Cedar Pine Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1640 N. Fair Oaks Avenue, Pasadena, California 91103
- CMS Provider Number
- 555213
- Inspections on file
- 52
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Cedar Pine Post Acute during CMS and state inspections, most recent first.
The facility failed to reconcile and implement a GACH discharge order for long-acting insulin (insulin glargine) for a resident with diabetes, ESRD, and COPD. The hospital discharge list included daily glargine, but on admission the facility only obtained and administered short-acting insulin lispro before meals, with no long-acting insulin ordered for over a month. The resident reported that he had long used both long- and short-acting insulin at home and that in the facility he initially received only short-acting insulin. Review of the MARs with an RN confirmed the absence of a glargine order until mid-April despite persistently high blood sugars, and the DON acknowledged that the admitting nurse did not fully follow the hospital discharge medication list. This failure resulted in hyperglycemia and transfer to the hospital, with documented risk for DKA, dehydration, confusion, and coma.
A resident with cancer, malnutrition, and recent hypotension had a physician’s order for peripheral IV NS hydration over four hours on three consecutive days. The IV hydration ordered for the first day was not administered as scheduled and was instead initiated late the following day by an RN, who reported that the prior shift had not carried out the order and that no IV line was in place at the start of her shift. The DON later stated she was unaware of the missed dose and acknowledged the importance of the hydration given the resident’s hypotension. Facility IV P&P required timely initiation of infusion therapy when ordered and available from the e-kit, but this was not followed.
Surveyors found that staff failed to complete and accurately document neurological evaluation flow sheets and fall risk assessments for two residents. One resident with a history of falls had an incomplete fall risk assessment, omitting key items such as ambulation/elimination status, gait/balance, and systolic BP, which led to an inaccurately low fall risk score. The same resident’s neuro checks were not performed or recorded at all required times, and respiratory patterns were charted with incorrect numerical entries instead of the specified letter codes. For another cognitively impaired resident with prior falls, respiratory patterns on the neuro flow sheet were documented using a non-approved letter that was not listed in the form’s instructions. These practices did not meet the facility’s policy requiring objective, complete, and accurate documentation using only approved abbreviations and symbols, and were cited as having the potential to cause miscommunication and improper care.
A resident with multiple chronic conditions was admitted with personal belongings that were not fully checked, as the resident did not allow a CNA to inspect a purse. During night care, a CNA found a semi-clear hard substance on the resident’s lower back but assumed it was candy. After the resident died, an LVN found a container with a similar substance in the resident’s belongings while searching for family contact information and showed it to staff. The LVN initially told the ADM and DON, and it was reported to the state, that a police officer had discovered the container, but later admitted he had found it himself. The CNA’s observation of a similar substance on the resident’s skin was not reported to administration, and the CNA was not interviewed during the internal investigation. As a result, the written report to the state did not accurately reflect who discovered the suspected contraband or all staff observations, contrary to facility policies on contraband and unusual occurrence reporting.
Two residents did not receive their scheduled morning medications within the required time frame, and one resident's medications were left unattended at the bedside. Nursing staff acknowledged that medications were overdue and that facility policy, which prohibits leaving medications unattended and requires administration within a specific window, was not followed. The DON confirmed that no residents were authorized for self-administration and that staff should observe medication intake.
Two residents engaged in non-consensual sexual activity in a hallway, witnessed by staff, due to inadequate supervision and insufficient care planning for one resident's disruptive behaviors. The facility lacked a policy on consensual sexual acts between residents and could not provide documentation of consent, resulting in a failure to prevent sexual abuse.
A resident with cognitive impairment and multiple diagnoses received PRN lorazepam for anxiety without a stop date or required physician reevaluation after 14 days, contrary to facility policy. Both the LVN and DON confirmed the absence of timely review and documentation for continued use of the medication.
A resident with severe cognitive impairment exhibited a behavioral change by screaming at another resident, which was not documented or addressed by staff. This lack of intervention led to a subsequent incident where another resident, who had moderate cognitive impairment and physical limitations, struck the first resident in the face, causing injury. Staff were aware of the behavioral issues but did not report or document them, and the DON confirmed that required procedures for change of condition and care planning were not followed.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, catheter management, and UTI prevention. The facility failed to provide adequate attention to continence needs, proper catheter care, and sufficient infection control measures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A deficiency was cited when a resident's care plan did not address all of their needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Two residents were not provided care in a manner that promoted dignity and respect, as required by facility policy. One resident, dependent on staff for daily activities, was dressed in a hospital gown instead of personal clothing without being given a choice. Another resident, also fully dependent, was observed with food debris around the mouth and a stained gown, with staff acknowledging the lack of cleanliness. These actions did not align with the facility's stated commitment to resident dignity and well-being.
Two residents with complex medical needs did not have accurate or comprehensive care plans addressing their specific medical devices. One resident's care plan incorrectly referenced a shunt instead of a central venous catheter for dialysis, while another resident with a heart monitor (Zio Patch) had no care plan interventions for device care or monitoring. Nursing staff and the MDS nurse confirmed these omissions, and the facility's policy requiring updated, individualized care plans was not followed.
Two residents were administered medications not in accordance with prescriber orders, resulting in a medication error rate above 5%. One resident received carvedilol without food, and another received sevelamer without a meal present, despite both medications being ordered to be given with food. Nursing staff confirmed the deviations from orders, and facility policy requires medications to be administered as prescribed.
Three unidentified loose pills were found on the floor of the medication storage room, and staff interviews confirmed that this was not in accordance with facility policy, which requires discontinued medications to be placed in a secure container for destruction. The pills were not identified, and staff acknowledged the risk of them being accessed outside the medication room.
Surveyors found that kitchen staff did not label food items in refrigerators and freezers with required information such as open dates and use by dates, and failed to discard expired pudding cups. Staff acknowledged these oversights, which were not in accordance with facility policy and could have led to unsafe food being served.
A resident with cancer and visual impairment, who was cognitively intact, repeatedly requested assistance to complete an Advance Directive but did not receive the necessary help from staff for seven years. The Social Services Worker failed to communicate with the Ombudsman and incorrectly believed the resident needed a designated decision-maker, resulting in the resident's wishes not being formally documented. Facility policy required staff to assist with advance directives, but this was not followed.
A resident with multiple complex medical conditions experienced eight episodes of low blood pressure while on antihypertensive medication. Despite reporting symptoms of syncope and having medication held due to low readings, the physician and responsible party were not notified, and no change of condition was documented by nursing staff, contrary to facility policy and standard practice.
A resident with a history of stroke and documented contractures in the left upper and both lower extremities was inaccurately assessed on the MDS, which failed to reflect any impairment in range of motion despite clear evidence from medical records and direct observation. The MDS nurse acknowledged the oversight, and the facility's policy requiring thorough assessments was not properly followed.
A resident with dementia and other medical conditions, who was dependent on staff for daily activities, did not receive regular oral care as required. Observations showed poor oral hygiene, and both the resident and a CNA confirmed that oral care was not provided consistently. Facility policy required staff to assist with oral hygiene, but this was not done.
Two residents did not receive their prescribed medications with food or meals as ordered by their physicians. One resident was given carvedilol without food, and another received sevelamer after eating, rather than with a meal. Nursing staff confirmed the medications were not administered according to orders, and facility policy requires medications to be given as prescribed.
A resident with chronic medical conditions and intact cognition experienced ongoing mouth pain and difficulty chewing due to the facility's failure to follow up on a dental consult and assist with obtaining dentures. Despite multiple requests and a care plan intervention for dental evaluation, the resident was overlooked for several months, leading to frustration and unmet dental needs.
A resident with multiple medical conditions and intact cognition repeatedly received meals that were unappetizing and did not align with his stated preferences, including overcooked vegetables and dry meats. Despite voicing his concerns to dietary staff, the facility did not consistently accommodate his food preferences, resulting in the resident refusing to eat and experiencing negative psychosocial effects.
A resident with multiple diagnoses and orders for adaptive feeding equipment was not allowed to use a weighted spoon and plate guard for self-feeding during a meal. Instead, a staff member used the specialized utensils to feed the resident directly, contrary to physician orders and the care plan, which specified these devices to promote independence. Staff interviews confirmed the equipment was present but not used by the resident as intended.
Staff did not follow the facility's infection control policy when providing wound care to a resident on enhanced barrier precautions. During a wound dressing change, a RN and a CNA failed to wear required PPE, including gown, gloves, and mask, despite the resident's need for such precautions due to a wound. This lapse was confirmed by another RN and the DON, both of whom stated that EBP should have been implemented during direct care.
A resident with significant physical impairments and dependence on staff for daily activities was observed lying in bed with the call light on the floor and out of reach. Staff interviews and review of the care plan and facility policy confirmed that the call light should have been within the resident's reach, but this was not followed.
A resident assessed as high risk for elopement, with a history of substance abuse and mobility issues, was allowed to leave the facility on an unsupervised out on pass without a specific care plan or clear supervision guidelines. When the resident did not return as expected, staff failed to initiate a search or notify the DON, administrator, or authorities in a timely manner, and did not follow established elopement risk procedures, resulting in a prolonged period before the resident was reported missing.
A resident with alcohol use disorder and psychoactive substance abuse did not receive a person-centered care plan or behavioral health services, including counseling or referral to a psychologist. The facility allowed the resident to leave on pass without clear supervision guidelines, and staff confirmed that no care plan or interventions were developed to address the resident's substance use, contrary to facility policy.
A resident with severe cognitive impairment and a history of aggression was inadequately supervised while wandering the facility, resulting in the resident entering another's room and scratching a fellow resident's face. Staff interviews revealed that the incident occurred when the CNA briefly looked away, and that closer monitoring and redirection could have prevented the altercation. Facility policies require monitoring of residents with dementia and protection from abuse, but these were not effectively implemented, leading to a deficiency.
The facility did not follow its Enhanced Barrier Precaution policy, as a CNA failed to wear an isolation gown during high-contact care with a resident on EBP. Additionally, isolation gowns were unavailable in three EBP rooms, as confirmed by staff. This deficiency increased the risk of cross-contamination and infection spread.
A facility failed to document a resident-initiated discharge, leading to potential confusion among the healthcare team. The resident, with multiple medical conditions, was evacuated due to a fire and later expressed a desire to move closer to friends and doctors. Staff interviews revealed a lack of documentation regarding the discharge process, contrary to facility policy.
A resident with functional quadriplegia reported an alleged abuse incident involving aggressive handling by staff, resulting in pain in the resident's left hand. The facility failed to report the allegation within the required two-hour timeframe to the local police, state survey agency, and ombudsman. The charge nurse reported the incident to the Social Services Worker eight hours after it was initially reported by the resident, contrary to the facility's policy requiring immediate reporting.
A facility failed to accurately assess and document oxygen use for three residents, leading to omissions in the MDS and care plans. One resident with multiple diagnoses was observed using oxygen, but this was not reflected in the MDS. Another resident with acute respiratory failure was receiving oxygen at a higher rate than ordered, yet the MDS did not indicate oxygen use. A third resident with COPD was also receiving oxygen, but this was not documented in the MDS. The MDS Nurse acknowledged the oversight in each case.
The facility failed to administer oxygen according to physician's orders and did not label humidifiers for three residents. One resident received 1.5 LPM instead of the prescribed 2 LPM, another received 4 LPM instead of 2 LPM, and a third received 5 LPM instead of the ordered 2 LPM with a possible increase to 3 LPM. None of the humidifiers were labeled, and there was no documentation of changes or physician notification.
A facility failed to maintain accurate medical records by documenting vital signs for a resident who was hospitalized and not present in the facility. The resident, with conditions including epilepsy and HIV, was transferred to a hospital due to tachycardia. Despite this, vital signs were inaccurately recorded for several days. A nurse admitted to fabricating these records, which was confirmed by other staff. This failure to adhere to documentation policies could lead to incorrect treatment decisions.
The facility failed to follow infection control measures for two residents and four rooms under enhanced barrier precautions (EBP). A resident with MRSA bacteremia lacked isolation signage, and another with a gastrostomy tube did not receive care with appropriate PPE due to the absence of PPE carts. Staff admitted to not wearing gowns, increasing infection transmission risk. EBP signage was present, but PPE carts were missing, violating facility policies.
A facility failed to provide padded side rails for a resident with a seizure disorder, as ordered by a physician. Despite the resident's history of seizures and the facility's policy on side rails, observations revealed the absence of the required padding. Staff interviews confirmed the oversight, highlighting the potential risk of injury during seizure episodes.
A resident with muscle weakness and end-stage renal disease did not receive necessary OT and PT services due to pending insurance authorization, despite physician orders and care plan requirements. The facility's assessment tool confirmed these services should be provided based on resident needs, but the delay in authorization was not communicated to the rehabilitation department, leading to a lack of therapy provision.
Two residents in the facility requested female CNAs for personal care due to discomfort with male CNAs. Despite clear communication of their preferences, the facility continued to assign male CNAs, disregarding the residents' rights to self-determination. Staff interviews confirmed awareness of these preferences, yet the facility's policy on accommodating resident needs was not followed.
The facility failed to provide a safe and homelike environment for two residents. One resident experienced a loss of personal property due to incomplete documentation and verification of belongings upon admission. Another resident's bathroom had missing tiles, which were not promptly repaired, affecting the homelike atmosphere. Staff interviews revealed lapses in adherence to procedures for inventory management and maintenance reporting, impacting residents' quality of life.
The facility failed to update care plans for two residents, one with a diet change and another requiring dialysis monitoring. A resident's care plan was not revised to reflect a change from a regular diet to liquids, risking aspiration. Another resident's care plan lacked updated I&O monitoring for dialysis, risking fluid overload. These deficiencies were identified through interviews and record reviews, indicating a failure to adhere to physician orders and facility policies.
The facility failed to provide adequate pressure ulcer care for three residents. A resident's low air loss mattress was not set according to their weight, risking skin integrity. Another resident was not repositioned every two hours as required, and their refusal to be turned was not addressed in the care plan. A third resident with a stage 4 pressure ulcer did not have a low air loss mattress ordered since admission, delaying appropriate care.
The facility failed to provide safe and appropriate dialysis care for two residents. For one resident, the facility did not assess the dialysis catheter on two occasions and did not update the care plan when a new AV shunt was placed. For the other resident, the facility did not re-evaluate the intake and output order after 30 days, failed to contact the physician regarding fluid restriction, and did not conduct an Interdisciplinary Team meeting. These deficiencies indicate a lack of proper monitoring and communication regarding the residents' dialysis care needs.
The facility failed to assess and document the use of side rails for two residents, leading to potential safety risks. One resident, with conditions like seizures and hemiplegia, did not receive the required quarterly reassessments for side rail use. Another resident, with cognitive impairments, had a side rail up without any documented assessment or physician order. The facility's policy requires assessments and informed consent for side rail use, which were not followed, posing a risk of inappropriate use and potential harm.
A resident did not receive several prescribed medications, including Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch, at the scheduled time. Additionally, Dexamethasone was administered at the wrong time. This failure to follow physician orders was confirmed by both an LVN and an RN, potentially leading to medical complications.
The facility failed to report medication regimen irregularities for two residents to their primary physicians. A resident was prescribed both Vascazen and Vascepa, and another was prescribed Zyprexa without verifying the diagnosis and target behavior. The pharmacist's recommendations were not communicated in a timely manner, potentially leading to unnecessary medication use.
A resident in an LTC facility experienced a 28% medication error rate due to a nurse's failure to administer several prescribed medications, including Dexamethasone, Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch. The resident, with a history of angioneurotic edema, hypertension, and seizures, did not receive medications as ordered, potentially impacting their health. The facility's policies on timely and accurate medication administration were not adhered to.
The facility failed to remove expired eye medications and improperly stored Basaglar Kwik Pens and Trulicity pens at room temperature instead of in the refrigerator. Additionally, the medication refrigerator was not defrosted as required, potentially affecting medication efficacy. These deficiencies were confirmed through staff interviews and observations.
The facility failed to follow proper food handling practices, including labeling foods with 'use by' dates, discarding expired food, and maintaining sanitary storage conditions. Observations included a resident's personal container with a used napkin on food seasoning, undated opened items, and expired turkey in the refrigerator. Unsanitary conditions were noted, such as a bowl on the floor and a water line filter touching the drain, along with improper storage of a bathroom plunger. These practices were against the facility's policies, posing a risk of contamination.
The facility did not follow its policy to monitor refrigerator and freezer temperatures for resident food brought from home, affecting four residents. From June 1 to June 11, 2024, temperature logs were incomplete, and the refrigerator was found at 50°F, above the safe threshold. The Dietary Supervisor confirmed the lapse, acknowledging the risk of food poisoning due to unsafe storage temperatures.
Failure to Reconcile Hospital Discharge Orders for Long-Acting Insulin
Penalty
Summary
The facility failed to reconcile and implement a General Acute Care Hospital (GACH) discharge medication order for long-acting insulin (insulin glargine) for one resident with type 2 diabetes mellitus, ESRD, and COPD. The GACH Discharge Medications List dated 2/23/2026 included an order for insulin glargine 20 units subcutaneously every 24 hours. Upon readmission on 3/14/2026, the facility’s admission process did not carry out this long-acting insulin order. The resident’s Order Summary as of 3/15/2026 showed only an order for insulin lispro 9 units subcutaneously before meals, with no long-acting insulin ordered. The facility’s P&P for Admission required the licensed nurse to notify the physician of admission and verify transfer and admission orders, and the Medication Administration P&P required drugs to be administered in accordance with written physician orders. The resident reported having taken long-acting insulin for more than 20 years and stated that at home he used both long-acting and short-acting insulin based on blood sugar results. He stated that in the facility he was only receiving short-acting insulin before meals after staff checked his blood sugar, and that long-acting insulin was started only days after his readmission. Review of the March and April 2026 MARs with RN 1 confirmed there was no order for insulin glargine from admission on 3/14/2026 until 4/17/2026, despite RN 1 observing consistently high blood sugars on the EMAR. The DON confirmed that the GACH discharge order for insulin glargine was not carried out upon admission and acknowledged that the admitting nurse did not completely follow the GACH Discharge Medications List. As a result of this failure, the resident experienced hyperglycemia and was transferred to the GACH on 4/10/2026, placing the resident at risk for DKA, dehydration, confusion, and coma.
Failure to Timely Administer Ordered IV Hydration
Penalty
Summary
The facility failed to administer ordered IV hydration as prescribed for one resident. The resident had diagnoses including malignant neoplasm of the lungs and bones, neoplasm-related pain, and malnutrition, and required varying levels of assistance with activities of daily living, including partial/moderate assistance with eating and oral hygiene and dependence for toileting, showering, lower body dressing, and footwear. A physician’s order dated 4/10/2026 directed that the resident receive peripheral IV hydration with normal saline over four hours on 4/10/2026, 4/11/2026, and 4/12/2026. However, the IV hydration ordered for 4/10/2026 was not administered on that date. During record review and interview on 4/23/2026, an RN reported that when she began her 7 AM–3 PM shift on 4/11/2026, it had been endorsed to her that the IV hydration order from the previous night had not been carried out, and the resident did not have an IV line in place at the start of her shift. The RN initiated the peripheral IV line and IV hydration on 4/11/2026 at around 11 AM. The DON stated she was not aware that the IV hydration ordered for 4/10/2026 had not been administered until 4/11/2026 and noted that the IV hydration order was important because the resident had experienced hypotension on 4/9/2026. The facility’s IV policy indicated that when an IV order is received, pharmacy should be called or faxed with IV orders, and if fluids and medications are available from the emergency kit supply, infusion therapy should be initiated as ordered in a timely manner. This policy was not followed for the IV hydration ordered on 4/10/2026.
Inaccurate Neurological and Fall Risk Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and policy-compliant medical records for two residents, specifically related to fall risk assessments and neurological evaluation flow sheets. For the first resident, admitted with diagnoses including fibromyalgia, cervical disc displacement, and hypertension, the General Acute Care Hospital history and physical documented a recent fall in the shower and that the resident was alert, oriented, and able to move all extremities. The facility’s fall risk assessment for this resident showed a score of nine, categorizing the resident as low risk for falls, but key sections on ambulation/elimination status, gait/balance, and systolic blood pressure were left incomplete. RN 1 and the DON both acknowledged that these omissions meant the assessment was incomplete and that, if fully completed, the score would have been 10 or higher, indicating a high fall risk. The same resident’s Neurological Evaluation Flow Sheet dated 4/8/2026 contained multiple documentation errors and omissions. The tool included instructions for an initial neurological assessment followed by checks every 15 minutes for four times, every 30 minutes for four times, every hour for two times, and then once per shift for 72 hours, as well as specific codes to document respiratory patterns (N, BR, C, B, T, H). The flow sheet showed an initial assessment at 5:30 PM and subsequent entries at 5:45 PM, 6:00 PM, 6:15 PM, 6:30 PM, 7:00 PM, 7:30 PM, 8:00 PM, 8:30 PM, 9:00 PM, 9:30 PM, and 10:00 PM, but the 10:00 PM column had no assessment documented, and there was no documented neurological assessment at 10:30 PM despite the required hourly frequency. RN 1, RN 2, and the DON all verified that the last completed assessment was at 9:30 PM, that the 10:00 PM column was blank, and that there was no evidence of resident refusal. They also confirmed that respiratory patterns were incorrectly documented as “3/10” and “0/10” instead of using the required letter codes, meaning the instructions on the form were not followed. For the second resident, who had diagnoses including anemia, muscle weakness, and osteoarthritis, the MDS indicated severely impaired cognitive skills for daily decision-making and varying levels of assistance needed for ADLs, as well as a history of at least one fall since admission. The resident’s Neurological Evaluation Flow Sheet from 3/19/2026 to 3/21/2026 contained instructions identical to those for the first resident regarding the use of specific letter codes to document respiratory patterns. However, the flow sheet showed the letter “R” documented in all respiratory pattern boxes over that period, even though “R” was not one of the approved codes listed in the instructions. RN 1 and the DON both confirmed that this documentation was inaccurate because it did not follow the specified coding system. The facility’s policy on charting and documentation required that medical record entries be objective, complete, and accurate, and that only facility-approved abbreviations and symbols be used, which was not adhered to in these instances. The survey findings concluded that these failures in documentation for both residents—leaving required sections of the fall risk assessment incomplete, omitting required neurological checks, and using non-approved or incorrect notations for respiratory patterns—did not comply with the facility’s charting and documentation policy. The report stated that this deficient practice had the potential to result in miscommunication, improper delivery of care, and inaccurate information about the care provided to the residents.
Inaccurate Reporting and Incomplete Investigation of Suspected Contraband
Penalty
Summary
The facility failed to provide an accurate report detailing the suspected presence of contraband for one resident. The resident was admitted with diagnoses including fibromyalgia, cervical disc displacement, and hypertension, and was documented as alert and oriented with full movement of extremities per a recent hospital H&P. On admission, the resident’s belongings list noted that the resident did not allow a CNA to check a black purse. Later, during the night shift, the CNA providing care found a semi-clear, hard substance stuck to the resident’s right lower back and believed it to be cracked menthol candy. After the resident’s death, an LVN located a container with a hard semi-clear substance in the resident’s belongings while looking for family contact information and showed it to staff; the CNA reported that the substance in the container resembled what she had found on the resident’s body. The facility’s initial report to the state agency stated that a police officer instructed staff not to touch the resident’s belongings and that the officer found a small container with an unknown substance. However, the police report documented that facility staff had located apparent methamphetamine in the resident’s backpack and that the LVN had unzipped the backpack and pointed out a clear container with a white crystalline substance, which the officer then picked up. In an interview, the LVN acknowledged that he, not the police officer, found the container and that he had reported this incorrectly to the administrator and DON, initially stating that the police officer found it. The LVN also stated he did not report the CNA’s observation of a similar substance on the resident’s skin to the administrator or DON. The DON later stated that the facility’s investigation and report were based solely on the LVN’s initial account, that the CNA assigned to the resident was not interviewed, and that the resulting investigation was inaccurate and confusing due to missing information. This sequence of events did not comply with the facility’s policies requiring immediate reporting to administration and a written report accurately detailing the incident and subsequent actions.
Failure to Administer and Monitor Medications According to Policy
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its own policies and physician orders for two residents. For the first resident, who had multiple diagnoses including schizoaffective disorder, hyperlipidemia, major depressive disorder, and GERD, the facility did not administer eight scheduled morning medications within the required time frame. The medications, which included anticoagulants, antidepressants, antipsychotics, and other essential drugs, were due at 9AM but were not given until 11:03AM. The nurse confirmed that the medications were overdue and acknowledged that they should have been administered within one hour before or after the scheduled time. The resident also reported receiving medications late. For the second resident, who had diagnoses including benign prostatic hyperplasia, GERD, and chronic venous hypertension, the facility also failed to administer morning medications on time. The resident's 9AM medications were given at 10:30AM, and the nurse left the medications unattended on the resident's bedside table. The resident was observed taking the medications at 11:45AM, but the nurse admitted that the medications should not have been left unattended and that she did not observe the resident taking them. The DON confirmed that facility policy prohibits leaving medications unattended and requires nurses to observe residents taking their medications. The facility did not have any residents authorized to self-administer medications. The facility's policy and procedure on medication administration, last revised in July 2013, states that medications must not be prepared in advance or left unattended and must be administered within one hour before or after the scheduled administration time. Both the DON and the nurse involved acknowledged that these policies were not followed in the incidents involving the two residents.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to prevent sexual abuse between two residents in the hallway, as witnessed by staff on 12/18/2025. One resident, who had a history of cocaine dependence and moderate cognitive impairment, was observed pulling down his pants and exposing himself, while another resident, diagnosed with schizoaffective disorder and major depressive disorder, performed oral sex on him. Multiple staff members, including a dietary orientee and a CNA, witnessed the incident through a glass window and reported it to the charge nurse. The event was documented in the residents' records and confirmed through interviews with both residents and staff. Resident records indicated that one resident was considered self-responsible but had moderately impaired cognitive skills, while the other was not self-responsible and had a care plan for socially inappropriate and disruptive behaviors, including touching and kissing staff and residents. The care plan intervention was to observe the resident's behavior around others, but this was not specific enough to address the risk of sexual abuse. Prior to the incident, the resident with disruptive behaviors had also exhibited other inappropriate actions, such as throwing feces and attempting to touch or kiss others. Interviews with staff and residents revealed that the facility did not have a policy regarding consensual sexual relationships or acts between residents, nor could they provide documentation of consent for the sexual activity that occurred. The DON acknowledged that the care plan for the resident with disruptive behaviors was insufficient and not tailored to prevent sexual abuse. The facility's policy on abuse and neglect required prevention of all forms of abuse, including sexual abuse, but the measures in place were inadequate to prevent the incident between the two residents.
Failure to Review and Discontinue PRN Psychotropic Medication per Policy
Penalty
Summary
The facility failed to ensure that a resident's PRN anti-anxiety medication, lorazepam, had a stop date and was reevaluated by a physician after 14 days as required by facility policy. The physician's order for lorazepam, initiated for anxiety, irritability, and restlessness, did not specify a stop date, and there was no documented evidence of a physician reevaluation for continued use after the initial 14-day period. Both the LVN and the DON confirmed that the medication order should have been reviewed and either renewed or discontinued within 14 days, in accordance with facility policy and procedure. The resident involved had a history of encephalopathy, type 2 diabetes mellitus without complications, and anxiety disorder. Assessment records indicated moderate cognitive impairment and significant dependence on staff for daily activities, including eating, hygiene, and dressing. Despite these needs and the facility's policy requiring timely review of PRN psychotropic medications, the required physician evaluation and documentation for continued use of lorazepam were not completed.
Failure to Address Behavioral Incident Leads to Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by not addressing a significant behavioral incident and not implementing appropriate interventions. One resident, with diagnoses including dementia, schizoaffective disorder, depression, and anxiety, exhibited a change in behavior by screaming at another resident. This behavioral change was not documented, monitored, or communicated to the physician as required by facility policy, nor was it incorporated into the resident's care plan. Staff separated the residents during the incident but did not report the event to a licensed nurse or take further action. Following the unaddressed behavioral incident, another resident subsequently hit the first resident in the face, resulting in a scratch under the eye and redness on the nose. The injured resident was severely cognitively impaired and dependent on staff for most activities of daily living. The resident who struck the other had moderate cognitive impairment and physical limitations. Interviews revealed that staff were aware of the first resident's tendency to invade others' personal space but did not report or document these behaviors, assuming it was common knowledge. The Director of Nursing acknowledged that the initial behavioral incident should have been treated as a change of condition, requiring immediate communication with the physician and care plan updates. Facility policies reviewed during the investigation emphasized the need to identify, document, and manage problematic behaviors and to intervene in situations likely to lead to abuse. The lack of documentation, monitoring, and intervention after the initial incident directly contributed to the subsequent physical altercation and injury.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents' bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Promote Resident Dignity and Respect in Personal Care
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not adhering to its own policies regarding resident choice and personal care. One resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, was observed wearing a hospital gown despite having personal clothing available in their closet. The resident reported that staff did not ask for their preference and dressed them in a hospital gown for staff convenience. A Certified Nursing Assistant confirmed the resident's dissatisfaction with wearing the gown, and the facility's administrator acknowledged that staff should offer residents a choice in what to wear. Another resident, who was severely cognitively impaired and dependent on staff for all personal care, was observed with food debris around their mouth and a brown stain on the shoulder of their gown. These observations were made during two separate visits, and both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed the presence of the food debris and the stained gown. The CNA stated that it is important to keep residents clean for their well-being and appearance, especially if family visits. The facility's policy on dignity and quality of life, revised in 2022, states that each resident should be cared for in a manner that promotes their sense of well-being, self-worth, and self-esteem. The observed actions and inactions by staff, including not offering clothing choices and not maintaining personal cleanliness, were inconsistent with this policy and resulted in a failure to uphold the residents' dignity and respect.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Medical Devices
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with specific medical devices and needs. For one resident with chronic kidney disease, anemia, and hypertension, the care plan inaccurately addressed a shunt for dialysis access, when the resident actually had a right upper chest tunneled central venous catheter. The care plan included interventions appropriate for a shunt, such as avoiding blood pressure measurements or blood draws in the shunt extremity and instructing the resident not to sleep on the side with the shunt, none of which were applicable. This inaccuracy was confirmed by both nursing staff and the MDS nurse, who acknowledged that the care plan did not reflect the correct dialysis access or the appropriate interventions required for a central venous catheter. Another resident, admitted with diagnoses including subdural hemorrhage, end stage renal disease, atherosclerotic heart disease, and atrial fibrillation, had a Zio Patch heart monitor placed by a cardiologist. Upon returning to the facility, the resident reported the presence of the device to nursing staff but did not receive any explanation or care instructions. The care plan was not updated to address the presence of the Zio Patch, and there were no interventions documented for monitoring the device, assessing skin integrity, or ensuring the device was returned as required. The MDS nurse and DON both confirmed that the care plan did not include the necessary information or interventions for the heart monitor. The facility's policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, and that care plans be revised as residents' conditions change. In both cases, the facility did not follow this policy, resulting in care plans that did not address the residents' actual needs or the specific care required for their medical devices.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 30 observed opportunities, resulting in a 6.67% error rate. The first error involved a resident with hypertension, osteoarthritis, and encephalopathy, who was ordered to receive carvedilol with food. During medication administration, the nurse gave the resident carvedilol without offering food, contrary to the prescriber's order. The nurse later confirmed that the medication was not administered with food, and the DON acknowledged the importance of following medication orders to ensure effectiveness and prevent complications. The second error involved a resident with end stage renal disease, anemia, and syncope, who was ordered to receive sevelamer with meals. During observation, the nurse administered sevelamer and other medications to the resident without a meal present at the bedside. The resident confirmed that medications were given after breakfast, but not with food. A registered nurse stated that medications ordered to be given with meals should be administered accordingly to avoid stomach upset or reduced effectiveness, and that food should be offered when administering sevelamer after breakfast is served. A review of the facility's medication administration policy indicated that drugs must be administered in accordance with the written orders of the attending physician and that all medications should be given following the scheduled administration times unless otherwise specified. The observed failures to administer medications as ordered, specifically regarding the requirement to give certain medications with food, directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Properly Dispose of Discontinued Medications
Penalty
Summary
Facility staff failed to follow established policy and procedure regarding the disposal of discontinued medications, as evidenced by the observation of three unidentified loose pills found on the floor of the medication storage room. During a survey, the Infection Preventionist Nurse (IPN) confirmed the presence of these pills, which included a light purple round pill, a yellow oblong pill, and a white round pill. The IPN was unable to identify the pills and acknowledged the risk that loose pills could be inadvertently moved out of the medication room and potentially accessed by residents. Further interview with a Registered Nurse (RN) confirmed that having loose pills on the floor was unacceptable and not in accordance with facility policy, which requires discontinued medications to be disposed of in a designated container for incineration. Review of the facility's policy indicated that all discontinued or outdated medications should be placed in a secure, designated location for destruction, which was not followed in this instance.
Failure to Label and Discard Expired Food Items in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to follow its own food handling policies and procedures by not labeling food items in the kitchen refrigerators and freezers with the required information, such as item name, date opened, and use by date. Specifically, a 1-gallon container of Thousand Island dressing in Refrigerator #2 was found without an open date, and the staff member acknowledged it had been opened the previous day but was not labeled as required. Additionally, three cups of vanilla pudding in the same refrigerator were found with a use by date that had already passed, and a dietary staff member confirmed these should have been discarded the previous day. Further observations revealed that a tray of ice cream cups in Freezer #2 lacked any labeling or use by dates, with staff confirming that dates should have been present to ensure safe service. Review of the facility's policy and procedure on labeling and dating of foods confirmed that all food items in storage, refrigerators, and freezers must be labeled and dated, and that prepared foods must be covered, labeled, and dated. These failures to adhere to policy had the potential to expose residents to pathogens due to improper food handling.
Failure to Assist Resident with Advance Directive Completion
Penalty
Summary
The facility failed to follow up on a resident's request to formulate an Advance Directive, resulting in a delay of seven years in addressing the resident's wishes. The resident, who had a diagnosis of malignant neoplasm of the right breast and blindness in one eye, was cognitively intact and required assistance with several activities of daily living. Upon admission and during subsequent care plan meetings, the resident expressed a desire to execute an Advance Directive but needed help completing the form due to her visual impairment. Despite these requests, the necessary assistance was not provided. Documentation in the resident's records, including the Minimum Data Set and care plan, indicated that the resident was capable of making her own decisions and had specifically requested CPR in the event of an emergency but did not want to be transferred to a hospital. The Social Services Worker acknowledged the resident's request but failed to communicate with the Ombudsman, who could have assisted in completing and witnessing the Advance Directive. The Social Services Worker incorrectly believed that the lack of a designated decision-maker, such as a child, prevented the resident from completing the document, and did not take further action. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the resident was eligible to complete an Advance Directive and that the facility's policy required staff to offer assistance in establishing such directives. The policy also required regular review of advance directives and documentation of offers to assist residents. However, these procedures were not followed in this case, resulting in the resident's wishes not being formally documented for an extended period.
Failure to Notify Physician of Repeated Hypotensive Episodes
Penalty
Summary
The facility failed to notify the physician of significant changes in condition for a resident who experienced eight episodes of hypotension related to the use of Losartan Potassium-HCTZ. Despite the resident having a history of subdural hemorrhage, syncope, end stage renal disease requiring dialysis, atherosclerotic heart disease, and atrial fibrillation, there was no documentation that the physician or the resident's responsible party was notified of these repeated low blood pressure readings. The medication order specifically instructed staff to hold the medication if the systolic blood pressure was less than 110 mmHg, which occurred on multiple occasions. The resident reported experiencing syncope both during dialysis treatments and while in bed at the facility, and attributed these symptoms to the new blood pressure medication. The resident communicated these symptoms to the LVN, who confirmed that the medication was held on several dates due to low blood pressure readings. However, the LVN did not notify the physician or the responsible party, nor did she document a change of condition in the medical record regarding these hypotensive episodes. The DON stated that any deviation from a resident's baseline blood pressure, especially when accompanied by symptoms such as syncope, should be reported to the physician and documented as a change of condition. The facility's policy required that sudden or serious changes in a resident's condition be communicated to the physician prior to the end of the assigned shift. Despite these requirements, there was no evidence that the physician was notified or that appropriate documentation was made for the resident's repeated episodes of hypotension and related symptoms.
Inaccurate MDS Assessment of Range of Motion
Penalty
Summary
The facility failed to ensure an accurate assessment of range of motion (ROM) for a resident with a history of cerebrovascular accident (CVA) and documented contractures in the left upper and bilateral lower extremities. Despite multiple records, including the admission nursing assessment and history and physical, indicating the presence of contractures, the Minimum Data Set (MDS) assessment did not reflect any impairment in the resident's functional limitation in ROM. The MDS nurse acknowledged that the MDS was inaccurately completed and should have indicated impairment on one side. Observations of the resident confirmed visible contractures and functional limitations, such as the left upper extremity being contracted and the resident's inability to use the left hand due to weakness. The resident also reported numbness and required assistance with repositioning. The facility's policy required comprehensive assessments of residents' physical needs upon admission and at regular intervals, but this process was not followed accurately in this case, resulting in an incomplete and inaccurate MDS assessment.
Failure to Provide Oral Hygiene Assistance to Dependent Resident
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living, specifically oral care, to a resident who was unable to perform these tasks independently. The resident, who had diagnoses including dementia, type 2 diabetes mellitus, and gastroesophageal reflux disease, was assessed as cognitively impaired and dependent on staff for transfers and daily decision-making. Despite these needs, the resident did not receive regular oral hygiene care as required. Observations revealed the resident had visible signs of poor oral hygiene, including drooling, dried and cracked lips, a yellow patch on the tongue, and yellowish teeth. The resident reported not receiving daily oral care since admission. A CNA confirmed that oral care was not provided regularly, and the DON acknowledged that daily oral hygiene is necessary to prevent oral health problems. Facility policy also required staff to assist residents with oral hygiene, but this was not followed for the resident in question.
Failure to Administer Medications as Ordered with Food or Meals
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and facility policy for two of seven sampled residents. For one resident with a diagnosis of hypertension, osteoarthritis, and encephalopathy, the physician's order specified that carvedilol should be administered with food. During a medication administration observation, the nurse gave the resident carvedilol along with other medications but did not provide food at the time of administration. The nurse later confirmed that the medication was not given with food as ordered. For another resident with end stage renal disease, anemia, and syncope, the physician's order required sevelamer to be administered with meals. During observation, the nurse administered sevelamer and other medications in the resident's room without a meal present. The resident later stated that he had eaten breakfast earlier and received his medications almost an hour after eating. The nurse confirmed that medications ordered to be given with meals should be administered accordingly to ensure effectiveness and prevent stomach upset. A review of the facility's policy indicated that drugs must be administered in accordance with the written orders of the attending physician. The failure to administer medications as ordered, specifically with food or meals, was confirmed through observation, record review, and staff interviews.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental services, specifically dentures, despite multiple requests and documented needs. The resident, who had diagnoses including cerebral infarction, anxiety disorder, and chronic pain syndrome, was cognitively intact and expressed ongoing mouth pain and difficulty chewing food. The resident's care plan included interventions for dental evaluation and intervention as needed, and a dental consult was ordered. However, the Social Service Director (SSD) did not follow up with the dental office regarding the resident's eligibility for dental services, resulting in the resident being overlooked for several months. Interviews revealed that the resident repeatedly asked staff for assistance in obtaining dentures but did not receive the necessary support. The SSD acknowledged that the resident was on a list to be checked for dental eligibility but was inadvertently missed. The facility's policy required social services to assist residents with dental appointments and arrangements, but this was not followed in the resident's case. As a result, the resident experienced frustration and continued difficulty with oral health needs.
Failure to Provide Palatable and Preferred Meals
Penalty
Summary
The facility failed to provide palatable and attractive food in accordance with its own policies for one resident. The resident, who had diagnoses including morbid obesity, GERD, and major depressive disorder, was cognitively intact and able to express his preferences and needs. Documentation and interviews revealed that the resident frequently received meals that were unappetizing, with food described as dry, mushy, and visually unappealing. The resident repeatedly voiced dissatisfaction with the taste and texture of the food, specifically noting that vegetables were overcooked and meats were excessively dry, leading him to avoid eating the meals provided. Despite the resident's clear communication of his food preferences and repeated requests for alternatives, the facility did not consistently accommodate these needs. Dietary staff acknowledged the resident's particular preferences and his tendency to refuse food that did not meet his standards, yet the issues persisted. Facility policy required that individual food preferences be accommodated within reason, but observations and interviews confirmed that the resident continued to receive meals he found unacceptable, negatively impacting his willingness to eat and his psychosocial well-being.
Failure to Ensure Resident Use of Adaptive Feeding Equipment
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, osteoarthritis, and schizophrenia, who was dependent on staff for eating and had physician orders for adaptive feeding equipment, was not provided the opportunity to use a weighted spoon and plate guard for self-feeding during a meal. Instead, a Restorative Nursing Assistant used the specialized utensils to feed the resident directly, rather than allowing the resident to attempt self-feeding as ordered. The resident's care plan and physician orders specified the use of these assistive devices to promote independence in eating, and the occupational therapist confirmed that these devices were intended to support the resident's self-feeding abilities. Interviews with facility staff, including the MDS nurse, occupational therapist, and Director of Nursing, verified that the adaptive equipment was present but was not used by the resident as intended. The occupational therapist was unaware that the resident was being fed by staff instead of using the assistive devices, and the Director of Nursing confirmed that the devices were meant for resident use, not staff. Facility policy also indicated that assistive devices are to be provided and supervised for resident use to support independence.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement the facility's infection prevention and control policy for one resident who was on enhanced barrier precautions (EBP) due to a wound requiring daily care. During wound care administration, a registered nurse and a certified nursing assistant did not don the required personal protective equipment (PPE), including an isolation gown, gloves, and mask, as mandated by the facility's EBP policy. This was directly observed by another registered nurse, who confirmed that the staff did not follow the established protocol for PPE use during high-contact care activities such as wound care. The resident involved had a history of hypertension, pain, and epilepsy, and required varying levels of assistance with daily activities, including being dependent for toileting hygiene, showering, and dressing. The resident had a treatment order for a right lateral heel wound, which required cleaning, application of ointment, and dressing changes. Both the Director of Nursing and the observing registered nurse acknowledged that EBP should have been implemented during direct care to protect the resident from infection, as outlined in the facility's revised policy.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who had been admitted with diagnoses including cerebral infarction, anxiety disorder, and chronic pain syndrome, was found to have their call light lying on the floor beneath the bed, out of reach. The resident's Minimum Data Set indicated intact cognitive skills but significant physical impairments, including upper and lower extremity impairment on one side and dependence on staff for most activities of daily living, including mobility and hygiene. During observation, the resident was lying in bed and unable to access the call light. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that facility policy requires call lights to be within reach of residents to maintain safety. The resident's care plan also specified that the call light should be kept within easy reach and answered promptly. Review of the facility's policy and procedure further supported this requirement, stating that the call device must be placed within the resident's reach before staff leave the room. Despite these policies and care plan interventions, the call light was not accessible to the resident at the time of observation.
Failure to Prevent Elopement and Timely Response for At-Risk Resident
Penalty
Summary
A resident with a history of psychoactive substance abuse, alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet was admitted to the facility and assessed as being at risk for elopement. Despite this assessment, the facility failed to develop a care plan or implement interventions to address the resident's elopement risk. The resident had a physician's order allowing out on pass (OOP) privileges, but the order was non-specific, lacking details about duration, accompaniment, or supervision requirements. The resident left the facility independently for an OOP and did not return at the expected time. Facility staff did not initiate a search for the resident when he failed to return as scheduled, nor did they notify the DON, administrator, or local authorities in a timely manner. Documentation shows that the resident's absence was noted, and attempts were made to contact him by phone, but no further action was taken to locate him or escalate the situation according to facility policy. The lack of a clear care plan and failure to follow established elopement risk procedures contributed to the delay in recognizing and responding to the resident's absence. Interviews with staff and review of facility policies revealed that staff were unclear about the procedures to follow when a resident did not return from OOP. The facility's policies required timely searches and notifications, but these were not carried out. The resident remained missing for an extended period before the incident was reported to the appropriate authorities, including the police and the Department of Public Health. The failure to implement and follow elopement risk protocols resulted in an Immediate Jeopardy situation.
Removal Plan
- All residents with out on pass order were reviewed and updated including the duration, purpose, and companion. If the resident will not return after specified duration, facility will call resident/family/companion for update on whereabouts and the time of return. If resident requests to go out on pass independently, resident must meet all of the following criteria to be considered eligible and Interdisciplinary Team will review request to go out unaccompanied and document in Interdisciplinary notes: Cognitive Competency (Recent BIMS), Behavioral Stability (No recent history of elopement), Medical Stability (Medically cleared by Attending Physician), Functional Mobility.
- MDS Coordinator and Registered Nurse Supervisor re-assessed all residents with out on pass order and baseline care plan was updated. Elopement Risk Assessment was done for all residents. Residents were identified as low risk or high risk for elopement.
- Elopement Risk Policy and Procedures was revised and updated. The licensed personnel were in-serviced and educated regarding timely assessment and identification of residents with high risk of elopement. Any episode of elopement reported and communicated to the Director of Nursing and Administrator so the facility leadership will be able to inform residents family, physician, regulatory Police Department, Ombudsman, California Department of Public Health and other regulatory agencies.
- Director of Staff Development/Director of Nursing in-serviced the licensed personnel regarding Policy and Procedure for elopement to emphasize reporting to local police, administrator, and residents' representative within 2 hours and to California Department of Public Health within 24 hours when resident elopement.
- All residents with out on pass order were reviewed and updated including the duration, purpose, companion, and return time. A log was available to both nursing stations, regarding the time out and estimated time to return to the facility.
- Residents on high risk for elopement are potentially affected by the deficient practice. Residents identified as high risk were re-assessed, care plan was developed and implemented, including monitoring every two hours. Log was available in the nursing station.
- An in-service was provided to Licensed Nurses and direct care givers by the Director of Staff Development and Social Service Director pertaining to: How to alert staff about resident elopement or missing, How to locate or search the resident, Reporting to governing agencies within 2 hours and CDPH within 24 hours.
- The Director of Nursing/Designee and Director of Staff Development conducted in-service to Licensed Nurses and Certified Nursing Assistants pertaining to the following: Revised Policy and Procedure for Out on Pass, Physician order for out on pass, Duration and companion, Protocol if the resident did not return after specific duration, Resident's decision against medical advice.
- Policy and Procedure for Elopement.
- During daily angel rounds the Department Managers will check the out on pass log and discuss in the daily stand-up meeting.
- The Director of Nursing Services/Registered Nurse Supervisor is responsible for monitoring the residents on a daily basis to ensure that the deficient practice will not be impacted. Results of the findings will be submitted and discussed to QAPI Committee during the monthly/quarterly QAPI meeting of its effectiveness.
Failure to Provide Behavioral Health Services and Care Planning for Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a primary diagnosis of alcohol use disorder and psychoactive substance abuse. Upon admission, the resident's diagnoses included psychoactive substance abuse, unspecified alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet. Despite these diagnoses, there was no documented evidence that the facility developed or implemented a person-centered care plan addressing the resident's behavioral health needs related to substance use. Interviews and record reviews revealed that the resident was allowed to leave the facility on pass without specific orders regarding supervision or duration, and there was no indication that behavioral health interventions or referrals to a psychologist were made. The resident's clinical records, both paper and electronic, lacked documentation of any care plan or interventions targeting the resident's alcohol use or psychoactive substance abuse. Staff interviews confirmed that no such care plan was developed or discussed in the interdisciplinary care team meetings. Facility policies required that residents with substance use disorders receive individualized care plans and behavioral health services, including monitoring for substance use and supporting efforts to prevent further use. However, these policies were not followed in this case, as evidenced by the absence of a care plan, lack of behavioral health service referrals, and insufficient documentation of interventions to address the resident's substance use and associated risks.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident scratched another resident's face. The incident occurred when a resident with severe cognitive impairment, who required substantial assistance with daily activities and was known to exhibit verbal aggression, was being followed by a CNA as the resident wandered the hallways in a wheelchair. Despite being followed, the resident was able to abruptly get up from the wheelchair, enter another resident's room, and scratch the face of a resident who was lying in bed. The CNA reported turning his head away momentarily, during which time the incident occurred, and was unable to prevent the altercation. The resident who was scratched had a history of intact cognitive skills but required assistance with several activities of daily living. The injury was documented as a scratch on the nose, and treatment was ordered by the resident's physician. Interviews with staff indicated that the resident who committed the act was new to the facility and had been exhibiting aggressive behaviors that required close supervision. Staff acknowledged that the incident could have been prevented if the resident had been more closely monitored and redirected when attempting to enter another resident's room. Facility policy and procedures reviewed by surveyors indicated that residents have the right to be free from abuse and that staff are required to monitor individuals with dementia. The failure to adequately supervise and redirect the resident with aggressive behaviors resulted in a physical altercation and injury to another resident, constituting a deficiency in protecting residents from abuse.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precaution (EBP) policy, which is designed to prevent the spread of multi-drug resistant organisms (MDRO) by using targeted gown and glove use during high-contact resident care activities. Certified Nurse Assistant 1 (CNA 1) did not wear an isolation gown while changing the diaper of Resident 1, who was on EBP. Resident 1 had severe cognitive impairment and was dependent on staff for daily activities, including toileting and personal hygiene. The failure to wear an isolation gown during this high-contact activity was confirmed by CNA 1, who acknowledged the need for such protective measures to prevent infections. Additionally, the facility did not ensure the availability of isolation gowns in three of the five sampled rooms (Rooms A, B, and C) that required EBPs. Observations and interviews confirmed the absence of isolation gowns in these rooms, which were necessary for staff to use when providing care to residents to prevent cross-contamination. The Infection Prevention Nurse (IPN) and Licensed Vocational Nurse 1 (LVN 1) confirmed the deficiency, emphasizing the importance of having easy access to personal protective equipment (PPE) in EBP rooms to prevent the spread of infections among residents, staff, and visitors.
Failure to Document Resident-Initiated Discharge
Penalty
Summary
Facility 1 failed to maintain complete and accurate medical records for a resident who initiated a discharge to another facility. The resident, who had been admitted with multiple medical conditions including atrial fibrillation, paranoid schizophrenia, and various fractures, was evacuated to Facility 2 due to a fire. The resident expressed a desire to be relocated closer to friends and outside doctors, leading to a discharge to Facility 3. However, the facility did not document the resident's discharge coordination or the resident's wishes and preferences in the medical records. Interviews with the facility's staff revealed that there was a lack of documentation regarding the resident's discharge process. The Social Services Designee (SSD 1) did not document conversations with the resident about the discharge, and the Admissions Coordinator (AC) failed to record the resident's request to be transferred to another facility. Additionally, the facility's policy for resident-initiated discharges, which required documentation of the resident's intent to leave and discharge planning, was not followed. The facility's Administrator acknowledged the failure to document the discharge process, which was necessary to avoid confusion and ensure all healthcare team members were aware of the resident's preferences and the discharge details. The lack of documentation could potentially confuse the healthcare team and negatively impact service delivery, as the facility could not provide evidence of the discharge process or the resident's preferences.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the local police department, state survey agency, and ombudsman. The incident involved a resident with functional quadriplegia who reported an alleged physical abuse incident involving aggressive handling by staff, which resulted in pain in the resident's left hand. The resident, who had intact cognition, was dependent on staff for various activities and had a physician's order for an X-ray due to the complaint of pain. However, the resident refused the X-ray, opting to consult with family and a primary physician instead. The Social Services Worker received the report of the alleged abuse from the charge nurse eight hours after the incident was initially reported by the resident. The Director of Nursing acknowledged that the charge nurse, who had been trained in abuse reporting, should have notified the Administrator immediately within the two-hour mandate. The Administrator, who is the facility's Abuse Coordinator, confirmed that the charge nurse failed to follow the facility's policy, which requires immediate reporting of abuse allegations. The facility's policy mandates that all alleged violations involving abuse must be reported immediately to the administrator and relevant authorities, but this was not adhered to in this case.
Failure to Accurately Assess Oxygen Use in Residents
Penalty
Summary
The facility failed to ensure accurate assessment of oxygen use for three residents, which was identified during a survey. Resident 4, who was admitted with multiple diagnoses including end-stage renal disease, type II diabetes, and congestive heart failure, was observed using oxygen at 1.5 liters per minute via nasal cannula. However, the Minimum Data Set (MDS) did not reflect this oxygen therapy, and there was no care plan initiated for it. The MDS Nurse acknowledged the oversight, stating that the resident's oxygen use should have been included in the MDS. Similarly, Resident 5, who had acute respiratory failure with hypoxia and other serious conditions, was observed with an oxygen level of 4 liters per minute via nasal cannula. The MDS for this resident also failed to indicate the use of oxygen, despite a medical order for oxygen therapy. The MDS Nurse admitted to not properly assessing the resident during the look-back period, resulting in the omission of oxygen therapy from the MDS and care plan. Resident 6, diagnosed with chronic obstructive pulmonary disease and heart failure, was observed receiving oxygen at 5 liters per minute. Like the other residents, the MDS did not reflect the use of oxygen therapy, and no care plan was initiated. The MDS Nurse confirmed that the MDS should have accurately reflected the resident's oxygen therapy status. The facility's policy requires that all pertinent data and information be documented in the resident's medical record, which was not adhered to in these cases.
Failure to Administer Oxygen as Prescribed and Label Humidifiers
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents by not administering oxygen according to physician's orders and not labeling humidifiers as per the facility's policy. Resident 4, who was admitted with multiple diagnoses including end-stage renal disease and dependence on supplemental oxygen therapy, was observed receiving oxygen at 1.5 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 2 LPM. There was no label on the humidifier with the resident's name and date, and no documentation of any changes to the oxygen level or physician notification was found in the resident's records. Resident 5, who had severe cognitive impairment and was dependent on supplemental oxygen therapy, was observed receiving oxygen at 4 LPM, while the physician's order specified 2 LPM. Similar to Resident 4, there was no label on the humidifier, and no documentation was found regarding the increase in oxygen level or physician notification. Additionally, there was no care plan addressing oxygen therapy in Resident 5's records. Resident 6, diagnosed with chronic obstructive pulmonary disease and heart failure, was observed receiving oxygen at 5 LPM, exceeding the physician's order of 2 LPM with a possible increase to 3 LPM if necessary. Again, the humidifier was not labeled, and there was no documentation of the oxygen level change or physician notification. The facility's policy on oxygen therapy, which requires labeling humidifiers with the resident's name and date, was not followed for any of the three residents.
Inaccurate Documentation of Vital Signs for Hospitalized Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident 1, by documenting vital signs while the resident was not present in the facility. Resident 1, who was admitted to the facility with diagnoses including epilepsy, HIV, and gastrostomy, was transferred to a General Acute Hospital due to a change in condition, specifically tachycardia. Despite being in the hospital from December 22 to December 25, 2024, vital signs were inaccurately recorded in the facility's records for these dates. The inaccurate documentation was identified during a review of Resident 1's weights and vitals summary, which showed recorded vital signs for the period when the resident was hospitalized. Registered Nurse 1 admitted to fabricating these vital signs, acknowledging that they were made up and not based on actual assessments. This was confirmed during interviews with the MDS nurse and another registered nurse, who both stated that the documentation was incorrect as the resident was not in the facility during those days. The facility's policy on documentation requires that all pertinent data and information of each resident be accurately recorded in their medical records. The failure to adhere to this policy by documenting fabricated vital signs could lead to incorrect treatment decisions, as vital signs are crucial for assessing a resident's condition and determining appropriate care. The inaccurate documentation was a result of actions taken by RN 1, who recorded vital signs without conducting actual assessments, leading to a deficiency in maintaining accurate medical records.
Inadequate Infection Control Measures in EBP Rooms
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed for two residents and four rooms under enhanced barrier precautions (EBP). Resident 4, who was readmitted with multiple diagnoses including MRSA bacteremia, did not have isolation signage posted outside their room. This lack of signage could lead to staff and visitors being unaware of the necessary precautions to prevent the spread of infection. Resident 7, who required substantial assistance with daily activities and had a gastrostomy tube, was not provided care with the appropriate personal protective equipment (PPE). Staff members, including a Certified Nurse Assistant and a Registered Nurse, admitted to not wearing gowns while providing care, as there were no PPE carts with gowns available outside Resident 7's room. This oversight in PPE availability and usage increased the risk of infection transmission. Additionally, rooms 3, 7, 9, and 11, which had residents on EBP, lacked PPE carts despite having EBP signage. Staff members confirmed the absence of PPE carts and acknowledged the potential for germs to spread due to the lack of gowns and gloves during high-contact care activities. The facility's policies required PPE to be available outside resident rooms and signage to indicate the type of precautions needed, which were not adhered to, leading to the identified deficiencies.
Failure to Provide Padded Side Rails for Seizure Precaution
Penalty
Summary
The facility failed to provide padded side rails for a resident with a seizure disorder, as indicated in the physician's order. The resident, who was admitted in 2003, has a history of seizures, schizophrenia, and repeated falls. The Minimum Data Set (MDS) assessment indicated that the resident was moderately impaired in cognitive skills and required supervision for daily activities. The physician's order, dated November 28, 2023, specified the use of padded side rails as a non-restrictive device for seizure precautions. However, during observations on January 2 and 3, 2025, it was noted that the resident's bed did not have the required padded side rails. Interviews with facility staff, including Licensed Vocational Nurses (LVN) and a Registered Nurse (RN), confirmed the absence of padded side rails and acknowledged the importance of such precautions for residents with seizure disorders. The facility's policy on side rails also indicated the necessity of padding to prevent injuries from involuntary movements. Despite the physician's order and the care plan's directives, the facility did not implement the required safety measures, potentially exposing the resident to injury during a seizure episode.
Failure to Provide Required OT and PT Services Due to Insurance Authorization Delays
Penalty
Summary
The facility failed to provide necessary Occupational Therapy (OT) and Physical Therapy (PT) services to a resident as indicated by the physician's order, care plan, and facility assessment tool. The resident, who was admitted with diagnoses including muscle weakness, gastrostomy, and end-stage renal disease, was assessed to require these therapies to prevent further decline in physical functions. Despite the resident's care plan and rehabilitation screening indicating a need for OT and PT, the services were not provided due to pending insurance authorization. The resident's Minimum Data Set (MDS) indicated a need for supervision and assistance with various activities of daily living, and the care plan included interventions to encourage participation in these activities. However, the MDS also showed that no therapy minutes were recorded, and the resident did not receive the necessary OT and PT services. Interviews with facility staff, including the Director of Rehabilitation (DOR) and the Business Office Manager (BOM), revealed that the delay in providing therapy was due to pending insurance authorization, which had not been communicated to the rehabilitation department. The facility's assessment tool confirmed that PT, OT, and speech therapy are services offered based on residents' needs, but there was no indication that these services should be contingent upon insurance authorization. The facility administrator was unaware of the situation and stated that therapy should have been provided as per the physician's order. This oversight placed the resident at risk for a decline in physical functions and developing contractures, which could negatively affect their overall wellbeing.
Failure to Honor Resident Preferences for CNA Gender
Penalty
Summary
The facility failed to honor the requests of two residents, Resident 37 and Resident 38, to be assisted by female Certified Nursing Assistants (CNAs) instead of male CNAs. Resident 37, who was admitted with conditions including benign lipomatous neoplasm, type 2 diabetes mellitus, and hemiplegia, had intact cognitive skills and was dependent on assistance for personal care. Despite her repeated requests and those of her husband, the facility continued to assign male CNAs to her care, which she found unsatisfactory and uncomfortable. Interviews with various staff members, including a Restorative Nurse Assistant and a CNA, confirmed that Resident 37's preference for female CNAs was known but not honored. Similarly, Resident 38, who had diagnoses including obesity and schizoaffective disorder, also expressed discomfort with male CNAs assisting her with personal hygiene tasks. Despite her moderate cognitive impairment, she clearly communicated her preference for female CNAs to the facility staff. However, the facility continued to assign male CNAs to her care. Interviews with a Registered Nurse and other staff members acknowledged the importance of respecting residents' preferences for the gender of their caregivers, yet these preferences were not accommodated. The facility's policy on accommodating residents' needs and preferences was not followed in these cases. The policy stated that residents' individual needs and preferences should be accommodated to the extent possible, except when health and safety are at risk. The failure to assign female CNAs as requested by Residents 37 and 38 was a violation of their rights to self-determination and had the potential to negatively impact their quality of life and psychosocial well-being.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for two residents, resulting in a violation of their rights. Resident 64 experienced a loss of personal property, including a purse containing important identification cards, upon admission to the facility. The facility's process for documenting and verifying resident belongings was not followed, as the inventory list was incomplete and lacked necessary signatures. This oversight led to the inability to confirm the presence of the missing items, causing distress to the resident and their responsible party. Additionally, Resident 31's bathroom was found to have four missing tiles, which detracted from the homelike environment the facility is required to maintain. The missing tiles were not reported or repaired in a timely manner, despite the facility's policy requiring maintenance issues to be addressed promptly. The lack of attention to the bathroom's condition affected the resident's perception of their living environment, making it feel less comfortable and familiar. Interviews with facility staff revealed a lack of adherence to established procedures for both inventory management and maintenance reporting. Staff members acknowledged the importance of verifying resident belongings and maintaining a homelike environment but failed to execute these responsibilities effectively. The deficiencies in both cases highlight a breakdown in communication and procedural compliance within the facility, impacting the residents' quality of life.
Failure to Update Care Plans for Diet and Dialysis Monitoring
Penalty
Summary
The facility failed to update and revise care plans for two residents, leading to deficiencies in care. For one resident, the care plan was not updated to reflect a change in diet from a regular diet to liquids for oral gratification as tolerated. Despite the physician's orders changing the diet due to the resident's inability to swallow, the care plan continued to indicate a regular diet, which posed a risk of aspiration. Interviews with the LVN and MDS Nurse confirmed that the care plan should have been updated to prevent the resident from consuming a regular diet, which could lead to aspiration. Another resident's care plan was not updated to address intake and output (I&O) monitoring related to dialysis treatment. The resident, who was on dialysis, initially had an order for I&O monitoring for 30 days, but this was not continued or re-evaluated after the period ended. The RN and MDS Nurse acknowledged that the care plan needed to be revised to include ongoing I&O monitoring and potential fluid restrictions, as the resident was at risk for fluid overload due to dialysis. The facility's policies indicated that care plans should be revised as residents' conditions change, but this was not adhered to in this case. The facility's failure to update care plans in accordance with physician orders and facility policies resulted in potential negative impacts on the residents' care. The deficiencies were identified through observations, interviews, and record reviews, highlighting the need for ongoing assessment and timely updates to care plans to ensure resident safety and appropriate care.
Deficiencies in Pressure Ulcer Care for Three Residents
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for three residents, leading to deficiencies in their treatment and prevention of pressure injuries. Resident 37's low air loss mattress (LALM) was not set according to their weight, which was 121 lbs, while the mattress was set at approximately 220 lbs. This incorrect setting was observed by the Restorative Nurse Assistant and confirmed by the Infection Preventionist Nurse, who stated that the setting should be below 140 lbs. The facility's policy required the LALM to be adjusted based on the resident's weight to maintain skin integrity and aid in healing. Resident 48 was not repositioned every two hours as per the physician's order and care plan, which was crucial due to their high risk for pressure injuries. Despite having multiple wounds and pressure injuries, Resident 48 was observed in the same position for several hours, and staff interviews revealed that the resident often refused to be turned due to pain. The facility lacked a care plan addressing the resident's refusal to be repositioned, and there was no documented evidence of informing the physician or responsible party about the refusal. Resident 60, admitted with a stage 4 pressure ulcer, did not have an order for a LALM since admission. The Treatment Nurse admitted to forgetting to inform the primary physician and obtain the necessary order. The resident was observed without a LALM until it was placed on 6/13/2024, despite the facility's policy requiring such interventions for residents with stage 3 and 4 pressure ulcers. The oversight in obtaining the LALM order and its delayed application potentially compromised the resident's pressure injury management.
Deficiencies in Dialysis Care for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents, Resident 60 and Resident 63, as per professional standards. For Resident 60, the facility did not assess the resident's left upper chest dialysis catheter on two occasions, and the dialysis care plan was not updated when a new AV shunt was placed. This oversight could lead to unnoticed or missed excessive bleeding and infection at the dialysis access sites. Additionally, the documentation of the dialysis communication records was incorrect and incomplete, which could cause confusion in care delivery. For Resident 63, the facility did not re-evaluate the order for intake and output after 30 days, nor did they ensure that licensed nurses contacted the physician regarding fluid restriction. The intake and output records were not documented according to facility policy, and an Interdisciplinary Team meeting was not conducted to discuss the resident's medical treatment and nursing care plan. These deficiencies indicate a lack of proper monitoring and communication regarding the resident's dialysis care needs. The report highlights that the facility's policies and procedures were not followed, leading to incomplete assessments and documentation. The Director of Nursing acknowledged the importance of accurate documentation and assessment to ensure proper care. The facility's failure to adhere to its own policies and procedures for dialysis care and monitoring contributed to the deficiencies observed in the care of Residents 60 and 63.
Failure to Assess and Document Side Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of side rails for two residents, leading to potential safety risks. Resident 32, who was readmitted with conditions such as seizures, hemiplegia, and cerebral infarction, had side rails used daily as a mobility aid and seizure precaution. However, the facility did not conduct the required quarterly reassessments to ensure the continued need and safety of the side rails, as the last assessment was completed in November 2023. This oversight was acknowledged by the Minimum Data Set Nurse, who admitted to not completing the necessary assessments in February and May 2024, contrary to the facility's policy. Resident 61, diagnosed with anxiety disorder, major depressive disorder, and insomnia, was observed with a side rail up without any documented assessment or physician order. The resident's Electronic Health Record lacked any order for side rail use, and staff interviews confirmed that no assessment had been conducted to justify the use of side rails. The facility's policy requires an assessment within seven days of admission and quarterly thereafter, along with obtaining informed consent and a physician's order, none of which were documented for Resident 61. The facility's failure to adhere to its policy on side rail usage and assessment posed a risk of inappropriate use of side rails, which could lead to resident harm. The lack of documentation and reassessment for both residents highlights a significant deficiency in ensuring the safety and appropriateness of side rail use, as required by the facility's own procedures.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 50, by not administering medications as ordered. On the specified date, the Licensed Vocational Nurse (LVN 1) did not administer several 9 AM medications, including Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch, which were crucial for managing the resident's conditions such as hypertension, edema, bowel management, seizures, and pain. Additionally, the LVN administered Dexamethasone at an incorrect time, deviating from the prescribed schedule of 6 AM, 2 PM, and 10 PM, which was intended to manage the resident's malignant neoplasm of the brain. The resident, who was admitted with diagnoses including angioneurotic edema, hypertension, and seizures, required partial assistance with daily activities and had intact cognitive skills. The failure to administer these medications as per the physician's orders was confirmed by both LVN 1 and a Registered Nurse (RN 1), who acknowledged the potential for medical complications, including uncontrolled high blood pressure and seizures, due to the missed doses. The facility's policy and procedure documents, which were reviewed, indicated that medications should be administered in a timely manner and in accordance with prescriber orders, highlighting the deviation from these protocols in this incident.
Failure to Report Medication Irregularities
Penalty
Summary
The facility failed to report medication regimen irregularities to the residents' primary physicians as required by their policy. This deficiency was identified during a review of the medication regimen reviews (MRR) for two residents. The pharmacist's recommendations for these residents were not acted upon in a timely manner, which could have led to the administration of unnecessary medications. Resident 12, who was admitted with diagnoses including heart failure and hyperlipidemia, was prescribed both Vascazen and Vascepa. The pharmacist recommended evaluating the necessity of both medications due to their similar effects. However, this recommendation was not promptly communicated to the resident's physician, potentially leading to the resident taking two medications with the same action. Resident 61, diagnosed with anxiety disorder, major depressive disorder, and insomnia, was prescribed Zyprexa three times daily. The pharmacist recommended verifying the diagnosis and specifying the target behavior for this medication. This recommendation was also not communicated to the resident's physician in a timely manner. The Director of Nursing acknowledged the delay in following up on the pharmacist's recommendations, which should have been reviewed and reported to the residents' doctors to prevent unnecessary medication use.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 28% error rate during a medication pass observation. Licensed Vocational Nurse 1 (LVN 1) did not administer several medications as ordered for one resident, leading to seven medication errors out of 25 opportunities. The errors included the failure to administer Dexamethasone at the correct time and the omission of multiple medications such as Cozaar, Lasix, Norvasc, Docusate Sodium, Levetiracetam, and a Lidocaine patch. The resident involved had a medical history of angioneurotic edema, hypertension, and seizures, and required partial assistance with daily activities. During the observation, LVN 1 prepared and administered only five of the resident's morning medications, omitting others that were crucial for managing the resident's conditions. The LVN acknowledged the failure to administer these medications and recognized the potential impact on the resident's health, such as uncontrolled blood pressure and the risk of seizures. Interviews with the nursing staff confirmed the medication administration errors and highlighted the importance of adhering to prescribed medication schedules to ensure the resident's well-being. The facility's policies on medication administration emphasize the need for timely and accurate administration of medications as per physician orders, which were not followed in this instance.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to adhere to its Medication Storage policy by not removing expired medications and improperly storing certain medications. Specifically, a box of expired eye gel and a box of expired eye drops were found in the medication storage room, which were not removed as required. Additionally, four unopened Basaglar Kwik Pens and four unopened Trulicity pens, which are medications used to control high blood sugar, were found stored at room temperature instead of in the refrigerator as required by the product labeling. This improper storage rendered the medications expired and unsafe for administration. Furthermore, the facility did not maintain the medication refrigerator properly, as it was found with accumulated ice, which could affect the temperature quality and efficacy of the refrigerated medications. The Director of Nursing acknowledged that the refrigerator should be defrosted and cleaned weekly, but there was no log to confirm when this was last done. These deficiencies were confirmed through observations and interviews with nursing staff, who acknowledged the risks associated with expired and improperly stored medications.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Several deficiencies were noted, including the failure to label foods in the kitchen with 'use by' or open dates, and the failure to discard expired food. Specifically, a resident's personal container with a used napkin was found on top of a Beef Base seasoning, and an opened and undated spray was observed. An opened pack of bread was also found undated. Additionally, expired turkey was found in the refrigerator, which should have been discarded according to the facility's policy. Further observations revealed unsanitary storage practices, such as a bowl on the floor under the dishwashing machine and a water line filter touching the floor drain, which could lead to contamination. A bathroom plunger was improperly stored under the receiving station next to the dishwashing machine. These practices were contrary to the facility's policies, which require proper labeling, storage, and separation of food and cleaning supplies to prevent cross-contamination and ensure safety. The Dietary Supervisor acknowledged these issues during interviews, indicating a lack of adherence to established procedures.
Failure to Monitor Refrigerator Temperatures for Resident Food
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring of refrigerator and freezer temperatures where residents' food brought from home was stored. This deficiency was observed for four out of five sampled residents. The facility's policy required daily temperature checks and recordings to ensure food safety, but from June 1 to June 11, 2024, the temperature logs were incomplete, with no recorded temperatures or comments. During an observation on June 11, 2024, the refrigerator's temperature was found to be at 50°F, which is above the safe threshold of 40°F, placing the food in the danger zone for bacterial growth. The Dietary Supervisor confirmed that the housekeepers were responsible for checking the temperatures, but they failed to do so during the specified period. The supervisor acknowledged that the current temperature of 50°F was unsafe and could lead to food poisoning. The facility's policy, revised in April 2024, stipulated that temperatures should be recorded daily by food service supervisors or designated employees, with acceptable refrigerator temperatures ranging from 35°F to 41°F. The failure to monitor and record temperatures as per the policy had the potential to result in food-borne illnesses among residents.
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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