Gilroy Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gilroy, California.
- Location
- 8170 Murray Avenue, Gilroy, California 95020
- CMS Provider Number
- 055797
- Inspections on file
- 35
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Gilroy Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognitive function was asked by a CNA to sign an arbitration agreement related to new facility ownership. The CNA, who had not received training on the agreement, provided only a minimal explanation, stating the resident could not sue the facility, and did not answer further questions. The resident signed the agreement without understanding its contents, contrary to facility policy requiring clear explanation.
A resident with quadriplegia and contractures in both upper and lower extremities was observed to have significant limitations in movement, as confirmed by therapy and medical documentation. However, the MDS assessment was inaccurately coded to indicate no impairment in range of motion, contrary to direct observations and staff interviews.
A systemic failure occurred when all residents receiving Levaquin or Metformin did not have required Black Box Warning (BBW) monitoring or care plans documented, and many lacked appropriate indications for antibiotic use. Nursing staff inconsistently documented BBW monitoring, with only day shift nurses seeing alerts, and evening and night shifts not consistently involved. The Infection Preventionist and Consultant Pharmacist did not identify or report these irregularities, resulting in widespread noncompliance with facility policy and regulatory requirements.
Six residents had POLST forms with the advance directive section left blank, despite facility policy requiring all sections to be completed. The DON confirmed that nursing staff did not complete these sections as required by policy.
Multiple residents did not have required care plans developed or implemented for conditions such as nebulizer therapy, epilepsy, helmet use, respiratory issues, infection, and anticoagulant therapy. Staff confirmed that care plans were missing despite physician orders and clinical needs, and one resident's call bell system was not assessed or adapted to their physical limitations.
Surveyors observed multiple medication administration errors, including failure to prime an insulin pen before injection, incorrect dosing of a nasal spray, and combining multiple crushed medications for G-tube administration instead of administering them separately with flushing. These actions were not in accordance with facility policies and physician orders.
Multiple residents reported that meals were bland, repetitive, and unappetizing, with specific complaints about tasteless and dry eggs served daily. During a test tray evaluation, surveyors, the RD, and the DM found the green beans to be overcooked, lacking flavor, and visually unappealing. Job descriptions for dietary staff required them to ensure food was appealing and to monitor food acceptance, but these standards were not met.
Surveyors found that metal pans used for food preparation and service were stacked and stored while still wet, rather than being air dried as required by professional standards. The dietary manager confirmed the improper storage, which had the potential to affect nearly all residents receiving food from the kitchen.
Surveyors identified multiple infection control deficiencies, including improper cleaning and disinfection of glucometers and medication trays, failure to wear required PPE during enteral medication administration, and improper storage and labeling of nebulizer kits, nasal cannulas, and basins. Additional lapses included soiled linen left on the floor, missing Enhanced Barrier Precautions signage for a resident with a pressure ulcer, and urinary catheter drainage bags touching the floor, all contrary to facility policy.
Six residents received antibiotics without meeting Loeb's criteria, with antibiotics prescribed for symptoms such as confusion, knee pain, or abdominal pain, and in some cases, without documented assessment or appropriate clinical indications. Antibiotics were started before culture results were available, and some prescribed antibiotics were not effective against the identified bacteria. The facility's antibiotic stewardship protocols and interdisciplinary oversight were not consistently followed.
Three residents with significant physical and cognitive impairments did not have accessible or appropriate call light systems, as their call light buttons were found on the floor and out of reach, and one resident was not provided with a suitable alternative call system despite being bedbound and unable to use the standard device. Staff confirmed the deficiencies, and facility policy required call lights to be accessible and tailored to individual needs.
The facility did not ensure that residents could easily access or were informed about the location of the latest State survey results. Multiple residents reported not knowing where to find the survey results, and staff interviews and observations confirmed that the required binder was not available in the designated area, contrary to facility policy.
Surveyors found that a resident's Foley catheter drainage bag was left uncovered and visible from the hallway, and two residents had personal care instructions posted openly in their rooms, making sensitive information visible to others. Staff confirmed these actions did not comply with facility policies requiring privacy and confidentiality.
The facility did not ensure that psychotropic medications were used only when necessary, as evidenced by two residents receiving antipsychotic and antidepressant medications without proper documentation of behavioral symptoms or attempts at non-drug interventions, and another resident receiving PRN lorazepam without a required stop date or physician reassessment. Staff and DON interviews confirmed the lack of documentation and adherence to facility policy regarding psychotropic medication use.
The facility did not accurately complete MDS assessments for two residents, resulting in incorrect documentation of discharge status, injectable medication use, and fall history. One resident was incorrectly coded as discharged to a hospital instead of home, while another had missing documentation of weekly SQ injections for diabetes and inaccurate fall reporting. These errors were confirmed by the MDS staff and DON during record reviews and interviews.
A resident with a right outer ankle pressure ulcer was found in bed without a dressing on the wound and without a Prevalon heel protector boot in place, despite physician orders for both. Staff confirmed the omission during observation, and records showed the required treatments and devices were not applied as ordered, resulting in a deficiency in pressure ulcer care.
Nursing staff did not consistently document the administration of PRN controlled medications on the MAR after signing them out from the CDR for three residents with physician orders for narcotic pain medications. This resulted in incomplete records and inaccurate accountability of controlled substances, as confirmed by the DON and ADON during record review and interviews.
A resident with type 2 diabetes had two similar orders for Dilaudid (hydromorphone) and a Fentanyl patch, but the Consultant Pharmacist did not identify or report the duplicate opioid orders during the monthly medication regimen review. The duplicate orders were confirmed by nursing staff, and records showed the resident received more than the maximum allowed dose of hydromorphone in one day.
Failure to Adequately Explain Arbitration Agreement Prior to Resident Signature
Penalty
Summary
The facility failed to ensure that a resident was provided with an adequate explanation of an arbitration agreement in a form and manner the resident could understand prior to obtaining her signature. A certified nursing assistant (CNA) approached the resident and requested her electronic signature for the arbitration agreement, which was related to a change in facility ownership. When the resident asked for clarification, the CNA only stated that signing meant she could not sue the facility and did not provide further explanation. The CNA also admitted to not having received any education or training from the facility regarding the arbitration agreement or how to explain it to residents. The resident, who had diagnoses including depression, hypertension, and type 2 diabetes, was assessed as having intact memory and full mental capacity at the time of the incident. Documentation confirmed that the resident was alert and oriented, and her medical records indicated she was capable of understanding information presented to her. Despite this, the resident signed the agreement without understanding its contents, as the explanation provided was insufficient. Facility policy required that such agreements be explained in a manner understood by the resident or their representative, but this was not followed in this instance.
Inaccurate MDS Coding for Range of Motion with Contractures
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with significant contractures and quadriplegia. Observations revealed that the resident had curled fingers on the right hand, contractures in the left wrist, and both ankles, and was unable to move both hands and legs. Interviews with the resident confirmed the inability to open fingers or hold objects due to joint restrictions, and no movement in both legs. The resident's medical history included quadriplegia and cerebrovascular disease, with occupational therapy notes and physician documentation confirming impaired range of motion (ROM) in both upper and lower extremities due to contractures. Despite this, the resident's MDS assessment indicated no impairment for upper or lower extremity ROM. Interviews with the Director of Rehabilitation and the MDS Coordinator confirmed the presence of contractures and impaired ROM, and acknowledged that the MDS assessment was inaccurately coded. The facility's policy requires comprehensive and accurate assessments of each resident's functional capacity, but this was not followed in this case, resulting in an inaccurate MDS assessment for ROM.
Systemic Failure to Monitor and Document Black Box Warning Medications
Penalty
Summary
Surveyors identified a systemic failure in the facility's management of medications with FDA Black Box Warnings (BBW), specifically Levaquin (levofloxacin) and Metformin, affecting all residents who received these drugs. For 54 residents who received Levaquin and 19 residents who received Metformin, there was no documentation that BBW monitoring was performed, and no care plans were developed addressing the BBW risks associated with these medications. Additionally, 30 residents who received Levaquin did not have an appropriate indication or diagnosis documented for its use. Six residents received both Levaquin and Metformin without proper BBW monitoring or care plans. These failures were confirmed through record reviews, interviews with staff, and examination of the facility's policies and procedures. Interviews with nursing staff, the Infection Preventionist (IP), and the Director of Nursing (DON) revealed inconsistencies and gaps in understanding and implementing BBW monitoring. While the facility's policy required nursing progress notes to reflect monitoring and resident response to BBW medications, staff interviews indicated that only the day shift nurse administering the medication would see the BBW alert, and documentation in progress notes was inconsistent or absent. Evening and night shift nurses were not consistently alerted or documenting BBW monitoring. Multiple resident records reviewed showed no evidence of BBW monitoring in either the Medication Administration Record (MAR) or nursing progress notes, despite ongoing or recent administration of Levaquin or Metformin. The facility's Infection Preventionist and Consultant Pharmacist failed to identify and report irregularities related to frequent Levaquin use, missed BBW monitoring, inappropriate antibiotic indications, and lack of care plans during their respective reviews. The deficiency was observed across all shifts and affected all residents prescribed these medications during the review period. The lack of monitoring and documentation was confirmed for multiple residents with complex medical histories, including those with kidney disease, diabetes, infections, and other serious conditions, as evidenced by detailed record reviews and staff interviews.
Incomplete POLST Forms for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms were fully completed for six out of eight sampled residents. Specifically, the section regarding advance directives (AD) was left blank on the POLST forms for these residents. Record reviews showed that, despite the residents' admissions and the preparation of their POLST forms, the required section for documenting advance directives was not filled out. This omission was confirmed during a concurrent record review and interview with the Director of Nursing (DON), who acknowledged that nursing staff should have completed all sections of the POLST forms. Facility policies and procedures require that a completed and fully executed POLST form is a legal physician order and must be immediately actionable. Additionally, the policies state that any decision-making regarding a resident's choices should be documented in the medical record and communicated. The failure to complete the advance directive section on the POLST forms for these residents represents noncompliance with these established policies.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for nine out of 26 sampled residents, as required by policy and professional standards. Specific deficiencies included the absence of care plans for residents receiving nebulization therapy, those with a diagnosis of epilepsy and prescribed anti-seizure medication, and residents requiring the use of a craniotomy helmet, including documentation of non-compliance with helmet use. Additionally, care plans were missing for residents experiencing wheezing or shortness of breath, those with active infections, and residents prescribed blood thinners such as Eliquis and Warfarin. Surveyors observed and confirmed through interviews and record reviews that these omissions occurred despite clear evidence in the residents' clinical records and physician orders indicating the need for such care plans. For example, residents with new or ongoing respiratory issues were receiving nebulizer treatments or inhaled medications without corresponding care plans. Similarly, residents with significant neurological or cardiovascular diagnoses, such as epilepsy or atrial fibrillation, were prescribed critical medications without individualized care plans addressing their conditions or the use of these medications. Further, the facility did not assess or document appropriate call bell system needs for a resident with significant physical limitations, resulting in the call light being inaccessible and not tailored to the resident's abilities. Staff interviews confirmed that care plans were not initiated or updated in a timely manner, and that the responsibility for care planning was not consistently fulfilled by the nursing staff, including the MDS nurse, ADON, and DON. Facility policies required comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not developed or implemented for the affected residents.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility was found to have a medication error rate of 18.18% during medication administration observations, with 6 errors identified out of 33 opportunities involving three residents. For one resident with diabetes, an LVN failed to prime the insulin pen before administering a 40-unit dose of insulin degludec, despite facility policy and manufacturer instructions requiring priming to ensure accurate dosing. The LVN acknowledged the omission during an interview, and both the DON and consultant pharmacist confirmed that priming is required before each use. Another resident was prescribed fluticasone nasal spray with instructions to administer two sprays in each nostril daily. During observation, an LVN administered only one spray per nostril. Upon review of the physician's order and facility policy, the LVN confirmed the error and acknowledged the correct dose should have been given as ordered. A third resident, who received medications via a gastrostomy tube, was administered four different crushed medications combined together in a single dose, contrary to facility policy. The RN responsible for the administration admitted that each medication should have been crushed and administered separately with appropriate flushing between medications. The DON and consultant pharmacist both confirmed that medications should not be mixed together for enteral administration, and the facility's policy requires separate administration and flushing.
Failure to Provide Palatable and Attractive Food to Residents
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and met expectations for taste and presentation. Multiple residents reported dissatisfaction with the meals, describing them as bland, lacking flavor, repetitive, and unappetizing. Specific complaints included breakfast being tasteless and monotonous, with eggs served daily that were described as dry and flavorless. These concerns were voiced by several residents during interviews conducted on the same morning. In response to these complaints, a test tray evaluation was conducted during a lunch service, with participation from the registered dietician (RD), dietary manager (DM), and surveyors. The green beans served as an alternate vegetable were found by surveyors to be unappealing in appearance, lacking color, overcooked, and without flavor. Both the DM and RD agreed with these assessments, with the DM noting the green beans were mushy and flavorless, and the RD stating they did not look appetizing enough to taste. Review of job descriptions for the cook and RD confirmed their responsibilities included ensuring appealing food presentation and monitoring food acceptance, which were not met in this instance.
Wet Stacking of Food Preparation Pans
Penalty
Summary
During a kitchen tour, surveyors observed 11 metal pans of various sizes stored under the steam table, stacked upside down inside one another while still wet on both the inside and outside surfaces. The dietary manager confirmed that the pans were wet and acknowledged that they should have been air dried before being stacked and stored. This practice did not comply with the 2022 FDA Food Code, which requires equipment and utensils to be air-dried after cleaning and sanitizing, and to be stored in a self-draining position that allows air drying. The failure to properly air dry and store the pans had the potential to affect 117 of 118 residents who received food from the kitchen.
Multiple Infection Control Deficiencies Observed
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. One nurse was seen using a glucometer on multiple residents without properly cleaning and disinfecting it according to manufacturer and facility policy. The nurse wrapped the glucometer in a disinfectant wipe without wiping it down first, and did not ensure the required wet contact time. Additionally, the same nurse failed to disinfect a medication tray between uses for different residents, despite facility policy requiring all reusable items to be cleaned between uses. Another nurse did not wear a gown during enteral tube medication administration, contrary to the facility's Enhanced Barrier Precautions policy, which requires both gloves and gowns for such procedures. Further deficiencies were noted in the handling and storage of resident care equipment. Used nebulizer kits, masks, and tubing were found unlabeled, undated, and improperly stored among residents' personal belongings or in plastic bags on nightstands. Staff interviews revealed inconsistent knowledge of cleaning, labeling, and replacement protocols for these items, with some staff unsure of the correct procedures or frequency of changes. Similar issues were observed with nasal cannulas, which were left uncovered, undated, and not stored in plastic bags when not in use. Used basins were also found unlabeled and stored inappropriately in shared bathrooms, and a bag of soiled towels was left on the floor outside the soiled linen room, both in violation of facility policy. Additional infection control lapses included the absence of Enhanced Barrier Precautions signage for a resident with a stage 3 pressure ulcer, and urinary catheter drainage bags observed touching the floor in two separate resident rooms. Staff confirmed that these practices did not align with facility policies, which require catheter bags to be kept off the floor and signage to be posted for residents requiring enhanced precautions. These observed failures were corroborated by staff interviews and a review of facility policies, all of which outlined proper procedures that were not followed during the survey period.
Failure to Follow Antibiotic Stewardship Program and Loeb's Criteria
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program by administering antibiotics to six residents who did not meet the Loeb's criteria for initiating antibiotic therapy. In multiple cases, antibiotics were prescribed and administered based on symptoms that did not align with established clinical guidelines, such as confusion, knee pain, or abdominal pain, without the presence of fever, dysuria, or other specific signs of infection. Documentation revealed that antibiotics were started before culture results were available, and in some instances, the prescribed antibiotics were not effective against the identified microorganisms, as shown by culture results indicating resistance. For example, one resident with Alzheimer's disease and a history of UTI was given levofloxacin for suspected UTI despite only exhibiting knee pain and increased confusion, with no fever or urinary symptoms. Another resident with paralysis of the vocal cords and diabetes received levofloxacin for pharyngitis based solely on a fever and sore throat, without further documented assessment or additional symptoms. Additional residents received antibiotics for confusion, abdominal pain, or asymptomatic bacteriuria, again without meeting the minimum clinical criteria for antibiotic initiation. Interviews with the Infection Preventionist (IP) and review of records confirmed that the facility's antibiotic stewardship meetings were infrequent, and there was a lack of consistent interdisciplinary oversight. The IP acknowledged awareness of the inappropriate antibiotic use but deferred to physician decisions, and the medical director confirmed a practice of prescribing antibiotics preemptively while awaiting culture results. The facility's policy required adherence to evidence-based criteria and monitoring of antibiotic use, but these protocols were not consistently followed, as evidenced by the findings.
Failure to Ensure Accessible and Appropriate Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the needs and preferences of three residents were reasonably accommodated, specifically regarding the accessibility and appropriateness of call light systems. For two residents with significant cognitive and physical impairments, the call light buttons were observed on the floor and out of reach while the residents were in bed. One resident, who had a history of spinal fracture and moderate cognitive impairment, was unable to access his call light and stated he did not know how long it had been on the floor. Another resident, with severe cognitive impairment and right-sided hemiplegia, was also unable to locate his call light, which was confirmed by staff to be on the floor. Staff interviews revealed that there should have been clips to secure the call lights within reach, and facility policy required call lights to be accessible to residents at all times. A third resident, who was bedbound with left-sided hemiplegia and aphasia following a stroke, was found to have a call light button hanging from urinary catheter tubing and resting on the floor, making it inaccessible. Staff confirmed that this resident never used the standard call light button and acknowledged that a different call system would have been more appropriate given the resident's limited movement and high dependency. Facility policy required that residents be evaluated for unique needs and that special accommodations, such as alternative call systems, be provided and documented in the care plan. These failures were identified through direct observation, resident and staff interviews, and record reviews. The lack of accessible and appropriate call systems for these residents had the potential to delay staff response and did not meet the residents' needs as required by facility policy and procedure.
Failure to Make State Survey Results Readily Available to Residents
Penalty
Summary
The facility failed to ensure that residents were made aware of the location of the latest State inspection results, including the Statement of Deficiencies and any subsequent survey findings. During a Resident Council meeting, six residents stated they were not aware of where to find the survey results and had not been informed by facility staff. Observations in the front lobby and at multiple nurse stations revealed that the State inspection results were not posted or available in the designated areas, and the binders present did not contain or indicate the survey results. Interviews with staff, including the activities supervisor, administrator, unit clerk, registered nurse, certified nursing assistant, and DON, confirmed that the survey results binder was not available in the lobby as required by facility policy. Staff members were either unaware of the binder's location or unable to provide clear information about its whereabouts. The facility's policy stated that the survey binder should be located in the main lobby and available for review, but this was not being followed at the time of the survey.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of three residents' personal and medical information. For one resident with muscle weakness and benign prostatic hyperplasia, surveyors observed that the resident's Foley catheter drainage bag was left uncovered on two separate occasions, making the contents visible from the hallway. The privacy curtains were open, and the drainage bag, containing yellow urine, was not concealed with a privacy bag as required by facility policy. Staff confirmed that the catheter bag should have been covered to protect the resident's privacy and dignity. Additionally, two other residents had personal care instructions posted openly in their shared rooms, making sensitive information visible to roommates and visitors. One resident had a large sign above the head of the bed instructing staff to remove and replace dentures, while another had two signs regarding the use of a neck brace and caution during care. Both residents were aware of the postings, and staff confirmed that such instructions should be covered or placed in a manner that maintains privacy. Facility policies reviewed by surveyors emphasized the importance of protecting residents' privacy and confidentiality in these situations.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications for multiple residents. One resident with Alzheimer's disease and dementia was administered a high dose of quetiapine (Seroquel) for reported auditory hallucinations, but there was no documentation in the clinical record specifying the nature of these hallucinations or evidence that they caused harm or significant distress. Observations and interviews with staff and the resident's family indicated that while the family reported past behavioral symptoms, there was no current documentation or monitoring of such symptoms in the facility records to justify the ongoing use of the medication. Another resident with bipolar disorder and depression was prescribed both Seroquel and fluoxetine, but the clinical record lacked evidence that non-drug interventions were attempted prior to administering these psychotropic medications. The Director of Nursing confirmed that nursing staff did not document any non-pharmacological approaches before medication administration, as required by facility policy. A third resident with depression received PRN lorazepam without a stop date, and the clinical record did not show that a physician had reassessed the need for continued use of the medication after 14 days, as required. The DON acknowledged the absence of physician re-evaluation and documentation for the ongoing PRN order. Facility policies require non-pharmacological interventions to be attempted and PRN psychotropic orders to be time-limited unless properly justified, but these procedures were not followed for the residents involved.
Inaccurate MDS Assessments for Discharge, Medication, and Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation of discharge status, medication administration, and fall history. For one resident, the discharge MDS was coded as a transfer to an acute hospital, despite physician orders and staff confirmation that the resident was discharged home with medications and home health services. This discrepancy was verified during a record review and interview with the Minimum Data Set Manager, who acknowledged the error and confirmed the resident was not discharged to a hospital as recorded. For another resident, the MDS assessment failed to document the use of injectable medication, despite physician orders and electronic medication administration records showing weekly subcutaneous injections for diabetes. Additionally, the MDS inaccurately recorded the resident's fall history, listing both a fall with no injury and a fall with injury, when only a fall with no injury was documented in the incident reports. These inaccuracies were confirmed by the Minimum Data Set Coordinator Manager and the Director of Nursing during interviews and record reviews, who both stated that the MDS assessments should have been completed accurately according to facility policy and the RAI Manual.
Failure to Provide Ordered Pressure Ulcer Care and Preventive Devices
Penalty
Summary
A deficiency occurred when a resident with a right outer ankle pressure injury was observed in bed without a dressing on the wound and without a Prevalon heel protector boot on the right foot. Certified nursing assistant (CNA) and registered nurse (RN) both confirmed during separate observations that the resident's pressure injury was not covered as ordered, and the heel protector boot was not in use, despite being present on the nightstand. The CNA acknowledged forgetting to verify and apply the boot, while the RN confirmed that the dressing had not been applied to the pressure injury at the time of observation. Record review showed that there were physician orders in place for daily cleansing and dressing of the pressure ulcer, as well as for the use of a Prevalon heel protector boot to the right foot. The facility's policy required redistribution of pressure and evidence-based treatments for residents with pressure injuries. The failure to follow these orders and policies resulted in the resident not receiving necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries.
Failure to Document Administration of Controlled Medications
Penalty
Summary
Nursing staff failed to accurately document the administration of controlled medications for three out of seven sampled residents. In each case, staff signed out controlled medications such as hydrocodone-acetaminophen and oxycodone from the Controlled Drugs Records (CDR), but did not record the administration on the Medication Administration Record (MAR). This discrepancy was identified during a review of the CDRs and MARs for residents who had physician orders for as-needed (PRN) narcotic pain medications. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the medications were signed out but not documented as administered on the MAR, and acknowledged that this documentation was required by facility policy. The facility's policies require that nursing staff sign the MAR after administering medications and maintain accurate controlled substance records, including the date, time, and signature of the person administering the medication. The DON stated that staff sometimes become busy and forget to document on the MAR, but confirmed that all controlled medications must be accounted for on the MAR. The failure to document these administrations resulted in inaccurate accountability of controlled substances for the affected residents.
Failure to Identify and Report Duplicate Opioid Orders During Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities during the monthly medication regimen review for one resident. Specifically, the resident was admitted with a diagnosis of type 2 diabetes mellitus and had two similar physician orders for Dilaudid (hydromorphone), both prescribed at the same dose and frequency, as well as an order for a Fentanyl patch. The orders included Dilaudid 2 mg, 4 tablets by mouth every 3 hours as needed for pain, and hydromorphone 8 mg, 1 tablet by mouth every 3 hours as needed for pain, with a maximum of 4 tablets per day. The duplicate orders were not identified or reported as irregularities in the medication regimen review conducted by the CP. Interviews and record reviews confirmed that the duplicate orders existed and were not addressed in the MRR. The CP acknowledged during an interview that the duplicate order was missed and should have been recommended for discontinuation. Additionally, a review of the controlled drug records showed that the resident received hydromorphone 8 mg five times in one day, exceeding the maximum ordered dose. The facility's policy required a thorough evaluation of the medication regimen to prevent, identify, report, and resolve medication-related problems, which was not followed in this instance.
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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