Bay Marina Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, California.
- Location
- 2919 Fruitvale Ave, Oakland, California 94602
- CMS Provider Number
- 056280
- Inspections on file
- 44
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bay Marina Post Acute during CMS and state inspections, most recent first.
Nursing staff did not obtain timely dental services for a resident who was cognitively able to report symptoms and complained of toothache, burning gums, difficulty chewing, and ongoing pain, despite documented missing/broken teeth and irritated gums. An RN recorded significant oral findings and notified the physician, but the dental consult was not actually scheduled until seven days later. Key staff, including the RD and an RN caring for the resident, were unaware of the dental issues, while the DON confirmed ongoing oral discomfort managed only with pain medication. A later hospital CT showed numerous bilateral dental caries, and the consulting DDS stated he would have expected immediate notification and clearer communication from the facility when the resident first reported oral pain.
A resident with cognitive impairment, history of traumatic brain injury, ataxia, and repeated falls was discharged via Uber to an assisted living setting without documented pre-discharge planning or a discharge care plan, despite facility policy requiring early and coordinated discharge planning. Although a medication list was documented as sent to the next provider, it was not provided to the resident, and a home health RN later found the resident without discharge medications or a medication list and had to obtain this from the facility. The Discharge Planning Review Form was completed after the discharge and lacked the resident’s or family member’s signature, and there was no documented follow-up with the family member who had previously contacted the facility about discharge and financial benefit arrangements. Assisted living staff reported the resident’s unsafe wandering, unusual gait without a walker, and episodes of leaving and becoming homeless, while the assisted living owner noted uncertainty about who controlled the resident’s financial benefits.
A resident with end stage renal disease developed new skin discoloration on the face and hand, which was documented by staff but not reported to the charge nurse or investigated as required by facility policy. Interviews confirmed that nursing staff did not follow procedures for reporting and investigating changes in condition.
Two residents receiving dialysis did not receive their prescribed medications as ordered due to unavailability in the medication cart. Staff substituted medications with incorrect dosages or alternative products, including using medications labeled for other residents and lower doses than prescribed. The facility did not follow its policy to reorder medications in advance, resulting in missed or incorrect medication administration.
The facility did not ensure that a resident's transfer or discharge was conducted in a manner that met their needs and preferences, nor did it adequately prepare the resident for a safe transition.
A resident with a history of stroke experienced emotional distress after a CNA yelled, used profanity, and made derogatory remarks in response to a comment from the resident. The CNA's actions were in direct violation of the facility's abuse prevention policy, which prohibits verbal mistreatment.
A CNA verbally abused a resident with a history of stroke, and despite the facility's policy requiring immediate removal of staff accused of abuse, the CNA continued to provide direct care after the incident. Time records confirmed the CNA worked additional shifts before separation, contrary to established abuse reporting procedures.
A resident with hypertension and epilepsy, who was cognitively intact, was physically and verbally abused by a visitor who entered a shared room, accused the resident of theft, and slapped the resident in the face, causing an abrasion and pain that required emergency evaluation. Staff attempted to intervene, but the visitor continued the abusive behavior before eventually calming down.
A resident with a history of hypertension and epilepsy, who was cognitively intact, reported being physically assaulted by a visitor, resulting in a visible injury. The facility failed to thoroughly investigate the incident, did not interview all staff witnesses, and did not submit the required investigation summary to the State Survey Agency within five working days, as mandated by policy.
A resident's family member reported to staff that a nurse called the resident 'stupid,' but both an RN and a Medical Records staff member failed to notify CDPH or the Ombudsman or submit the required SOC 341 abuse report within the facility's mandated two-hour timeframe.
Two residents experienced deficiencies related to accident hazards and supervision: one resident with neurological and mobility impairments was provided a bed with wheels that did not lock, causing fear of falls, while another resident with a history of TBI and depression, assessed as at risk for elopement, was left unsupervised during smoking and left the facility undetected, with no care plan or investigation documented.
A resident with a history of hemiparesis and hemiplegia fell during a physical therapy session. The PTA guided the resident to the floor, but the LVN failed to assess the resident for injuries or notify the doctor, resulting in delayed treatment for a hip fracture. The facility's policy requires immediate assessment and notification following falls.
The facility failed to honor the dietary preferences of two residents, leading to a deficiency in resident self-determination. One resident, with a diagnosis of Adult Failure to Thrive, was served turkey salad despite disliking turkey, while another resident with Unspecified Protein-Calorie Malnutrition was given milk against their preference for juice. The facility's policy to provide meals consistent with residents' preferences was not followed.
A resident with end-stage renal disease felt upset and disrespected after a Rehabilitation Coordinator told him he was being kicked out of the facility. The incident, witnessed by an RN, was not handled according to the facility's policies on resident rights and discharge procedures. The Social Worker and Director of Nursing confirmed that the resident was not ready for discharge and that the RC's actions were inappropriate.
A resident with Neuralgia and Neuritis did not receive their prescribed Gabapentin on two occasions due to unavailability. The facility staff failed to notify the physician or obtain a new order to skip or delay the dose, contrary to the facility's medication administration policy.
A resident with dementia and delusional disorder threw a flower vase at her roommate, causing a lip wound and hospital transfer. The facility was aware of ongoing conflicts and previous aggressive behavior but failed to implement a care plan to prevent such incidents, violating their abuse prevention policy.
The facility failed to maintain proper food storage and preparation standards, with the walk-in fridge exceeding safe temperatures and beverages stored improperly. Ground beef was thawing without proper labeling or logs, and the kitchen environment was excessively hot, with an ineffective AC unit. These conditions risked food contamination for 90 residents.
A resident was moved to a different room without receiving the required written notification explaining the reason for the change. The resident, who was cognitively intact, was informed verbally on the day of the move, but the Social Service Director did not provide a written notice as required by the facility's policy.
A resident was denied re-admission to a facility after hospitalization, despite available beds. The resident, with a history of hemiplegia and other conditions, was discharged from a hospital following neurosurgery. Facility staff cited non-compliance as the reason for refusal, although the resident wished to return.
A resident with severe cognitive impairment showed signs of difficult breathing and tested positive for COVID-19, but the LVN failed to notify the physician or family. The LVN placed the resident on oxygen but did not report the condition change to another LVN during her break. Upon returning, the resident was found unresponsive, leading to a Code Blue. Facility policy requires immediate notification of such changes, which was not followed.
The facility failed to provide appropriate foot care for two residents, resulting in significant discomfort and potential health risks. Both residents had overgrown, discolored, and thickened toenails, and had not received podiatry services for over four months. Despite requests for nail care, the facility did not provide the necessary services, and records lacked documentation of any offers or declinations of toenail care.
Failure to Provide Timely Dental Consultation for Resident with Oral Pain
Penalty
Summary
Facility nursing staff failed to provide timely dental services after a resident reported significant oral pain. The resident, who had a history of hemiplegia following a stroke and documented missing or broken teeth, was cognitively able to report symptoms and did so, describing toothache, burning sensations in the upper and lower gums, difficulty chewing, and ongoing pain. An eInteract Change in Condition Evaluation completed by an RN on 3/9/2026 documented the resident’s report of toothache with burning gums, multiple missing and dark discolored teeth, cracked teeth, loss of lower teeth, and irritated gums. The physician was notified and a referral for a dental consultation was noted, and progress notes on 3/10/2026 indicated staff were monitoring the toothache and burning gum sensation, with gums described as slightly irritated and the resident continuing to report discomfort. Despite these findings and the facility’s Oral Healthcare & Dental Services policy stating that a consultant dentist would provide emergency dental care as needed, the actual dental consult was not scheduled until 3/16/2026, seven days after the initial complaint of oral pain. During interviews, the RD and an RN caring for the resident stated they were unaware of any issues with the resident’s teeth or chewing, and the DON confirmed the resident’s oral discomfort and that staff continued to administer pain medication. The DON acknowledged that nursing staff should have been more proactive in addressing the symptoms, which could indicate infection. A CT head and neck angiography performed at the hospital later showed numerous bilateral dental caries, and the dental consultant stated he would have expected immediate contact from staff upon the resident’s complaint of oral pain and emphasized the need for clear communication from the facility to his office. The resident reported still having pain during a subsequent interview.
Failure to Implement Effective Discharge Planning Leading to Post-Discharge Instability
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident with multiple cognitive and physical impairments. The resident was admitted with diagnoses including cognitive communication deficit, a history of traumatic brain injury, ataxia, and repeated falls, and had a BIMS score of 12 indicating moderate cognitive impairment. The facility’s own policy required that discharge planning begin upon admission, with an initial discharge assessment within seven days and a discharge care plan developed by Social Services with the IDT. However, the Director of Nursing confirmed that the clinical record contained no evidence of discharge planning prior to the actual discharge date and no discharge care plan was developed. An IDT note documented that a family member had contacted the facility about discharge plans and was working on financial benefits, but there was no further documentation of coordination or follow-up with the family member regarding these plans. On the day of discharge, the resident was sent in an Uber to an assisted living facility with medications and a medication list documented as provided to the subsequent provider, but not to the resident. The Discharge Planning Review Form was completed and signed the day after discharge and lacked the resident’s or family member’s signature. Following discharge, a home health RN reported that when she assessed the resident for home health admission, the resident did not have a medication list or discharge medications, requiring the home health office to contact the facility for this information. Staff at the assisted living reported that the resident claimed to self-administer medications but did not show which medications, ambulated without a walker in an unusual manner, and frequently wandered off to an unknown shelter. The assisted living owner reported that the resident occasionally left the home, sometimes becoming dirty after being homeless for a few days, and that although the resident received financial benefits, they did not know who the payee was or who was receiving the money.
Failure to Report and Investigate Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a change in a resident's condition was reported and properly investigated. A resident with multiple diagnoses, including end stage renal disease, was noted in progress notes to have new skin discoloration on the face and hand, and subsequently on the left eye and nose over several days. Despite these documented changes, nursing staff did not report the new skin discoloration to the charge nurse, and no investigation into the cause of the discoloration was initiated by the facility. Interviews with facility staff confirmed that nurses are expected to report any change in a resident's condition to the charge nurse for further investigation, as outlined in the facility's policy on unusual occurrence reporting. However, the responsible LVN admitted to not reporting the discoloration, and the Minimum Data Set Coordinator confirmed that no investigation was conducted. This failure to follow reporting and investigation procedures resulted in the deficiency.
Failure to Provide and Administer Prescribed Medications for Dialysis Residents
Penalty
Summary
The facility failed to ensure that routine medications were available and administered as ordered for two residents receiving dialysis. For one resident with end stage renal disease, hyperlipidemia, and gastro-esophageal reflux disease, several prescribed medications were not present in the medication cart, including atorvastatin, famotidine, Nephro-Vite Rx, sevelamer hydrochloride, and metoclopramide. Instead, staff administered alternative medications not matching the physician's orders, such as using a higher dose of famotidine labeled for another resident, substituting regular multivitamins for Nephro-Vite Rx, using sevelamer meant for a discharged resident, and giving a lower dose of metoclopramide than prescribed. For another resident with end stage renal disease and chronic pain syndrome, the required medications calcium carbonate 1250 mg and nortriptyline 75 mg were not available in the medication cart. Staff administered a lower dose of calcium carbonate than ordered. The facility's policy required medications to be reordered five days before they were needed, but this process was not followed, resulting in the unavailability of necessary medications for these residents.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. There is no mention of specific residents, medical history, or conditions at the time of the deficiency.
Verbal Abuse by CNA Resulting in Resident Distress
Penalty
Summary
A resident with a history of stroke and no documented behavioral symptoms reported that a Certified Nursing Assistant (CNA) entered his room, yelled, and used profane language towards him. During an interview, the facility administrator confirmed that the CNA admitted to telling the resident, 'You are ugly too,' after the resident allegedly called her ugly. The resident stated that the CNA used to curse at him and that the situation caused him emotional distress. The facility's abuse prevention policy prohibits any form of resident abuse, including verbal mistreatment, but the CNA's actions violated this policy.
Failure to Immediately Remove Staff Following Alleged Verbal Abuse
Penalty
Summary
A certified nursing assistant (CNA) verbally abused a resident by yelling and cursing at them during the night. The resident, who had a history of stroke but no behavioral symptoms such as hallucinations or delusions, reported the incident to staff. The CNA admitted to responding to the resident with a derogatory comment after the resident made a remark about her appearance. The resident stated that the CNA had previously cursed at him and that the situation was upsetting. Despite the facility's policy requiring immediate suspension and removal of staff accused of abuse during an investigation, the CNA continued to provide direct care to residents following the reported incident. Time card records confirmed that the CNA worked additional shifts after the alleged abuse before her official separation from the facility. This failure to immediately remove the CNA from resident care did not align with the facility's established abuse reporting procedures.
Failure to Protect Resident from Abuse by Visitor
Penalty
Summary
A deficiency occurred when a family member (FM) of a resident entered a shared room and physically and verbally abused another resident. The FM, who was upset and accused staff of mistreating her sibling, began yelling, throwing objects, and then slapped the other resident in the face. The resident, who had a history of hypertension and epilepsy and was cognitively intact according to a recent BIMS assessment, sustained an abrasion on the left eyelid and complained of pain, which led to an emergency department evaluation. Multiple staff interviews confirmed that the FM was visibly upset, made threats, and accused the resident of stealing a TV remote. The FM physically attacked the resident, holding his arms and slapping him, while also calling him derogatory names. Staff, including a registered nurse and an infection preventionist, attempted to intervene and de-escalate the situation, but the FM continued to yell and refused to leave the room immediately. The resident appeared frightened and asked the FM to go away. Documentation in the resident's medical record, including an eINTERACT Change in Condition Evaluation and interdisciplinary team notes, confirmed the physical injury and the circumstances of the incident. The facility failed to protect the resident from abuse by a visitor, resulting in physical harm and emotional distress.
Failure to Investigate and Report Alleged Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident and a visitor, and did not report the results of the investigation to the State Survey Agency within the required five working days. The incident involved a resident with a history of hypertension and epilepsy, who was cognitively intact at the time, and who reported being physically assaulted by the sister of another resident. The visitor entered the room, accused staff of mistreatment, became agitated, and physically struck the resident, resulting in a scratch and discoloration on the resident's eyelid. This account was corroborated by a registered nurse who witnessed the aftermath and documented the injury. Despite the seriousness of the allegation and the visible injury, the facility administrator was unable to provide evidence that all staff who witnessed the incident were interviewed as part of the investigation. The administrator only provided a handwritten note from an interview with the alleged perpetrator, who denied the incident, and acknowledged that the investigation summary was not completed in a timely manner. Additionally, the administrator did not review or reconcile the nurse's documentation with the visitor's denial. The facility's policy required a written report of the results of all abuse investigations to be submitted to the California Department of Public Health Licensing and Certification within five working days of the reported allegation. However, the investigation summary was not completed or sent within this timeframe, and there was no evidence of a comprehensive investigation as required by policy.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and procedure to immediately report an alleged abuse incident involving a resident. Specifically, the sister of a resident with a diagnosis of chronic pain informed both a Registered Nurse (RN) and a Medical Records (MR) staff member that an unknown nurse had called the resident 'stupid.' Both the RN and MR staff acknowledged that they did not complete or submit a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the California Department of Public Health (CDPH) or the Ombudsman, nor did they notify these authorities of the alleged abuse as required. The facility's policy, revised in March 2018, mandates that the Administrator or designated representative notify CDPH, the Ombudsman, and Law Enforcement by telephone within two hours of an abuse allegation, and submit a written SOC 341 report within the same timeframe. Despite this, the initial notifications and required documentation were not completed by the staff members who first received the allegation, resulting in a delay in reporting the incident to the appropriate authorities.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
Two deficiencies were identified regarding the facility's failure to provide an environment free from accident hazards and to ensure adequate supervision of residents. For one resident with a history of epilepsy, hemiplegia, hemiparesis, right foot drop, and previous falls, the facility replaced her bed with one whose wheels did not lock. The resident, who was cognitively intact, reported that the bed moved whenever she repositioned herself, causing fear of falling. The Environmental Service Director confirmed the bed had been replaced two weeks prior but was unaware of any current issues with the bed. Another deficiency involved a resident with a history of myocardial infarction, depression, traumatic brain injury, and a need for assistance with personal care. This resident was assessed as being at risk for elopement upon admission, but the elopement evaluation lacked clinical suggestions or comments, and no baseline care plan was created to address the risk. Documentation showed that the resident was last seen after requesting to smoke and subsequently left the facility undetected. Multiple staff notes confirmed the resident's absence, and at the time of the survey, the facility did not know the resident's whereabouts. The facility's policy required assessment of elopement risk upon admission and documentation of preventative interventions, as well as specific actions to be taken if a resident was found missing. However, the clinical record did not indicate that these procedures were followed, and there was no documentation of an investigation or contact with the resident or family after the elopement.
Failure to Assess and Notify After Resident Fall
Penalty
Summary
The facility failed to ensure that their skilled nursing licensed staff provided care based on professional standards for a resident who experienced a fall. The resident, who had a history of hemiparesis and hemiplegia following a cerebral infarction, was participating in a physical therapy session aimed at strengthening her core. During the session, the resident leaned forward unexpectedly, and the Physical Therapy Assistant (PTA) guided her to the floor. Despite the fall, the licensed nurse did not immediately assess the resident for injuries or notify the doctor, which is a requirement according to the facility's Fall Management Program. The incident resulted in unnecessary pain and a delay in treatment for the resident, who was later found to have sustained a left hip fracture. The PTA reported the fall to the Licensed Vocational Nurse (LVN) and the Director of Rehabilitation, but there was no documentation indicating that the doctor was notified or that an immediate assessment was conducted. The LVN acknowledged the importance of assessing the resident and notifying the doctor following a fall, but failed to do so in this instance. The facility's policy requires that the Director of Nursing and/or the Administrator be notified of fall incidents as soon as possible, along with the resident's attending physician and responsible party.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to honor the dietary preferences of two residents, leading to a deficiency in resident self-determination. Resident 1, who was admitted with a diagnosis of Adult Failure to Thrive, had a BIMS score of 15, indicating intact cognitive status. Despite this, Resident 1 was served a turkey salad for lunch, which was against their stated preference as indicated on their meal ticket. The Kitchen Director acknowledged that the staff should have adhered to the meal ticket, and the Assistant Director of Nursing emphasized the importance of respecting residents' food preferences to prevent them from feeling disrespected and potentially eating less. Similarly, Resident 2, admitted with Unspecified Protein-Calorie Malnutrition and a BIMS score of 13, was served milk with their lunch, contrary to their stated dislike. Resident 2 expressed a preference for juice instead. The Kitchen Director confirmed that milk should not have been provided. The facility's policy, which mandates that the Dietary Department provide meals consistent with residents' preferences and physician orders, was not followed in these instances, resulting in the deficiency.
Resident Disrespected by Rehabilitation Coordinator
Penalty
Summary
The facility failed to treat a resident with respect and dignity when the Rehabilitation Coordinator (RC) informed the resident that he was being kicked out of the facility. The resident, who had been living in the facility for about two and a half years, was diagnosed with end-stage renal disease and required dialysis three times a week. The resident reported feeling upset and disrespected after the RC told him that the Administrator wanted him out, which was witnessed by a Registered Nurse (RN). The RN confirmed witnessing the incident, noting that the RC's communication with the resident was not polite, leaving the resident visibly upset and stressed. The Social Worker (SW) stated that a care conference should have been held to discuss discharge plans, as the resident was not ready to be discharged due to his medical condition and lack of a place to go. The SW emphasized that discharging the resident without a home would have been unsafe. The Director of Nursing (DON) acknowledged that the RC should not have discussed discharge plans with the resident, as it was not within her responsibilities. The facility's policy and procedure on resident rights and discharge procedures were reviewed, indicating that residents should be treated with kindness, respect, and dignity, and that proper notice and procedures should be followed for discharge. The RC's actions were deemed unacceptable by the DON, as they did not align with the facility's policies.
Failure to Administer Gabapentin as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received Gabapentin as prescribed by their physician, which had the potential to cause unnecessary pain. The resident was admitted with a diagnosis of Neuralgia and Neuritis and had a doctor's order for Gabapentin to be administered every evening for neuropathy pain. However, the medication was not available on two occasions, and the resident missed their doses on those days. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that the missed doses were not communicated to the doctor, nor was a new order obtained to skip or delay the dose. The facility's policy required medications to be administered as prescribed, with a one-hour window before or after the scheduled time, but this was not adhered to in this case.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident threw a flower vase at her, resulting in a wound on her lip and necessitating transfer to an acute care hospital for treatment. The incident occurred in the room shared by the two residents, where a disagreement over the room's sliding door shades escalated. The resident who committed the act had a history of dementia and delusional disorder, with documented physical and verbal behavior symptoms directed toward others. Prior to the incident, staff were aware of the ongoing conflict between the two residents but failed to take adequate measures to prevent the altercation. The facility's Director of Nursing acknowledged that there was a previous incident involving the same resident who exhibited aggressive behavior towards another resident, yet no care plan was developed to address these behaviors. The facility's policy on abuse prevention emphasizes the importance of care planning and monitoring for residents with behaviors that might lead to conflict, but this was not adhered to in this case. The lack of a care plan and failure to address the resident's aggressive behavior contributed to the incident, highlighting a deficiency in the facility's ability to ensure a safe environment for its residents.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as observed during a survey. The walk-in fridge's temperature was recorded between 40-48 degrees Fahrenheit, exceeding the recommended maximum of 40 degrees. Beverages were stored without labels and at temperatures above 40 degrees. Additionally, four packages of ground beef were found thawing in the fridge without proper labeling or a thaw log, and the fridge's temperature was not conducive to safe thawing practices. The Dietary Manager acknowledged these issues, noting the absence of a thawing log and the inappropriate fridge temperature for thawing meat. The kitchen environment was also found to be excessively hot, with temperatures ranging from 85 to 98 degrees Fahrenheit, which could have affected the fridge's temperature. A temporary portable air conditioning unit was in place but was ineffective, blowing warm air and covered in lint, dust, and dirt, indicating it had not been cleaned in over a month. The Dietary Manager and Maintenance staff confirmed the AC unit's ineffectiveness and the kitchen's high temperatures, which should not exceed 80 degrees. These conditions posed a risk of food contamination, potentially leading to foodborne illness for the 90 residents in the facility.
Failure to Provide Written Notification for Room Change
Penalty
Summary
The facility failed to provide written notification to a resident before a room change, violating the resident's right to receive such notice. The resident, who was cognitively intact according to the Minimum Data Set (MDS) assessment, was informed verbally about the room change on the same day it occurred, without receiving a written explanation for the move. During an interview, the resident expressed feeling that insufficient time was given before the room change. The Social Service Director (SSD) acknowledged completing the Notification of Room Change form but admitted not providing a copy to the resident. The facility's policy and procedure, dated March 2018, requires that residents receive timely advance written notice, including reasons for room changes, which was not adhered to in this instance.
Facility Refusal to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, despite having available beds. The resident, who had been admitted with hemiplegia, hemiparesis, dysphagia, and chronic obstructive pulmonary disease, was transferred to an acute care hospital for a stroke and underwent neurosurgery. Upon discharge, the resident was ready to return to the facility, but the facility refused re-admission, citing non-compliance with daily care and facility rules. Interviews with facility staff, including the Director of Staff Development and the Charge Nurse, confirmed the decision not to allow the resident's return, despite the availability of three vacant male beds. The resident expressed a desire to return to the facility, as he had no other place to go. This refusal to readmit the resident after hospitalization was identified as a deficiency, with potential psychosocial distress implications for the resident.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician and representative of a significant change in the resident's health condition. The resident, who had a severe cognitive impairment, exhibited signs of difficult breathing and tested positive for COVID-19. Despite these changes, the responsible Licensed Vocational Nurse (LVN) did not inform the physician or the resident's representative. The LVN placed the resident on oxygen but did not report the change in condition to the other LVN on duty during her break. Upon returning from her break, the LVN found the resident unresponsive, leading to a Code Blue being called. Interviews with facility staff, including the LVN involved and another LVN, revealed that the facility's policy requires immediate notification of the physician and family in the event of a significant change in a resident's condition. The facility's administrator confirmed this requirement. However, the LVN admitted to not notifying the physician or the resident's representative, which could have delayed necessary medical intervention. The facility's policy on Change of Condition Notification emphasizes the importance of promptly informing relevant parties to ensure appropriate medical assessment and coordination.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for two residents, resulting in significant discomfort and potential health risks. Resident 1, who was admitted with a diagnosis of diabetes, had not received podiatry services for over four months since her admission. Her toenails were observed to be dark brown, overgrown, curved, and thickened, causing her discomfort and preventing her from wearing socks or walking. Despite her requests for nail care, the facility did not provide the necessary podiatry services. The facility's records did not document any offers or declinations of toenail care for Resident 1 during this period. Similarly, Resident 2, who was admitted with severe protein-calorie malnutrition and deep vein blood clots, also had not received podiatry services. Her toenails were discolored, overgrown, curved, and thickened, causing discomfort from the sheets and blankets touching her feet. This discomfort made her feel sad and uncared for. The facility's records also lacked documentation of any offers or declinations of toenail care for Resident 2. The social worker responsible for arranging podiatry appointments was unable to find any records of referrals for both residents, despite the facility's policy stating that podiatry care should be offered to any resident requiring it.
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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