
Multiple cognitively intact, mobility-impaired residents who required staff assistance for transfers and toileting reported prolonged waits after activating call lights, sometimes 30–60 minutes, leading to incontinent episodes and the need to self-transfer from the bathroom and into bed. One resident stated a CNA entered, turned off the call light, and left without assisting from the toilet, resulting in the resident independently transferring to a wheelchair and then to bed after waiting a long time. Another resident reported being told by agency staff to void in a brief and described nearly daily incontinence due to delayed toileting assistance. Staff interviews and schedules described frequent call-outs, short staffing on specific stations, numerous unanswered call lights, and missed or delayed basic care such as showers, indicating that available CNAs could not consistently respond promptly to residents’ toileting needs.
A resident admitted with diabetes, kidney disease, and depression did not have a baseline care plan for diabetes developed within 48 hours as required by facility policy, and a diabetes care plan was not created until 15 days after admission. The eMAR contained parameters to notify the physician for blood glucose ≥400, and documented blood sugars of 435 and 400, with an alert note showing that a nurse administered ordered medication and contacted the physician after one high reading. The resident reported that blood sugars had been significantly higher since admission and that no one had discussed the elevated levels or management with them. During interview and record review, the DON and ADON acknowledged that diabetes should have been included on the care plan and updated following high blood sugar events.
The facility failed to ensure that NAs were properly trained, certified, and supervised before providing direct resident care. Facility records showed that the site did not have a state-approved NATP, yet multiple uncertified NAs, listed as training aides, were assigned to take vital signs and manage resident assignments, often independently and without required CNA pairing, contrary to the facility’s own job descriptions and "can’t do" list. Review of employment and certification data confirmed that several NAs worked for months while still uncertified, and interviews with CNAs, NAs, and leadership revealed that student and uncertified NAs were routinely used on PM and NOC shifts for direct observation and hands-on care while awaiting certification, despite leadership acknowledging that only another affiliated facility had an approved NATP and that NAs should not be performing direct care before certification.
The governing body failed to ensure that only state‑certified CNAs, or properly supervised NA trainees, provided direct resident care. Facility policies required governing body oversight of administrative policies and specified that NAs in training could not perform direct care tasks such as taking vital signs, feeding, transfers, or changing briefs. Despite this, staffing records and assignment sheets showed multiple uncertified NAs were hired, assigned independent resident care and vital signs duties, and often worked on PM and NOC shifts without consistent CNA pairing. Interviews with the administrator and NAs confirmed that uncertified staff were employed, provided direct observation for fall‑risk residents, took vital signs, and had independent assignments, while leadership acknowledged responsibility for policy oversight and regulatory compliance across the facilities.
A resident with multiple fractures and recent fall did not receive two physician-ordered creams after a nurse failed to transcribe the orders into the EMR, despite the orders being noted following a urology appointment. Facility leadership confirmed the medications were not entered or administered as required.
A resident with a history of stroke and left-sided weakness was forcefully shoved back into a wheelchair by a CNA, as witnessed by another CNA. The incident was reported internally, but the administrator failed to notify authorities within the required two-hour timeframe as specified in the facility's abuse policy.
A resident's representative was not given the resident's personal belongings after the resident's death, as another family member removed the items without proper documentation or updating of the inventory form. Staff could not provide information to the representative about the belongings' removal, resulting in the representative being unable to retrieve them.
A resident with moderate cognitive impairment, mobility issues, and high fall risk experienced four unwitnessed falls in one week after her indwelling catheter was not replaced. The facility did not update the care plan with new interventions, failed to complete required neurological assessments and alert charting, and did not implement a toileting program or increased supervision, despite policy requirements. These failures led to repeated falls, a head injury, and ultimately the resident's death.
A resident with moderate cognitive impairment and unable to make healthcare decisions experienced multiple unwitnessed falls, a dislodged catheter, and a significant change in condition requiring transfer to the ED. Nursing staff failed to notify the responsible party as required, often documenting the resident as her own RP despite clear instructions to contact the daughter. This lack of timely notification prevented the family from being informed and involved in care decisions.
A resident with multiple health issues, including cognitive impairment and mobility difficulties, experienced several unwitnessed falls resulting in a head injury and subsequent death from a subdural hematoma. Despite facility policy requiring timely reporting of such incidents, staff did not notify CDPH of the injury or major accident, as confirmed by the DON, because the resident was transferred to the hospital and did not return.
A resident admitted with an indwelling catheter did not receive an assessment for continued catheter need, and the catheter was discontinued without a physician order. After removal, there was no bladder assessment, bladder training, or care plan update, and required monitoring was not documented. The resident was left to manage toileting without adequate support, resulting in multiple unassisted bathroom trips and several falls.
A staff member was reported to have used profane and disrespectful language toward a resident with moderate cognitive impairment, failing to uphold the facility's standards for dignity and respectful communication. The incident was witnessed by another CNA, and the resident, who has Parkinson's Disease and dementia, recalled hearing swearing but could not identify the staff member involved.
A medication cart was left unlocked and unattended near residents with dementia, containing accessible syringes and a bottle of povidone iodine with a broken cap. Staff interviews confirmed the cart was shared among nursing staff, and the responsible nurse had left early for a family emergency. Facility policy requires carts to be locked when not in use, and staff were aware of previous similar incidents.
A resident with multiple serious medical conditions did not have their Advance Directive (AD) included in their medical record, despite facility policy requiring this upon admission. Staff interviews confirmed that the resident had an AD and the mental capacity to make decisions, but the facility failed to obtain and file the document as required.
A physician documented that a resident was incapable of making healthcare decisions based solely on a diagnosis of cerebral palsy, without adequate assessment or evidence of mental incapacity. Staff interviews and record review indicated the resident was able to communicate wants and needs clearly, and the order was not supported by a comprehensive evaluation.
Nursing staff did not develop or update care plans for two residents with severe cognitive impairment after an altercation in which one attempted to pull the other from bed. Despite facility policy requiring care plan changes following such incidents, both the DON and Social Services Director confirmed that no care plans were created or updated in the medical records.
Two medication carts containing medications, including topical creams, were left unlocked and unattended at a nursing station, making them accessible to residents with dementia and others. A surveyor was able to open the carts without staff intervention, and an LVN later confirmed the carts should have been locked according to facility policy.
A resident with a history of multiple falls and significant mobility and vision impairments did not have bilateral fall mats at the bedside as required by the care plan. Despite the care plan update specifying two mats after previous falls, only one mat was present during observation, and staff confirmed the omission.
A CNA entered the room of a COVID-positive resident wearing only a face shield and gloves, omitting the required N95 respirator and gown as specified by facility and state protocols. Interviews with staff confirmed that full PPE, including gown, gloves, N95, and eye protection, is required for all staff entering the room of a COVID-positive resident until isolation is discontinued.
Three residents, all with significant physical or cognitive impairments and care plans requiring call lights to be within reach, were found unable to access their call lights, which were placed out of reach or on the floor. Staff confirmed the oversight, and a family member reported repeated incidents of a call light being inaccessible, leading the resident to attempt independent movement.
A resident with MRSA in both urine and a wound was not moved to a private room for two weeks, despite available empty rooms, and continued to share a room with two other residents who had open wounds and significant comorbidities. The Infection Preventionist was not informed of room changes, and the Social Service Department made placement decisions without proper communication, resulting in a failure to follow infection control policies and CDC guidelines.
A resident reported a missing ATM card and unauthorized transactions while receiving dialysis. Although the Social Services Director assisted with disputing charges and filing a police report, the incident was not reported to CDPH because the perpetrator was unknown, contrary to facility policy requiring all allegations of misappropriation to be reported.
A resident with chronic pain and multiple health conditions was repeatedly given the wrong dosage of Hydrocodone-Acetaminophen due to staff administering an outdated strength from the medication cart. Nursing staff failed to follow medication administration protocols, resulting in at least nine documented errors over nine days, with inconsistent documentation and lack of required reporting to the DON or responsible party. The resident continued to experience significant pain, and the responsible party was not informed of the errors.
Three residents reported being treated with disrespect by an LPN, who used a demeaning tone and was rough during medication administration. The residents, all cognitively intact and dependent on staff, expressed fear and anxiety due to the LPN's behavior. Staff members corroborated these accounts, describing the LPN as rude and unapproachable. The facility's administrator acknowledged the LPN's poor customer service skills.
A resident experienced a significant decline in health, including shortness of breath and a headache, but the LN failed to notify the physician and the resident's family as required by facility policy. The LN did not document the change in condition or place the resident on alert charting, leading to a negative clinical outcome.
A facility failed to document a resident's change in condition, including new onset of shortness of breath and need for oxygen. The resident, with a history of multiple health issues, was not added to alert charting, and there was no record of physician notification or care plan updates. A nurse admitted to not documenting these changes, and the administrator confirmed the lack of documentation.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and incidents of incontinence among residents. Residents reported waiting 30 to 45 minutes for assistance, with some unable to locate their call lights. Observations showed staff walking past activated call lights without providing help, highlighting insufficient staffing levels.
The facility failed to provide a safe, clean, and homelike environment, with issues such as unlined trash cans, damaged walls and furniture, missing electronics, and non-functional bathroom fans. Staff confirmed these deficiencies, acknowledging the need for repairs and improvements.
The facility failed to store parsley under sanitary conditions, as it was not covered, labeled, or dated in the walk-in refrigerator. Additionally, the walk-in freezer had frost build-up on the ceiling, which was confirmed by both the Dietary Manager and Maintenance Supervisor. These issues were contrary to the facility's policies on food storage and maintenance.
A nurse failed to sanitize a blood pressure cuff between two residents, contrary to the facility's infection control policy. This oversight was acknowledged by the nurse, who stated it was standard practice to clean equipment between residents. Other staff confirmed the importance of this practice for infection control.
Two residents with cognitive impairments were involved in a physical altercation after one reported verbal abuse from the other. Despite facility policies, staff failed to notify administration or separate the residents, leading to the incident. The lack of communication and adherence to procedures contributed to the deficiency.
A resident's medical records regarding skin assessments and treatments were inconsistent, with discrepancies in documentation of a skin tear and bruising. Despite observations by nursing staff, a physician's order was delayed, and a nurse failed to document or report the incident, leading to incomplete records.
A resident in a long-term care facility was verbally abused by an LVN who used inappropriate and threatening language when the resident attempted to assist another resident after a fall. The LVN's behavior was reported by multiple staff members and residents, revealing a pattern of negative interactions with residents. The facility's administration was notified, and the LVN was suspended. The incident violated the facility's abuse prevention policies.
The facility failed to respond timely to residents' requests for assistance, affecting three residents. One resident was left soiled due to a CNA's oversight, another was at risk of falling after being ignored for over 12 minutes, and a third experienced repeated delays in call light responses. These incidents highlight lapses in staff coverage and adherence to facility policies.
A resident in an LTC facility suffered a bruise after a CNA insisted on changing her brief despite her refusal. The resident, who had a history of stroke and was cognitively intact, reported that the CNA pulled on her blankets and remote, causing the injury. Staff interviews indicated the CNA was demanding and did not report the incident as required.
The facility failed to provide sufficient nursing staff, resulting in extended call light wait times for several residents, ranging from 10 to 55 minutes. Residents expressed feelings of neglect and embarrassment, while nursing staff reported being overwhelmed and unable to provide adequate care. Despite a policy indicating staffing adjustments should be made, the current levels were insufficient to meet residents' needs.
A resident with cognitive impairment and multiple health issues was injured by a CNA in a long-term care facility. The CNA, who was from a staffing agency, left the facility without reporting off, and the resident was later found with a significant skin tear on her hand. The injury was discovered by the next shift CNA, and the incident was reported to authorities. The resident described being attacked, and the injury was consistent with being grabbed.
The facility failed to consistently follow physician orders for dialysis dressing management, affecting several residents. A resident with end-stage renal disease experienced clotting of the dialysis access site due to the facility's failure to remove compression dressings within the required timeframe. Similar issues were noted for two other residents, with staff interviews revealing inconsistent practices and a lack of understanding regarding the proper care of dialysis dressings.
The facility failed to provide scheduled showers or baths for two residents who required maximal assistance with ADLs. One resident received only four baths in a month, while another received just one shower. The facility's policy required twice-weekly bathing, but there was no documentation of refusals or updates to responsible parties, indicating non-compliance with the bathing schedule.
An LTC facility administrator directed nursing staff to alter progress notes related to a resident's care, violating regulations and professional standards. The resident, who had chosen CPR in their POLST, experienced an unexpected death. The administrator asked staff to change documentation, including removing timing details and terms like 'asphyxiation,' leading to concerns about the accuracy of medical records.
A resident with a full code status was found unresponsive and without a pulse, but CPR was delayed by 10 minutes due to staff inaction. Despite facility policy requiring immediate CPR, the staff failed to initiate it promptly, leading to a delay in emergency care. Interviews revealed a lack of adherence to CPR protocols, despite recent BLS training emphasizing the importance of immediate action.
A resident in an LTC facility experienced signs of a stroke, including slurred speech and left-sided weakness, but there was a three-day delay in notifying the physician and transferring the resident to the hospital. Despite the facility's policy requiring prompt action for significant changes in condition, staff failed to act in a timely manner, leading to a decline in the resident's health and eventual death.
The facility experienced significant staffing shortages, leading to delayed responses to call lights and missed showers for residents. Observations and interviews revealed that residents waited long periods for assistance, with some receiving only one out of four scheduled showers. Staff reported feeling overwhelmed and unsupported, with management acknowledging the challenges but struggling to maintain adequate staffing levels.
A resident in an LTC facility experienced a delay in medical intervention for a stroke due to staff's failure to promptly identify and report a change in condition. Despite showing symptoms like slurred speech and left-sided weakness, the resident was not transferred to the hospital until three days later, resulting in increased pain and functional decline. Interviews revealed staff's misunderstanding of comfort care policies and the importance of timely intervention.
A resident with intact cognition was upset by inappropriate comments made by a CNA, who told the resident to "stop being a smartass" and later called the resident a "dumbass." The incident, witnessed by another CNA, led to the resident crying and recalling past abuse. The facility's administrator acknowledged the inappropriate language, which affected the resident's dignity.
A resident with a history of falls and mobility issues was discharged from an LTC facility without adequate preparation or family training, leading to her return within 24 hours. The interdisciplinary team failed to ensure a safe discharge plan, and the resident's family was not instructed on how to assist her at home. The discharge was deemed unsafe, and the facility did not discuss the risks or consider an AMA discharge.
The facility failed to maintain essential equipment, including the AC system and lighting, leading to uncomfortable temperatures and inadequate lighting in resident rooms. A resident reported feeling hot due to a non-functional PTAC fan, and two residents were at risk for falls due to non-working lights. Maintenance staff acknowledged the issues, with ongoing repairs not yet completed.
A resident with a history of severe obesity and difficulty walking fell and sustained fractures to her right knee after a CNA and NA failed to use a Hoyer lift for a transfer, as specified in her care plan. The resident experienced severe pain and a delay in physical therapy treatments.
Failure to Ensure Safe, Coordinated Discharge Planning and Caregiver Training Resulting in Fall During Car Transfer
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a safe and coordinated discharge plan for a resident whose discharge was being driven by a caregiver’s demands, despite clear evidence that the resident required substantial assistance with mobility and transfers. The resident had heart disease, difficulty walking, and needed help with personal care. An MDS assessment documented that the resident required partial to maximum assistance for bed mobility and transfers, was dependent for sit-to-stand, and could not ambulate due to medical or safety concerns. Physical therapy notes showed the resident had significant fear of falling, excruciating right knee pain, intermittent inability to bear weight, and anxiety during transfer training, with car-transfer training either not completed or canceled. The Interdisciplinary Team (IDT) and multiple staff members were aware of ongoing concerns about the caregiver’s behavior and the resident’s fear and distrust of the caregiver. IDT and social services notes documented that the resident reported the caregiver was taking financial advantage of her, had pressured her into signing a financial POA after an inheritance, and that the facility had reported these concerns to CDPH and the Ombudsman. Staff documented that the caregiver frequently called the resident, including early in the morning and in the middle of the night, yelled at the resident, threatened to take the resident’s dog, and demanded that pain medications be withheld, calling the resident a drug addict. A licensed nurse documented an incident where the caregiver verbally abused both the resident and the nurse over the phone. Despite these concerns, the resident continued to express a desire to return home with the caregiver, and the caregiver continued to push for discharge by specific dates. Therapy and nursing staff identified that car-transfer training and caregiver competency were necessary for a safe discharge, but the caregiver repeatedly refused or canceled scheduled training sessions. The Director of Rehabilitation stated that multiple attempts were made to arrange car-transfer training and that the discharge plan did not clearly specify who would be responsible for transport. On the day of discharge, the caregiver appeared rushed and did not wait for staff assistance or completion of discharge instructions and medication preparation. A licensed nurse reported that when he returned with medications, the resident and caregiver were already outside, and the resident had fallen in the parking lot during a transfer from wheelchair to car after the caregiver failed to wait for staff help. The IDT documented that the caregiver had been offered hands-on car-transfer training multiple times and refused, including again on the day of discharge. The facility’s own policies required ensuring safe transfer/discharge and making reasonable attempts to ensure safety when a resident leaves against medical advice, but staff, including the DON, acknowledged there was no evidence of a complete or coordinated discharge plan for this resident, culminating in the unsafe attempted discharge and fall in the parking lot.
Failure to Timely and Separately Report Allegations of Verbal and Medication-Related Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the State Survey Agency within 2 hours as required by state law and the facility’s Abuse Prevention and Management policy. The policy required the Administrator or designee to notify law enforcement immediately or within 2 hours of an initial report and to send a written report to the Ombudsman, law enforcement, and CDPH within 2 hours. On 2/25/26 at approximately 3:45 p.m., a CNA reported that the resident’s responsible party told the resident she was an addict and that she would contact the physician to have the resident’s pain medication discontinued. This allegation was reported to CDPH at 7:19 p.m., more than three and a half hours after the incident, exceeding the 2-hour reporting requirement. In addition, the Director of Rehabilitation documented that an allegation of abuse was reported to her on 2/25/26 at 4:30 p.m. after she witnessed the responsible party yelling at the resident on the telephone. The resident told the DOR she was concerned that, upon discharge home with the responsible party, her pain medications would be thrown away and stated that the responsible party had mental health issues. The DOR reported her concerns to the Administrator and was instructed to write a statement to be submitted with a similar allegation of abuse. The Administrator stated she planned to combine two distinct allegations involving the same resident into a single report instead of reporting each allegation independently. Both the Administrator and the DOR acknowledged that each allegation must be reported separately and that, as mandated reporters, they did not follow the facility’s abuse reporting policy.
Delayed Response to Call Lights and Toileting Needs Due to Insufficient Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and competent nursing staff to meet residents’ toileting needs, resulting in prolonged waits after call lights were activated. The CNA job description required CNAs to keep incontinent residents as clean and dry as possible, answer call lights promptly, and assist residents to and from the bathroom promptly. Resident 1, admitted with orthopedic aftercare following surgical amputation, difficulty in walking, and need for assistance with personal care, had a BIMS score of 14 and required partial/moderate assistance with transfers. Resident 1 reported that one evening after dinner and medications, a male staff member took him to the restroom; after he finished and pressed the call light, a female CNA entered, turned off the call light without assisting him out of the bathroom, and left. Resident 1 stated he then transferred himself to his wheelchair, waited approximately 45 minutes for staff to assist him back to bed, and ultimately self-transferred into bed after no one came. Resident 2, admitted with spinal stenosis, difficulty in walking, and need for assistance with personal care, had a BIMS score of 13 and used a wheelchair, requiring partial/moderate assistance for toileting. Her bowel and bladder care plan identified risk for urinary tract infection related to insufficient fluid intake and urine retention secondary to avoidance of voiding in a brief, and directed staff to offer privacy, dignity, and prompt assistance when toileting. Resident 2 stated that staffing levels varied by day and staff, that there were not enough staff to meet her needs, and that the facility was often short staffed on day shift. She reported having to wait 30 minutes to an hour for assistance to use the restroom, leading to incontinent episodes that she felt interfered with her efforts to control bowel and bladder. She stated an agency staff member once told her to void in her brief, another CNA told her to “have fun” when she tried to go to the bathroom on her own, and that she almost daily had incontinent episodes due to waiting for toileting assistance, including an episode where she fell asleep in the bathroom while waiting about 30 minutes for help. Resident 3, admitted with spinal surgery and arthritis and having a BIMS score of 15, used a wheelchair and was dependent on staff for all transfers. Resident 3 reported needing assistance to transfer from bed to wheelchair and that it took a while for staff to answer call lights, stating it seemed the facility was short staffed. She reported having incontinence episodes due to delayed staff response to call lights, stating that by the time staff arrived she had already voided before they could provide a bedpan. Facility records showed that on a specific date, two employees called out on the station where these residents resided, and a CNA was temporarily reassigned there and encountered numerous active call lights. Staff interviews described frequent short staffing, call-outs, and delayed responses to call lights, including an account that a CNA turned off a resident’s call light while the resident remained in the bathroom and that the resident waited a long time and had to get into a wheelchair and into bed independently. These events collectively demonstrate that residents requiring assistance with toileting experienced prolonged waits and unmet care needs due to insufficient and ineffective staffing coverage.
Failure to Develop Timely Baseline Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop and implement an initial person-centered baseline care plan addressing diabetes within 48 hours of admission for one resident. Facility policy titled "Person-Centered Care Planning" required that a baseline care plan, including minimum healthcare information necessary to properly care for each resident and addressing resident-specific health and safety concerns, be developed and implemented within 48 hours of admission. Record review showed that the resident was admitted with diagnoses including diabetes, kidney disease, and depression, yet the initial care plan report created on 2/6/26 did not include a baseline care plan for diabetes care. A diabetes care plan was not created until 2/20/26, which was 15 days after admission. Further record review of the resident’s eMAR showed that on 2/5/26 there was an order to notify the physician if the resident’s blood sugar level was 400 or greater. The eMAR documented blood sugar levels of 435 on 2/11/26 at 5:30 p.m. and 400 on 2/16/26 at 5:30 p.m. An alert note dated 2/11/26 at 8:22 p.m. documented that a licensed nurse administered medication as ordered and contacted the doctor for further orders after the 435 blood sugar reading. During an interview, the resident reported that prior to admission their blood sugar ranged from 55–200, but since being at the facility it had been between 300–500, and stated that no one had discussed the high blood sugars or what was being done to manage them. In a concurrent interview and record review, the DON and ADON confirmed that diabetes should have been included on the resident’s care plan and that the care plan should have been updated when the resident experienced high blood sugars that required physician notification.
Uncertified Nurse Aides Providing Independent Resident Care Without Approved Training
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides (NAs) who had worked more than four months were trained and competent, and that NAs who had worked less than four months were properly enrolled in an approved training program before providing direct resident care. Facility 1 did not have a California Department of Public Health (CDPH)-approved Nursing Assistant Training Program (NATP), yet employed multiple uncertified NAs identified as "INS-Staff Training Aides." The facility’s own NA job description required enrollment in a CDPH-approved NATP and clinical competency, and an internal "Can and Can't Do" list stated that NAs could not perform any direct resident care, including observation, vital signs, changing briefs, feeding, or transfers. Despite these written expectations, surveyors’ review of staffing records and schedules showed that uncertified NAs were assigned to resident care tasks and vital signs, often independently and without required pairing or supervision by a CNA. Record review of the CNA/NA list and the California CNA registry showed that several NAs were hired, graduated from NATP at another facility, and either remained uncertified or were not yet certified during the time they were assigned resident care duties. For example, NAs were documented as taking vital signs independently on various shifts and being given resident assignments, sometimes after only brief orientation or partial shadowing with a CNA. Some NAs, such as NA 3, were assigned independent resident assignments on night shift before certification, and others, such as NA 5 and NA 6, were repeatedly assigned to take vital signs independently without being paired with a CNA. Interviews with CNAs confirmed that student NAs from the NATP were often hired and then assigned to units working independently rather than strictly shadowing, and that there were many new staff working under these conditions. Interviews with facility leadership and NAs further substantiated that uncertified NAs were providing direct resident care and observation. The Director of Staff Development acknowledged that only Facility 2 had an approved NATP and that NAs for Facility 1 were selected jointly by Facilities 1, 2, and 3, then oriented and paired with CNAs for competencies, but the assignment sheets showed that this pairing did not consistently occur. The Administrator admitted that uncertified NAs had been working on PM and NOC shifts and stated they were unaware that uncertified NAs and NA students were not allowed to be employed or have clinical training at Facility 1. Uncertified NAs themselves reported providing direct observation for fall-risk residents, having independent assignments, and occasionally performing hands-on care when residents were in need, despite still waiting for state certification numbers. The Governing Body representatives confirmed that only Facility 2 was approved for NATP, that Facility 1 and 3 were not approved due to regulatory history, and agreed that NAs should not be feeding and changing residents, while acknowledging their responsibility for oversight of policies and hiring practices across the three facilities.
Governing Body Failed to Prevent Uncertified NAs From Providing Independent Resident Care
Penalty
Summary
The deficiency involves the governing body’s failure to provide adequate oversight of facility administration to ensure that nurse aides were properly certified and competent before providing independent resident care. The facility’s operations manual stated that the governing body engages administrative services to develop policies and procedures for management and operations, and that the governing body reviews and confirms adoption of new and updated policies at least annually. The governing body was also to be informed of any deviations from template policies. Despite this framework, a current CNA/NA employee list showed nine uncertified nursing assistants, and the facility’s own NA job description required that NAs be enrolled in a CDPH‑approved Nursing Assistant Training Program and have clinical competency while enrolled. Additional facility documents showed that NAs were not to provide any direct resident care, including observation, vital signs, changing briefs, feeding, transfers, or any direct care at all. However, review of nursing staff assignment sheets over multiple dates showed uncertified NAs were assigned to take vital signs and given resident assignments, sometimes independently and sometimes with CNAs, contrary to the stated restrictions. Specific review of the CNA/NA list against the California CNA registry revealed multiple NAs who were hired, had completed NATP, but were not yet state certified, and were nonetheless assigned to resident care tasks and vital signs, often not paired with a CNA. Some NAs, such as NA 3, were assigned independent resident assignments on night shift before certification, and others, such as NA 5, NA 6, and NA 9, were repeatedly assigned to take vital signs independently on various shifts while still uncertified. Interviews further confirmed that uncertified NAs and NA students were working on PM and NOC shifts and providing direct resident care. The administrator acknowledged that uncertified NAs were and had been working at the facility and stated they were not aware that uncertified NAs and NA students were not allowed to be employed or have clinical training at the facility, noting that the NATP and clinical routines had been established under previous leadership. Uncertified NAs themselves reported providing direct observation for fall‑risk residents, having independent assignments, and sometimes shadowing CNAs only when the CNA chose to demonstrate care tasks. In a later interview, members of the governing body, including the vice president of operations, regional administrator, and chief clinical officer, stated that only one sister facility had an approved NATP, that the governing body assisted administrators and DONs in creating policies and procedures, and that the administrators and governing body were ultimately responsible for ensuring the NATP program and NA hiring followed federal and state regulations, underscoring the lack of effective oversight that led to uncertified NAs providing resident care.
Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to transcribe physician-ordered medications into the electronic medical record (EMR) for a resident who had recently been admitted with multiple fractures and a recent fall. The resident, who was cognitively intact and able to make their own decisions, attended a urology appointment where the physician prescribed two creams: Clotrimazole cream for skin irritation and Esterace cream for vaginal symptoms. The facility's process involved sending residents to appointments with a blank physician's order form, which the physician completed and the nurse was responsible for reviewing and transcribing into the EMR. Despite the physician's orders being noted and acknowledged by the RN, the two medications were not entered into the EMR, and as a result, the resident did not receive the prescribed treatments during their stay. This failure was confirmed through interviews and record reviews with facility leadership, who verified that the orders were not transcribed and the medications were not provided as directed by the physician.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required timeframe as outlined in its own abuse prevention and management policy. According to the facility's policy, all allegations of abuse must be reported to law enforcement and regulatory agencies immediately or within two hours of the initial report. In this incident, a Certified Nursing Assistant (CNA) was observed by another CNA forcefully grabbing a resident's shirt and shoulders and shoving him back into his wheelchair to prevent a fall. Another CNA then made a comment to the resident about why he is not assisted to get up. The incident was reported internally to a Licensed Nurse, but the facility administrator did not notify the California Department of Public Health (CDPH) until the following day, well beyond the required two-hour window. The resident involved had a history of stroke with left-sided weakness and required assistance with care but was able to make his own healthcare decisions. The delay in reporting the abuse allegation was confirmed during an interview with the administrator, who initially believed the reporting timeframe was within 24 hours if there were no injuries. Upon review of the facility's policy, the administrator acknowledged that the correct timeframe was immediately or within two hours, and confirmed that the facility did not adhere to this requirement for the reported incident.
Failure to Return Resident's Personal Belongings to Designated Representative
Penalty
Summary
The facility failed to ensure that a resident's representative was given the opportunity to retrieve the resident's personal belongings following the resident's death. According to facility policy, personal property is to be safeguarded and returned to the resident or their representative upon discharge or death, with documentation of the transfer. In this case, the resident's representative was listed as the emergency contact and next of kin, and the resident's belongings were inventoried upon admission. However, there was no documentation showing that the belongings were returned to the representative after the resident's death. Instead, a family member who was not the designated representative removed the resident's belongings from the facility, as observed by an LVN. The inventory form was not updated to reflect this removal, and staff could not provide documentation or information to the representative regarding which belongings were taken or by whom. The administrator confirmed that the inventory form only documented the intake of belongings and not their release, resulting in the representative being unable to retrieve the resident's personal property.
Failure to Provide Adequate Supervision and Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who experienced four unwitnessed falls within seven days, three of which occurred after her indwelling catheter was not replaced. Despite the facility's fall management policy requiring increased observation and structured routines for residents with multiple falls, the care plan was not updated with new interventions. Nurses did not complete required neurological assessments or alert charting for 72 hours after each unwitnessed fall, and there was no individualized toileting program or bladder assessment after the catheter was removed. These omissions occurred even though the resident had a history of moderate cognitive impairment, muscle weakness, difficulty walking, and was on medications that increased her risk for falls and bleeding. The resident's medical records indicated she required moderate assistance with transfers, toileting, and walking, and had been recommended for 24-hour supervision by therapy staff. After the catheter was not replaced, the resident attempted to toilet herself frequently, leading to repeated falls. Staff interviews revealed that the resident did not use her call light, often shut her door, and needed frequent checks, but there were no special instructions or documented safety checks. Staff also reported insufficient training on updating care plans and a lack of consistent interventions such as one-on-one supervision or increased monitoring, despite recognizing the resident's high fall risk. Following the series of falls, the resident developed a head injury that progressed to a brain bleed, ultimately resulting in hospitalization and death. Documentation reviews confirmed that required post-fall assessments, neurological checks, and care plan updates were not completed as per facility policy. The Director of Nursing and other staff acknowledged these failures, including the lack of a bladder training program and the absence of new interventions after each fall, which were required by the facility's own policies and procedures.
Failure to Notify Responsible Party of Resident Falls and Change in Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's falls, change in condition, and transfer to the emergency department, as required by facility policy. The resident, who was moderately cognitively impaired and unable to make healthcare decisions, experienced four unwitnessed falls, a dislodged indwelling catheter that was not replaced, and a significant change in condition due to a possible head injury. Despite documentation indicating that the resident's daughter was to be notified of any changes, there was no evidence that the RP was informed of these incidents in a timely manner. Record review showed that nursing staff repeatedly documented the resident as her own RP, even after social services noted that the daughter should be contacted for healthcare decisions. Progress notes for each fall and the catheter incident either incorrectly listed the resident as her own RP or lacked documentation of RP notification. When the resident was transferred to the emergency department for further evaluation after a change in condition, the daughter was not contacted until several hours after the transfer, and only a voicemail was left. Interviews with staff confirmed confusion regarding who was the appropriate RP, and the DON acknowledged that the daughter had requested to be notified of any changes but was not. The lack of timely and accurate notification to the RP prevented the family from being aware of the resident's condition changes and participating in care decisions, as required by facility policy.
Failure to Report Injury of Unknown Origin and Major Accident to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin and a major accident involving a resident to the California Department of Health (CDPH) as required by their own policy and state regulations. The resident, who had multiple diagnoses including cognitive impairment, muscle weakness, and difficulty walking, experienced several unwitnessed falls over a period of days. Documentation shows that the resident suffered a head injury resulting in a bruise and bump on the forehead, and subsequently exhibited a change in condition, including altered mental status and abnormal vital signs. Despite these events, which included a significant change in the resident's condition and eventual transfer to the hospital, the facility did not notify CDPH within the required timeframe. The resident was found to have extensive intracranial bleeding on hospital evaluation and later died as a result of a subdural hematoma caused by the unwitnessed fall. The facility's policy required reporting of major accidents and other occurrences affecting resident welfare to the appropriate authorities within 24 hours, but this was not followed in this case. Interviews with facility staff, including the DON, confirmed that the incident was not reported to CDPH because the resident was sent to the hospital and did not return to the facility. The lack of timely reporting delayed the involvement of required agencies in investigating the injury of unknown origin and determining whether abuse or neglect may have been a factor.
Failure to Assess, Document, and Plan Care After Catheter Removal
Penalty
Summary
The facility failed to provide appropriate care and services for a resident who was admitted with an indwelling urinary catheter. Upon admission, the resident had multiple diagnoses including urinary tract infection, overactive bladder, urinary retention, and required assistance with mobility and personal care. The resident's indwelling catheter fell out shortly after admission and was not replaced, but there was no documented assessment to determine the continued need for the catheter, nor was there a physician order to discontinue its use. Following the removal of the catheter, the facility did not conduct an assessment of the resident's bladder status or initiate a bladder training program as required by facility policy. There was also no documentation of alert charting to monitor for signs or symptoms of urinary retention or other complications after the catheter was removed. The resident's care plan was not updated to include interventions or an individualized bowel and bladder training program to address her needs after the catheter was discontinued. Interviews with nursing staff and the DON confirmed that there was no assessment for the need of the catheter, no physician notification or order for discontinuation, and no care planning or bladder training implemented after the catheter was removed. As a result, the resident was left to manage toileting without appropriate support, leading to multiple unassisted bathroom trips and several falls.
Staff Use of Profane Language Toward Resident
Penalty
Summary
A staff member reportedly spoke to a resident using profane language and a disrespectful tone, which did not meet the facility's requirements for maintaining resident dignity and a home-like environment. The resident involved had a history of Parkinson's Disease, cognitive communication deficit, depression, and dementia, with a BIMS score indicating moderate cognitive impairment. The facility's policy prohibits demeaning practices and requires staff to promote dignity and communicate respectfully with residents. The incident was reported when a CNA overheard another CNA telling the resident to "shut the [expletive] up" and to stop screaming, as it was disturbing others. The resident recalled hearing swearing by a staff member but could not identify who or what was said due to confusion. The accused CNA denied recollection of the event, while another CNA confirmed overhearing the profane language directed at the resident. The administrator acknowledged receiving the report and noted that several staff members overheard the incident.
Unattended Unlocked Medication Cart with Accessible Syringes and Iodine
Penalty
Summary
A medication cart on nursing station 4 was found unlocked and unattended, with drawers open and accessible to residents, including those with dementia who were present in the adjacent hallway. The cart contained six 1-ml hypodermic syringes and a 12-ounce bottle of povidone iodine with a broken cap and visible residue. No staff intervened as the cart was inspected, and the closest nurse was unaware of the responsible nurse's whereabouts. The facility's policy requires all medication carts to be locked when unattended. Interviews with staff revealed that the nurse responsible for the cart had left early for a family emergency, and the cart was shared among various nursing staff for wound treatments. Staff acknowledged awareness of the policy and previous incidents of the cart being left unlocked, particularly when the regular treatment nurse was on vacation. The facility had previously been cited for a similar issue with the same cart and location.
Failure to Implement Advance Directive Policy for Resident
Penalty
Summary
The facility failed to implement its policy regarding Advance Directives (AD) for one resident. Upon admission, the facility's policy required staff to obtain a copy of the resident's AD and include it in the medical record, or provide information about ADs if the resident did not have one. Record review showed that the resident was admitted with multiple diagnoses, including cerebral palsy, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. Although the resident had signed a Physician Orders for Life-Sustaining Treatment (POLST) form and stated he had an AD, there was no AD or Power of Attorney (POA) document found in his facility records. Interviews with facility staff, including Medical Records, Social Services, and the Director of Nursing, confirmed that the facility did not follow up with the acute care hospital to obtain a copy of the resident's AD, despite documentation indicating the resident had one at the time of admission. Staff acknowledged that the resident had the mental capacity to make his wishes known and that the AD should have been present in the chart, but it was not. The facility did not adhere to its own policy for securing and maintaining advance directive documentation for this resident.
Inappropriate Physician Order for Healthcare Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that a physician's order regarding a resident's capacity to make healthcare decisions was appropriate and based on a thorough evaluation. The physician documented that the resident was incapable of making healthcare decisions, citing cerebral palsy as the reason, without further explanation or evidence of mental incapacity. Record review showed the resident had a diagnosis of cerebral palsy, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment, but staff interviews revealed that the resident was able to make his wants and needs known and had clear speech. Multiple staff members, including Social Services, Medical Records, and the Director of Nursing, confirmed that the resident appeared alert, oriented, and capable of communicating effectively. The physician later acknowledged that cerebral palsy is primarily a physical condition and, in this case, should not have been used as the sole basis for determining mental incapacity. The physician's order was not supported by a comprehensive assessment of the resident's decision-making capacity, leading to an inappropriate assignment of a healthcare decision maker.
Failure to Update Care Plans After Resident-to-Resident Altercation
Penalty
Summary
Nursing staff failed to develop or update care plans for two residents following a resident-to-resident altercation. Both residents had significant cognitive impairments, as indicated by their low BIMS scores, and complex medical histories including stroke, morbid obesity, anxiety, chronic pain, alcohol abuse, leg fracture, and muscle weakness. The altercation involved one resident attempting to pull another from her bed, but no injury was sustained. Despite this incident, a review of the medical records showed that no care plans were written or updated for either resident after the event. Facility policy requires prompt action to prevent and address resident-to-resident altercations, including reviewing the incident with nursing leadership and making necessary changes to care plans. However, interviews with the Director of Nursing and Social Services Director confirmed that care plans addressing the altercation were missing from the records. Both staff members acknowledged that care plans should have been created or updated for the involved residents, but this was not done.
Unattended Unlocked Medication Carts with Accessible Medications
Penalty
Summary
Two medication carts were found unlocked and unattended at Nursing Station Three, with medications, including topical creams, accessible to individuals in the area. The surveyor was able to open the carts without being questioned or observed by staff, despite the presence of residents with dementia nearby. A Licensed Vocational Nurse later confirmed responsibility for the cart and acknowledged it should have been locked. Facility policy requires that medications and biologicals be stored securely and only accessible to authorized personnel, with carts locked when not attended.
Failure to Follow Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with a significant fall history. The resident, who had been admitted after cranial surgery for a brain tumor and had visual loss in one eye, required substantial assistance with mobility and was at high risk for falls. The care plan, updated after a fall, specified the use of bilateral fall mats at the bedside. Despite this, only one fall mat was present during observation, and staff interviews confirmed that the care plan required two mats. The resident herself noted the absence of the second mat and recalled that it had previously been removed. The facility's fall management policy required post-fall evaluations and care plan updates, as well as adherence to interventions listed in the care plan. Multiple falls had occurred for this resident after the care plan was updated to include bilateral fall mats, yet the intervention was not consistently implemented. Staff, including the resident's nurse and the DON, acknowledged the care plan's requirements were not met at the time of observation.
Failure to Follow PPE Protocols for COVID-Positive Resident
Penalty
Summary
A Certified Nurses Assistant (CNA) entered the room of a resident who was confirmed to be COVID positive without wearing the required personal protective equipment (PPE). The CNA was observed wearing only a face shield and gloves, but was not wearing a mask or a gown, as mandated by both facility policy and state guidance. The facility's infection prevention protocol, as well as the California Department of Public Health's guidance, specifically require staff to wear an N95 respirator, gown, gloves, and eye protection when entering the room of a COVID positive resident. During interviews, the CNA stated that full PPE was only necessary if physically touching the COVID positive resident, which contradicted the established protocols. Other staff members, including another CNA, an LVN, and the Unit Manager, all confirmed that the correct protocol is to wear complete PPE, including a gown, gloves, N95 respirator, and eye protection, until the resident is no longer in isolation. The failure to follow these protocols was identified through observation, interviews, and record review.
Call Lights Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were available for use and within reach for three of five residents sampled. According to facility policy, call alert devices are to be placed within the resident's reach and staff are to answer call alerts promptly. For one resident with heart failure, dysphagia, and major depressive disorder, and another with parkinsonism, chronic pain, and anxiety, both were found lying in bed unable to locate or reach their call lights, which were observed on a nightstand behind and to the side of their beds. Both residents were dependent on staff for toileting, dressing, personal hygiene, and transfers, and their care plans specifically required that call lights be within reach. A CNA confirmed that the call lights were not accessible and admitted forgetting to return them to the residents' reach. A third resident, who had COPD, required assistance with personal care, had difficulty walking, and a history of falls, was also affected. This resident's care plan required the call light to be within reach and for staff to encourage its use. The resident's family member reported multiple instances of finding the call light on the floor, and noted that the resident would attempt to get up independently, resulting in frequent falls. The administrator confirmed that call lights should always be within reach and that it was not facility practice for them to be out of reach.
Failure to Implement Infection Control Program for Residents with MDROs
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as required, specifically in the management of residents with multidrug-resistant organisms (MDROs). A resident tested positive for MRSA in both urine and a wound but continued to reside in a shared room with two other residents for approximately two weeks after the positive result. Facility policy and CDC guidelines require that residents with MDROs be placed in private rooms or cohorted with others with the same organism, especially when they have conditions that may facilitate transmission. Despite the availability of multiple empty rooms during this period, the resident was not moved to a private room until much later. The two other residents sharing the room had significant comorbidities and open wounds, making them particularly vulnerable to infection. One of these residents was later diagnosed with cellulitis and prescribed antibiotics, though no wound culture was performed to determine if MRSA was present. The decision to move residents between rooms was made by the Social Service Department without adequate communication with the Infection Preventionist (IP), who was not aware of the room changes or the availability of private rooms at the time. The IP acknowledged that, in retrospect, the resident with MRSA should have been placed in a private room immediately upon receiving the positive result. Interviews with facility staff, including the Nursing Unit Manager and Director of Nursing, confirmed that there was a lack of communication and coordination between departments regarding infection control measures and resident placement. The facility's own policies, as well as CDC guidelines, were not followed in this instance, resulting in the potential for the spread of infection among vulnerable residents. The deficiency was directly related to failures in communication, policy implementation, and timely action by the infection control team.
Failure to Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the California Department of Public Health (CDPH) as required by its own policy and state regulations. A resident, who was cognitively intact and responsible for his own healthcare decisions, reported his ATM card missing to the Social Services Director (SSD) after discovering unauthorized transactions while he was at a dialysis center. The SSD assisted the resident by contacting the bank, disputing charges, and filing a police report, but did not notify CDPH of the suspected misappropriation. Interviews with both the SSD and the Administrator confirmed that the incident was not reported to CDPH because the identity of the person who took the card was unknown. The facility's policy required reporting all allegations of abuse and misappropriation, regardless of whether the perpetrator was identified. The omission resulted in the potential for financial abuse to go unrecognized and unresolved within the facility.
Failure to Accurately Administer and Document Narcotic Pain Medication
Penalty
Summary
Nursing staff failed to accurately administer and document narcotic pain medications for a resident with chronic pain and multiple comorbidities, including chronic ulcers, heart failure, respiratory failure, and end-stage renal disease. The resident was prescribed Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for moderate to severe pain. However, review of the Individual Narcotic Record (INR) and Medication Administration Record (MAR) revealed inconsistencies, including documentation errors, missing signatures, and lack of clarity regarding medication administration. On multiple occasions, the INR showed that a tablet was removed and marked as an error without proper explanation or required signatures, while the MAR indicated the medication was given. Further investigation revealed that the resident was administered the incorrect dosage of Hydrocodone-Acetaminophen (5-325 mg instead of the prescribed 10-325 mg) on at least nine occasions over a nine-day period. The error occurred due to the presence of both old and new medication packs in the medication cart, and nursing staff failed to verify the correct strength before administration. The facility's policies required adherence to the seven rights of medication administration and proper documentation and reporting of medication errors, but these procedures were not followed in this case. Additionally, there was no evidence that medication errors were reported to the Director of Nursing, the attending physician, or the resident's responsible party as required by facility policy. The resident's responsible party was unaware of the medication errors and reported that the resident continued to experience significant pain. The lack of proper documentation, communication, and adherence to medication administration protocols resulted in multiple medication errors and inadequate pain management for the resident.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect by Licensed Nurse (LN) D. The nurse was reported to have spoken to residents in a demeaning tone, rushed through medication administration, and was not gentle during the process. This behavior was observed and reported by both residents and staff members, indicating a pattern of disrespectful and rough treatment. Resident 9, who was cognitively intact and dependent on staff for all activities of daily living, expressed fear and distrust towards LN D, citing her roughness and disrespectful attitude. Similarly, Resident 8, also cognitively intact and dependent on staff, reported increased anxiety due to LN D's behavior and expressed fear of reporting her. Resident 6, with a similar dependency and cognitive status, described LN D as rude and disinterested in her job, which affected the resident's perception of care. Interviews with staff members, including Certified Nursing Assistants and other Licensed Nurses, corroborated the residents' accounts. They described LN D as rude, paranoid, and unapproachable, with a tendency to yell at both staff and residents. The facility's administrator acknowledged LN D's poor customer service skills but was unaware of her behavior towards residents. Previous corrective actions had been taken against LN D for violations related to safety and pain management, indicating ongoing issues with her conduct.
Failure to Notify Physician and Family of Resident's Change in Condition
Penalty
Summary
The facility failed to update a change of condition for a resident, identified as Resident 1, when the Licensed Nurse (LN) did not notify the physician about the resident's need for oxygen due to a new onset of shortness of breath. Additionally, the LN did not inform the resident's family or responsible party about a major decline in the resident's health status. This oversight resulted in a negative clinical outcome for the resident. The facility's policy on Change of Condition Notification requires that a Licensed Nurse notify the resident's attending physician and legal representative or an appropriate family member when there is a significant change in the resident's physical, mental, or psychosocial status. Despite this policy, the LN failed to call the attending physician immediately when Resident 1 experienced unexpected shortness of breath, which is considered an emergency situation according to the policy. Furthermore, the LN did not document any notes about the resident's change in condition or place the resident on alert charting. Interviews with facility staff revealed that the LN did not take appropriate action when informed of the resident's symptoms, such as a headache and difficulty breathing. The LN admitted to not informing the responsible party and only texting the physician instead of calling. The facility administrator confirmed that the LN did not follow the required procedures, including failing to document the change of condition and not updating the responsible party.
Failure to Document Change in Resident's Condition
Penalty
Summary
The facility failed to ensure timely, accurate, and complete documentation for a resident when there was a change in condition. The facility's policy required that a licensed nurse document the date, time, and pertinent details of any incident and subsequent assessment in the nursing notes, including the time the attending physician was contacted and any orders received. Additionally, the policy required updating the care plan to reflect the resident's current status and documenting the incident in the 24-hour report. However, during a record review, it was found that there were no progress notes for nursing documentation indicating the resident's new onset of shortness of breath, the need for oxygen, notification to the physician, or an update to the responsible party. The resident was also not added to alert charting for communication for all staff per facility policy. The resident involved had a medical history that included diabetes, cerebral vascular accident, congestive heart failure, severe protein malnutrition, dysphagia, altered mental status, heart disease, high blood pressure, seizures, chronic pain, and tobacco use. Despite being cognitively intact with a BIMS score of 13 out of 15, the resident was totally dependent on staff for all activities of daily living. During interviews, a licensed nurse admitted to not documenting any changes for the resident, not making entries in the nurses' notes, not documenting communication with the physician, and not adding the resident to alert charting. The facility administrator confirmed the lack of documentation and noted the absence of notes for administering oxygen to the resident.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient and qualified nursing staff to meet the needs of residents, resulting in prolonged response times to call lights. This deficiency was observed in multiple instances where residents were left waiting for assistance, leading to incidents of bowel and bladder incontinence. Residents reported that call lights were often left unanswered for extended periods, sometimes taking 30 to 45 minutes or more, causing them to soil themselves and experience humiliation. Several residents, including those with moderate to severe cognitive impairments, were unable to locate their call lights or had them placed out of reach. In some cases, residents had to rely on roommates to call for help or physically go to the nurse's station to request assistance. Observations revealed that staff members walked past rooms with activated call lights without providing assistance, further highlighting the inadequacy of staffing levels and response times. Interviews with residents and the Director of Nursing confirmed the ongoing issue of delayed responses to call lights. The facility's policy and job descriptions for CNAs and LVNs emphasize the importance of promptly answering call lights and ensuring they are within residents' reach. However, the facility's failure to adhere to these policies resulted in compromised resident care, as evidenced by the numerous complaints and observations of unmet needs.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several areas being unclean and in disrepair. In the Station One shower room, a trash can was found to contain trash without a liner and had brown material smeared inside. Resident 28's room was observed to have significant damage, including deeply scratched plasterboard, chipped molding on the restroom door, and a bedside table with missing laminate exposing dirty, porous fiberboard. Additionally, a wall-mounted electronic device outside room three was missing, leaving a broken mounting plate and exposed electronic cord. Further observations revealed that built-in wooden cabinets in several rooms were chipped, scratched, and uncleanable. Resident 92's bathroom ceiling fan was covered in greyish debris and was non-functional. Interviews with staff confirmed these deficiencies, with the Maintenance Supervisor acknowledging the disrepair and indicating that improvements were underway. The facility's policies on maintaining a clean and safe environment were not adhered to, potentially impacting residents' well-being.
Improper Food Storage and Freezer Maintenance
Penalty
Summary
The facility failed to ensure that food was stored under sanitary conditions, as evidenced by the improper storage of parsley in the walk-in refrigerator. During an observation, it was noted that a metal pan containing parsley was not covered, and the parsley appeared shriveled and dry. Additionally, a clear plastic bag within the same pan contained a larger quantity of parsley that was neither labeled nor dated. The Dietary Manager confirmed these observations, acknowledging that the parsley should have been covered, labeled, and dated according to the facility's policy on food storage and handling. Furthermore, the facility did not maintain the walk-in freezer in a condition free from frost build-up. During an initial tour, frost was observed on multiple areas of the ceiling in the walk-in freezer. Both the Dietary Manager and the Maintenance Supervisor confirmed the presence of frost, with the Maintenance Supervisor noting that the frost had recently started to accumulate and persisted despite removal efforts. This failure to maintain the freezer in good repair was contrary to the facility's maintenance policy, which requires the building to be kept in good working order and free from hazards.
Failure to Sanitize Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to adhere to its infection prevention and control program when a Licensed Vocational Nurse (LVN K) did not sanitize a blood pressure cuff between using it on two residents, Resident 74 and Resident 42. This action was observed on February 4, 2025, at 1:10 PM, when LVN K took a blood pressure reading from Resident 74 and then immediately proceeded to use the same cuff on Resident 42 without cleaning it. During a concurrent interview, LVN K acknowledged the oversight, stating that cleaning blood pressure cuffs between residents is standard nursing practice, but she had forgotten to do so. Further interviews with other staff members, including LVN L and the Infection Prevention Nurse (IP J), confirmed that it is standard practice to clean reusable equipment between residents to prevent the spread of infection. LVN L was observed following this practice and emphasized the importance of infection control due to the prevalence of illnesses. The facility's policy, last revised on January 1, 2012, aligns with CDC and OSHA guidelines, requiring the cleaning and disinfection of reusable items between residents. The failure to follow this policy resulted in a potential risk for spreading infection and illness among residents.
Failure to Prevent Resident Abuse Leads to Altercation
Penalty
Summary
The facility failed to prevent abuse between two residents, Resident 16 and Resident 63, which resulted in a physical altercation. Resident 16, who has chronic obstructive pulmonary disease, diabetes, and dementia, reported verbal abuse from their roommate, Resident 63, who has hemiplegia, dysarthria, and depression. Despite Resident 16's complaints about derogatory statements made by Resident 63, the facility did not separate the residents, leading to an incident where they threw water at each other. The facility's policies on abuse prevention and resident safety were not followed. Staff members, including Licensed Nurses A and B, were aware of the verbal disputes but did not notify the administration or the Social Services Director (SSD) as required. Instead, they chose to monitor the situation and pass the information to the next shift. The SSD was not informed of the issues over the weekend, and no room change was initiated despite Resident 16's request. Interviews with staff revealed a lack of communication and adherence to procedures for handling resident disputes. The Director of Staff Development indicated that staff should have contacted the SSD or administration and separated the residents if the SSD was unavailable. However, this protocol was not followed, resulting in the altercation between the residents.
Inconsistent Documentation of Skin Assessments and Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 16, regarding skin assessments and treatments. The inconsistency in documentation was observed in several instances. Initially, a Long-Term Care Evaluation noted no skin changes, but subsequent notes by the Director of Nursing and other Licensed Nurses documented a skin tear and bruising on the resident's left hand. Despite these observations, a physician's order to monitor the bruising was not documented until four days after the initial incident. Additionally, a Care Plan problem was revised to include the skin tear, but a later Skin Check note again indicated no skin changes. The deficiency was further highlighted during interviews with nursing staff. Treatment LN D could not find documentation about a pink foam dressing on the resident's hand, and LN C admitted to not documenting or notifying the Skin Team about the incident when the resident's hand was injured. LN C applied a dressing and did not follow the facility's policy for reporting and documenting skin-related conditions. This lack of documentation and communication among staff members led to incomplete records, which could potentially impact the resident's skin care and treatment.
Verbal Abuse by LVN in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Licensed Vocational Nurse (LVN 1). The incident involved LVN 1 using inappropriate and threatening language towards a resident (Resident 1) who was attempting to assist another resident (Resident 2) after a fall. LVN 1 told Resident 1 to mind his own business and threatened to kill him if he called 911. This interaction was unexpected for Resident 1, who had previously had a good relationship with LVN 1. Resident 1's mental capabilities were intact, as indicated by a BIMS score of 14/15. Further interviews with staff and residents revealed a pattern of negative behavior by LVN 1 towards residents. Certified Nursing Assistants (CNAs) and other staff members reported that LVN 1 often spoke negatively about residents and expressed a belief that residents were intentionally trying to agitate her. LVN 1 was also reported to have made inappropriate comments to Resident 2, who has dementia, wishing harm upon her. Resident 2's mental capabilities were not intact, as indicated by a BIMS score of 99, and she was diagnosed with dementia and generalized anxiety disorder. The facility's administration was notified of the incident, and LVN 1 was suspended. Multiple staff members, including other nurses, confirmed the inappropriate behavior of LVN 1, and residents expressed feeling unsafe when she was on duty. The facility's abuse prevention policies clearly state that any form of abuse is not condoned, yet the actions of LVN 1 were in direct violation of these policies, leading to a deficiency in protecting residents from abuse.
Failure to Respond Timely to Residents' Requests
Penalty
Summary
The facility failed to ensure timely response to residents' requests for assistance, affecting three residents. Resident 3, who had a stroke and required assistance with personal care, was left soiled because the assigned CNA forgot to return after a lunch break. The family member had to change the resident, highlighting a lapse in staff coverage during breaks. The facility's policy requires CNAs to answer call lights promptly, but this was not adhered to, resulting in the resident's dignity being compromised. Resident 4, who had a history of falls and Parkinson's disease, was left calling for help for over 12 minutes while leaning on her bedrail, posing a risk of falling. Despite being near the nursing station, three staff members walked past without responding to her call light. The assigned CNA did not inform the team of her break, leading to a lack of coverage and delayed assistance. The facility's care plan for Resident 4 emphasized the need for prompt response to requests for assistance, which was not met. Resident 5, with COPD and requiring assistance with personal care, experienced multiple instances of delayed response to her call light. The responsible party reported these delays, indicating a pattern of neglect in attending to the resident's needs. The facility's policy and job descriptions emphasize the importance of prompt response to call lights, yet the staff failed to comply, affecting the resident's quality of life and care.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a CNA insisted on changing the resident's brief despite the resident's refusal. The incident resulted in a 4.5 cm x 5 cm bruise between the resident's thumb and first finger, leaving the resident feeling angry and humiliated. The facility's policy on abuse prevention, which prohibits any form of resident abuse, was not adhered to in this situation. The resident, who had a history of stroke and required assistance with personal care, was cognitively intact as indicated by a BIMS score of 14. On the night of the incident, the resident reported that the CNA pulled on her blankets and, despite her protests, continued to insist on changing her brief. When the resident attempted to reach for her bed remote to sit up and communicate, the CNA pulled the remote from her hand, causing the bruise. The resident felt that the CNA acted deliberately and was intimidated by the CNA's actions. Interviews with staff revealed that the CNA did not report the incident as required by facility policy. The CNA claimed not to have heard the resident's refusal and did not leave the room when asked. Other staff members noted that the CNA was demanding and became rough when residents refused care. The incident was corroborated by other staff who observed the bruise and heard the resident's account of the event.
Inadequate Staffing Leads to Extended Call Light Wait Times
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by extended call light wait times for four out of five residents sampled. Residents reported waiting between 10 to 55 minutes for assistance, which led to feelings of neglect, embarrassment, and concerns about skin integrity. Despite some residents expressing overall satisfaction with their stay, the prolonged wait times for call lights were a significant issue, with one resident mentioning incidents of waiting while wet and another experiencing accidents due to delays. Interviews with nursing staff, including Licensed Vocational Nurses and a Registered Nurse, revealed that they felt overwhelmed and unable to provide the level of care their residents deserved. The staff reported working extended hours and dealing with heavy workloads, which contributed to their inability to respond promptly to residents' needs. The facility's policy on staffing, revised in 2012, indicated that adjustments should be made to meet residents' needs, but the current staffing levels were insufficient, as noted by both residents and staff.
Resident Injured by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from injury, resulting in a skin tear on the resident's left hand. The resident, who had difficulty walking, falls, a fractured leg, colon cancer, and vascular dementia, was unable to complete a mental assessment and was assessed with moderate cognitive impairment. On the morning of the incident, a Certified Nursing Assistant (CNA) from a staffing agency was assigned to the resident during the night shift. The CNA left the facility without reporting off to anyone, and the resident was later found with a significant skin tear and bleeding by the next shift CNA. The facility's administrator confirmed that the CNA had abandoned her shift, and attempts to contact her were unsuccessful. Interviews with staff and the resident revealed that the resident described being attacked by a woman, consistent with the description of the CNA. The Licensed Vocational Nurse (LVN) who administered the resident's medication earlier that morning did not observe any skin tear at that time. The next shift CNA discovered the injury and reported it immediately. The resident's injury was described as a curved, thumb-shaped skin tear with a deep bruise, suggesting it may have been caused by being grabbed. The incident was reported to the state, police, and ombudsman, but the CNA involved denied any knowledge of the injury.
Inconsistent Dialysis Dressing Management
Penalty
Summary
The facility failed to adhere to physician orders regarding the care of dialysis dressings for several residents, which could potentially lead to complications. Resident 2, who was admitted with conditions including end-stage renal disease, diabetes, and dementia, had issues with the management of his dialysis access site. The facility did not consistently remove the compression dressing from Resident 2's dialysis site four hours after treatment, as ordered by the physician. This oversight was noted by the Dialysis Social Services, who reported that on at least two occasions, Resident 2 returned to dialysis with the bandage still on, leading to clotting of the access site and requiring surgical intervention. The report also highlights similar issues with Residents 3 and 4, who experienced inconsistent care regarding the removal of their dialysis dressings. Resident 3's dressing was observed to remain on beyond the recommended four-hour period, and Resident 4 reported that her bandage sometimes stayed on too long, causing irritation. Interviews with facility staff, including Licensed Vocational Nurses and a Certified Nursing Assistant, revealed a lack of consistent practice and understanding regarding the removal of dialysis dressings. Some staff members were unaware of the specific time frame for removing the dressings, while others admitted to not always following the protocol. The inconsistency in following the standard of care for dialysis dressings was acknowledged by the Dialysis Social Services and the facility's unit manager. The unit manager was aware of the issue and indicated that not all staff were informed about the correct procedures. This lack of consistent practice and communication among staff members contributed to the deficiency in providing appropriate dialysis care for the residents involved.
Failure to Provide Scheduled Showers or Baths
Penalty
Summary
The facility failed to ensure that two residents received their scheduled showers or baths, as required for assistance with activities of daily living (ADLs). Resident 1, who required maximal assistance with transfers, toileting, bathing, and dressing, only received four baths or showers in April 2024, despite the facility's policy of twice-weekly bathing. There were no documented refusals or updates to Resident 1's responsible party regarding the missed baths. Resident 1 had multiple diagnoses, including a need for assistance with personal care, high blood pressure, and chronic obstructive pulmonary disease. Resident 2, who was cognitively intact and able to make her own medical decisions, only received one shower in April 2024. She confirmed in an interview that she only received one shower during her stay. The facility's Licensed Nurse and Director of Nursing confirmed that showers and baths are scheduled twice weekly and that any refusals should be documented and communicated to the charge nurse. However, the lack of documentation indicated that the scheduled bathing was not completed for these residents.
Administrator's Directive to Alter Medical Records
Penalty
Summary
The facility failed to comply with applicable Federal, State, and local laws, regulations, and accepted professional standards and principles, as evidenced by the actions of the administrator. The administrator directed several nursing staff members to alter progress notes related to the care of a resident, which is a violation of California Penal Code, Section 471.5, that prohibits fraudulent alteration of medical records. Specifically, the administrator requested a Registered Nurse (RN) to reword her progress note and directed two Licensed Nurses (LNs) to change their progress notes, which could lead to inaccurate documentation of care provided. The report highlights the case of a resident who was readmitted to the facility with diagnoses including dysphagia following a cerebral infarction and required assistance with personal care. The resident had chosen to have Cardiopulmonary Resuscitation (CPR) in the event of no pulse and not breathing, as indicated in the Physician Orders for Life-Sustaining Treatment (POLST). However, discrepancies in the documentation of the resident's unexpected death were noted. A Licensed Nurse documented the timeline of events, including the initiation of CPR and the arrival of Emergency Medical Services (EMS), but was later asked by the administrator to redraft the note to remove the timing details, which the nurse refused to do. The administrator's actions included instructing a nurse to remove the term 'asphyxiation' from a progress note, fearing it might be interpreted as the cause of death. This request was made despite the nurse's insistence that the original note was accurate. The administrator's influence over the staff, including making a nurse sign an agreement to comply with any requests, created an environment where staff felt pressured to alter medical records, compromising the integrity of the documentation and potentially affecting the quality of care provided to residents.
Delayed CPR Initiation for Full Code Resident
Penalty
Summary
The facility failed to immediately initiate Basic Life Support (BLS), including Cardiopulmonary Resuscitation (CPR), for a resident who was found unresponsive and without a pulse. The resident, who had a full code status indicating a desire for full treatment in life-threatening situations, was discovered by a Licensed Nurse (LN A) at 5:45 pm. Despite the resident's full code status, CPR was not initiated until 10 minutes later, at 5:55 pm, which delayed the provision of emergency care. The facility's policy, aligned with the American Heart Association guidelines, requires immediate initiation of CPR by certified staff when a resident is found unresponsive with no pulse or respirations. However, LN A, upon finding the resident unresponsive, did not start CPR immediately. Instead, LN A sought confirmation from another nurse, who also did not initiate CPR, and then checked the resident's code status. This delay was contrary to the facility's policy, which mandates immediate CPR initiation and specifies that only a licensed physician can declare a resident dead. Interviews with staff revealed a lack of awareness and adherence to the facility's CPR policy. LN A expressed a wish to have known the resident's code status beforehand to act promptly. Another nurse, LN B, highlighted that recent BLS training emphasized the importance of knowing residents' code statuses and starting CPR immediately if a resident is found without a pulse or breathing. The Director of Nursing confirmed that the expectation was for CPR to be initiated immediately, but the staff did not follow this protocol, leading to a significant delay in emergency response.
Delayed Stroke Response in Resident
Penalty
Summary
The facility failed to promptly notify the Medical Director, who was the attending physician, of a significant change in condition for a resident experiencing signs and symptoms of a stroke. The resident, who was initially admitted with cellulitis, difficulty in walking, and high blood pressure, showed signs of a stroke, including slurred speech and left-sided weakness. Despite these symptoms, there was a delay in notifying the physician and transferring the resident to the hospital, resulting in a three-day delay in receiving appropriate treatment. The facility's policy on change of condition required prompt notification of the resident's physician and family in the event of significant changes, such as signs of a stroke. However, staff observations and progress notes indicated that the resident's condition deteriorated over several days without appropriate action being taken. The resident was noted to be pale, lethargic, and had difficulty swallowing, yet there was no immediate notification to the physician or transfer to the hospital until the Director of Nursing intervened. Interviews with staff revealed a lack of understanding of the facility's comfort care policy and the importance of timely intervention in cases of suspected stroke. The resident, who was on comfort-focused treatment, expressed a desire to be transferred for further evaluation, but this was not acted upon until much later. The delay in treatment contributed to the resident's significant decline in functional abilities and eventual death within a month of admission.
Staffing Shortages Lead to Delayed Care and Missed Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly during the week of March 30, 2024, through April 5, 2024. This staffing shortage resulted in multiple nursing stations being inadequately staffed, leading to significant delays in responding to call lights and providing necessary care. Observations and interviews revealed that residents experienced long wait times for assistance, with call lights going unanswered for extended periods. For instance, a call light in one room was not answered for 30 minutes, and residents reported having to ambulate to seek help due to the lack of timely response from staff. The deficiency also affected the residents' ability to receive scheduled showers and other activities of daily living (ADLs). Several residents, including those with specific medical needs such as a colostomy bag or a history of amputation, did not receive the scheduled number of showers, with some receiving only one out of four scheduled showers. The lack of adequate staffing also impacted the timely administration of medications, with reports of medications being administered 30 minutes late. Interviews with staff indicated that the shower team, which was supposed to consist of 4-5 CNAs, was often understaffed or nonexistent, further exacerbating the issue. Staff interviews highlighted a culture of overwork and stress, with many staff members feeling overwhelmed and unsupported by management. There were reports of staff taking extended breaks, feeling pressured to work double shifts, and experiencing emotional stress due to the workload. The facility's use of outside registry staff was mentioned, but these staff members often did not show up for scheduled shifts, compounding the staffing issues. The Director of Nursing and Administrator acknowledged the staffing challenges, noting efforts to address chronic call-outs and underperformance among CNAs, but the deficiency persisted, affecting the quality of care provided to residents.
Delayed Stroke Recognition and Response
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies to promptly identify and report a change in condition for a resident, leading to a significant delay in medical intervention. The resident, who was experiencing signs and symptoms of a stroke, was not transferred to the hospital until three days after the initial symptoms were observed. This delay resulted in increased pain and discomfort for the resident, who suffered significant declines in functional abilities, including slurred speech, left-sided weakness, and inability to swallow. The facility's policy on change of condition required staff to promptly inform the resident, consult with the primary care physician, and notify the resident's legal representative or family member when a significant change in condition occurred. However, despite multiple observations of the resident's declining condition by various staff members, including pale appearance, mumbling speech, and decreased level of consciousness, there was a failure to notify the physician in a timely manner. The Director of Nursing eventually assessed the resident and suspected a stroke, leading to the resident's transfer to the hospital. Interviews with staff revealed a lack of understanding of the facility's comfort care policy and the importance of timely medical intervention. The Director of Nursing acknowledged that the staff should have recognized the signs and symptoms of a stroke and that the resident should have been sent to the hospital earlier. The resident, who was on comfort-focused treatment, expressed dissatisfaction with the care received, indicating a failure to meet the resident's needs and preferences.
Inappropriate Staff Communication Upsets Resident
Penalty
Summary
The facility failed to ensure that a direct care staff member interacted and communicated in a manner that promoted the mental and psychosocial well-being of a resident. This deficiency involved a Certified Nursing Assistant (CNA) who made inappropriate comments to a resident, referred to as Resident 9. The incident occurred when CNA G, along with another CNA, entered Resident 9's room to assist the roommate. Resident 9, who had intact cognition as indicated by a BIMS score of 15, expressed feelings of being treated like a prisoner. In response, CNA G told Resident 9 to "stop being a smartass," which upset the resident and led to crying. Further investigation revealed that CNA G had made additional derogatory comments, calling Resident 9 a "dumbass" and suggesting that the resident was acting like a child. These interactions were witnessed by another CNA, who also made an inappropriate comment. The facility's administrator acknowledged the incident, stating that the language used was inappropriate and affected the resident's dignity. Resident 9, who had a history of diabetes and required assistance with personal care, was visibly upset during an interview, recalling past abuse and expressing distress over the language used by the staff.
Unsafe Discharge Planning Leads to Resident's Return
Penalty
Summary
The facility failed to develop and implement a safe and successful discharge plan for a resident, resulting in her return to the skilled nursing facility within 24 hours after being discharged. The resident, who had a history of falling, muscle weakness, morbid obesity, and heart disease, was discharged home without ensuring that she and her family were adequately prepared for her care. The interdisciplinary team did not provide necessary training to the family members who were to become her caregivers, nor did they discuss the risks and benefits of returning home or the possibility of an Against Medical Advice (AMA) discharge. The resident's medical records indicated that she required a slide board for transfers and was unable to stand or walk independently. Despite these challenges, the discharge planning review noted that her family would be her caregivers, although they were not trained to assist her. The resident expressed that she was unable to perform transfers independently and always required assistance from facility staff. After being discharged, she was unable to get out of bed and became stuck on the toilet, necessitating a call to 911 and her subsequent return to the facility. Interviews with facility staff, including the Director of Therapy, Business Office, Social Service Assistant, and Administrator, revealed that the resident's discharge was considered unsafe. The Director of Therapy confirmed that the resident was still a maximum assist with walking and transferring, and there was no documentation of family training. The Business Office stated that the resident was informed her benefits had run out, and she would need to pay or apply for assistance, which had not yet been approved. The facility staff confirmed that the risks of returning home were not discussed with the resident, and the discharge should have been classified as AMA.
Failure to Maintain AC and Lighting Systems
Penalty
Summary
The facility failed to maintain essential equipment, specifically the Central Air Conditioning (AC) system and Packaged Terminal Air Conditioners (PTAC) on Stations 3 and 4, leading to uncomfortable temperatures during warmer months and resident discomfort. During an observation, room temperatures in several resident rooms without working fans and chilling coils were recorded as high as 79.3 degrees Fahrenheit. A resident expressed feeling warm and hot in her room, and it was confirmed that her PTAC fan had not been fixed. Maintenance staff acknowledged the issue but indicated that repairs were ongoing and not yet completed. Additionally, the facility failed to ensure proper lighting in a resident room, putting two residents at risk for falls. During an observation, it was noted that the room was dark, and a resident had to request assistance to use another bed's light due to non-functional lights above Beds A and C. Maintenance staff confirmed the issue and admitted they were unaware of the non-working lights. It was also noted that the window air conditioning unit in the same room needed reinstallation, which had not been completed. Maintenance efforts were ongoing, with some AC fan motors replaced, but issues with chilling coils persisted.
Failure to Implement Safe Transfer Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the plan of care for a safe transfer was implemented for a resident when a CNA and an NA did not use a Hoyer lift and assisted the resident to a standing position. The resident, who was unable to stand, was lowered to the floor, resulting in an avoidable fall that caused fractures to her right knee, pain, and a delay in physical therapy treatments. The resident had a history of a displaced trimalleolar fracture of the right lower leg, morbid obesity, and difficulty walking. Her records indicated she required assistance and support for transfers and was not steady, only able to stabilize with staff assistance. The resident's care plan specified the use of a Hoyer lift for transfers with the assistance of two staff members. Despite this, the CNA and NA attempted to assist the resident to stand, leading to her fall. The incident occurred when the CNA and NA were preparing the resident for a shower. The resident offered to stand to facilitate the removal of her brief, and the CNA assisted her to stand, but the resident's legs gave out. The CNA was unable to support the resident's weight, resulting in the resident hitting her knee on the floor. The resident was subsequently diagnosed with fractures in her right knee and experienced severe pain, requiring changes in her pain medication regimen.
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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