Meadowbrook Behavioral Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3951 East Blvd., Los Angeles, California 90066
- CMS Provider Number
- 05A269
- Inspections on file
- 33
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Meadowbrook Behavioral Health Center during CMS and state inspections, most recent first.
A resident with schizophrenia and generalized anxiety disorder, who was cognitively intact but had hallucinations and delusions, was not shown as attending IDT care conferences held to discuss psychotropic meds. The resident said he had not been able to speak with anyone about his meds and reported increased confusion and more voices after starting current medications. Staff confirmed the resident’s increased Zyprexa dose was discussed, but there was no indication he attended or was invited.
Failure to follow physician orders for BG monitoring: A resident with type 1 DM, prior ketoacidosis, and insulin use had a care plan and physician progress notes calling for BG checks twice daily. The resident's BGs were monitored for several days in January, and the MAR showed insulin glargine was later discontinued while metformin continued. During interview, an LVN said the NP's plan of care required twice-daily BG monitoring and that the physician or NP must tell the nurse the order, while an RNS stated nurses are supposed to read physician progress notes but not all do.
Two residents who smoked did not receive required quarterly smoking assessments per facility policy. One resident with paranoid schizophrenia had intact cognition and a smoking care plan based on an initial eval, but the next assessment was delayed beyond the expected quarterly interval. Another resident with paranoid schizophrenia, HTN, and HLD also had intact cognition and was observed smoking on the patio with staff assistance, yet the smoking evals were spaced more than six months apart. The RNS stated the missed assessments were used to determine whether residents could smoke safely.
Failure to Address Significant Weight Loss: A resident with schizophrenia, HTN, and hyperlipidemia had progressive weight loss from 241 lbs to 206 lbs, but the facility did not initiate a COC for the significant loss, did not hold a weight variance IDT, and did not revise the nutrition-related care plans. An SBAR noted earlier weight loss and an RD eval recommendation, but the resident’s ongoing decline was not reflected in updated interventions.
Failure to Notify Physician of Abnormal HGB Result: A resident with CKD stage 4 and chronic anemia had a low HGB lab result that was not documented as reported to the physician. The resident later went to a nephrology appt and was sent to the ED for chronic anemia, where the anemia was noted to be due to a GI bleed and the resident had chest pain. RN confirmed there was no evidence the abnormal lab had been communicated to the MD per policy.
A facility failed to ensure that three resident rooms held no more than 4 residents per room. During a tour, Rooms 3 and 4 each had six beds and Room 5 had five beds, all with curtains. A resident stated there were no problems with the number of residents in the room and that everyone comes and goes as they please. The facility’s waiver request letter stated that residents have chronic and persistent mental illnesses and are generally ambulatory, physically stable, and able to exit independently.
Insufficient room space per resident: The facility failed to provide at least 80 sq ft per resident in 17 of 27 rooms, with several multi-bed rooms measuring between 67.2 and 78.8 sq ft per bed. Record review showed the room waiver letter and accommodations analysis documenting the undersized rooms, and during observation an interviewed resident stated the room gave each resident adequate space. The waiver request described residents as generally ambulatory, physically stable, and able to egress independently.
A resident with a documented history of poor boundaries and inappropriate touching, including public masturbation and intrusiveness, was not adequately monitored or managed, resulting in the resident entering a shared bathroom and attempting to touch another resident's private area without consent. The victim, also with a psychiatric diagnosis, reported feeling scared and violated, and staff interviews confirmed ongoing issues with the perpetrator's behavior. The psychologist was not fully informed of the extent of the behaviors, and facility policy requiring identification and intervention for at-risk residents was not effectively implemented.
A resident with paranoid schizophrenia repeatedly engaged in inappropriate behaviors, including touching other residents and staff without consent, as well as public masturbation. Despite extensive documentation and staff awareness of these incidents, the psychologist was not informed of the frequency or severity of the behaviors, nor of specific boundary violations. This lack of communication resulted in another resident experiencing psychological distress and a physical altercation, highlighting a failure to provide appropriate mental health services and interventions.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents with significant mental health conditions and lacking decision-making capacity engaged in sexual activity without adequate staff awareness or oversight. Staff interviews revealed inconsistent knowledge of the relationship, and after the encounter, one resident experienced emotional distress, reported feeling unsafe, and was transferred to a hospital following allegations of aggression. The facility failed to ensure a safe environment and proper supervision for these residents.
A resident with a history of exchanging money for sex engaged in non-consensual sexual contact with another resident who lacked capacity to consent, despite prior documentation of sexually inappropriate behavior. Facility staff failed to investigate or act on known risks, and did not implement necessary supervision or interventions, resulting in sexual abuse and emotional harm.
The facility failed to implement its abuse prohibition policy, resulting in a resident who lacked capacity being sexually abused by another resident with a known history of exchanging money for sex. Staff were aware of the perpetrator's sexually inappropriate behaviors but did not properly report or investigate these actions, and the facility did not take adequate steps to prevent or address the abuse as required by policy.
A facility failed to prevent the spread of sexually transmitted infections by not ensuring that residents, who lacked decision-making capacity and were under conservatorship, practiced safe sex. Despite knowing that a resident with a confirmed STI engaged in unprotected sex with others, staff did not implement or monitor infection control measures such as condom use, and interviews revealed a lack of procedures to ensure safe sexual practices.
Two residents were subjected to physical abuse in separate incidents: one involving a physical altercation with a staff member, and another involving a fight between two residents after a verbal dispute escalated. In both cases, staff failed to prevent or promptly intervene in the altercations, resulting in injuries that required medical evaluation.
A resident was not allowed to return to the facility after hospitalization despite being medically cleared for discharge on oral antibiotics. The facility cited the need for isolation due to MSSA, although no isolation order was present. The resident remained in the hospital longer than necessary, and their bed was given to a new resident.
Residents in the facility were unable to access the results of the most recent survey due to the survey binder being placed in a quarantined area, inaccessible to them. Despite having intact cognition and the ability to perform ADLs independently, residents expressed interest in reviewing the survey results but were unaware of their location. Staff confirmed the binder's placement in a restricted area, violating the facility's policy on resident rights to access information about their care.
The facility failed to ensure safe food storage and preparation, with unlabeled and undated cooked chicken and meats in the freezer, and raw chicken improperly stored above vegetables. Interviews revealed non-compliance with facility policies, risking contamination.
The facility failed to use an effective cleaning agent for infection control and did not maintain an adequate supply of N95 masks, as all available masks were expired. The Housekeeping Supervisor was not trained on infection control, and the Director of Nursing confirmed the need for non-expired masks to ensure resident safety. The facility's policy required available PPE at all times, which was not met.
The facility failed to maintain essential kitchen equipment and infrastructure, resulting in a leaking pipe under the kitchen sink and a separated wall panel, creating gaps for pests. The Dietary Supervisor and Maintenance Director were unaware of these issues, and improper food storage practices were also observed. The facility's maintenance policy was not effectively implemented, leading to these deficiencies.
The facility failed to accurately code the MDS for a resident's antipsychotic medication use and did not transmit assessments for two residents within the required timeframe. A resident was incorrectly marked as not taking antipsychotic medication despite being prescribed Zyprexa. Additionally, two residents had completed MDS assessments that were not transmitted on time. The DON acknowledged these issues, which are against facility policy requiring timely and accurate MDS submissions.
The facility failed to develop and implement comprehensive care plans for two residents, one with herpes and another on psychotropic medication. Resident 16's care plan lacked interventions for herpes, while Resident 14's plan did not address the use of Buspirone. Interviews with staff confirmed non-compliance with facility policies requiring timely and person-centered care plans.
The facility failed to ensure housekeeping staff were competent in infection control practices, risking infection spread among residents. The Housekeeping Supervisor admitted the disinfectant used did not specify its effectiveness against bacteria or viruses, and had not received any infection control training. The Director of Staff Development did not maintain files for contracted housekeepers, and a review of the HS's file showed no infection control training records, despite facility policy requiring such training.
The facility did not post nurse staffing information in a location accessible to residents, as required by policy. The staffing form was placed in a restricted area, confirmed by the DSD and DON, making it inaccessible to residents. A resident expressed interest in knowing staff numbers, but the information was not available to them.
The facility was found to have exceeded the maximum resident capacity in three rooms, with two rooms housing seven residents each and one room housing five residents. Despite the overcrowding, a resident reported adequate space. The facility had requested a waiver, citing that their residents, diagnosed with chronic mental illness, were ambulatory and capable of egress without staff assistance, and that the room arrangements did not adversely affect their health and safety.
The facility did not meet the required 80 square feet per resident in six rooms, with sizes ranging from 67.2 to 78.1 square feet per bed. Despite this, a resident reported feeling that the space was adequate.
A resident reported non-consensual sexual abuse by an LVN, who allegedly kissed and touched her inappropriately. The facility failed to promptly investigate or report the incident, and the LVN admitted to being alone with the resident in a non-resident area, violating facility policies. The resident felt unsafe and did not want to remain in the facility.
The facility failed to maintain updated competency evaluations and necessary documentation for its nursing staff, including LVNs and CNAs. Employee files lacked current licenses, CPR cards, and evidence of annual competencies or abuse training. Interviews with staff revealed that some had not completed required training since hiring, highlighting a potential deficit in skills and knowledge necessary for resident care.
The facility failed to supervise two residents in the staircase, leading to one resident pushing another, placing them at risk for serious injury. Both residents had diagnoses of paranoid schizophrenia and exhibited behavioral issues leading up to the incident. Staff interviews revealed that the stairwell was often left unsupervised, contributing to the altercation.
Resident Not Included in Psychotropic Medication Care Conferences
Penalty
Summary
The facility failed to ensure that one sampled resident participated in care plan meetings to discuss psychotropic medications, despite the resident being cognitively intact and having diagnoses of schizophrenia and generalized anxiety disorder. The resident’s MDS dated 1/24/2026 indicated intact cognition, hallucinations, and delusions. The resident’s care plan, initiated on 10/14/2024, identified risk for complications related to psychotropic medications, including Seroquel, Zyprexa, and Trazodone, and included interventions to monitor mental status and functional level, monitor the continued need for medication, and provide informed consent to the resident or healthcare decision maker. Physician orders showed Trazodone 100 mg at bedtime ordered on 1/26/2026, Seroquel XR 300 mg at bedtime ordered on 2/9/2026, and Zyprexa 20 mg at bedtime ordered on 3/10/2026 for symptoms related to schizophrenia and generalized anxiety disorder. IDT care conference forms showed a psychotropic medication meeting on 2/18/2026 attended by the PD and RNS 1, and another on 3/11/2026 attended by the PD, RNS 1, DSD, and APD, but the resident was not listed as an attendee on either form. During interview, the resident stated he had not been able to speak to anyone about his medications, said his medications were making him more confused and that he had started hearing more voices since beginning his current medications, and stated that although he had attended IDT meetings, his medications were not addressed. RNS 1 stated the resident and responsible party are part of the IDT care conference, that the resident’s increased Zyprexa dosage was discussed at the last medication conference, and that there was no indication the resident attended or was invited.
Failure to Follow Physician Orders for Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure licensed nurses notified the physician for orders related to blood glucose monitoring twice daily as indicated in the physician's plan of care for one resident. The resident was admitted with paranoid schizophrenia, type 1 diabetes mellitus with ketoacidosis without coma, and long-term use of insulin. The care plan, initiated in December 2025 with a target date in April 2026, identified diabetes dependent on insulin and included goals for the resident to remain free of signs and symptoms of hypoglycemia and hyperglycemia, with interventions to access and record blood glucose levels. The resident's MDS dated 1/13/2026 indicated cognition was intact and that the resident did not use mobility devices when ambulating. Physician progress notes dated 1/05/2026, 1/20/2026, 1/29/2026, 2/06/2026, and 3/03/2026 documented the diagnoses of type 1 diabetes mellitus with ketoacidosis without coma, paranoid schizophrenia, and long-term use of insulin, and also indicated to continue blood glucose monitoring twice daily. Blood glucose monitoring in January 2026 showed checks from 1/01/2026 through 1/06/2026, with values ranging from 88 mg/dL to 142 mg/dL. The MAR showed insulin glargine started on 12/18/2025 at 9 PM and discontinued on 1/06/2026 at 1:52 PM, with instructions to hold the insulin when blood glucose was less than 100 mg/dL. The MAR for February, March, and April 2026 showed metformin started on 12/03/2025 with no end date. During interview, an LVN stated the NP's plan of care indicated continued blood glucose monitoring twice daily and said the physician or NP needs to tell the nurse the order. An RNS stated nurses are supposed to read physician progress notes but that not all nurses do, and did not answer when asked what the physician's progress note was if it is not read by nurses.
Missed Smoking Assessments for Two Residents
Penalty
Summary
The facility failed to follow its Smoking policy by not completing required quarterly smoking assessments for two residents who smoked. Resident 35 was admitted with diagnoses including paranoid schizophrenia and syphilis. A Quarterly MDS dated 3/3/2026 indicated the resident’s cognition was intact. The resident’s smoking evaluation dated 11/20/2025 stated the resident could safely smoke without a smoking apron, and the care plan for smoking supervision was based on that assessment. Resident 35’s smoking evaluation showed the last assessment was completed on 3/30/2026, with the prior assessment completed on 11/20/2025. During a concurrent interview and record review on 4/3/2026, the Registered Supervisor stated there should have been a smoking assessment completed in February 2026 and that the assessment is used to evaluate whether the resident can smoke safely. The supervisor stated that not completing the assessment placed Resident 35 at risk for smoking injury and could affect the resident’s health. Resident 71 was admitted with diagnoses including paranoid schizophrenia, high cholesterol, and high blood pressure. The resident’s MDS indicated cognition was intact. A smoking evaluation dated 3/12/2025 stated the resident could safely smoke without a smoking apron, and the smoking care plan required supervision based on the assessment. The resident’s smoking evaluations showed the last two assessments were completed on 9/12/2025 and 4/1/2026, leaving more than six months between assessments. During observation on 4/2/2026, Resident 71 was seen entering the smoking patio, receiving a pack of cigarettes from staff, removing one cigarette, and having staff light it before smoking. During the 4/3/2026 interview and record review, the Registered Supervisor stated smoking assessments should have been completed in December 2025 and March 2026, and that the missed assessments placed Resident 71 at risk for smoking injury and could affect the resident’s health.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to provide timely nutritional intervention for a resident with significant weight loss. Resident 51 was admitted with diagnoses including paranoid schizophrenia, high cholesterol, and high blood pressure, and his admission weight was documented as 241 lbs. The resident’s MDS dated 3/3/2026 showed intact cognitive skills for daily decision-making, independence with ADLs, and a weight of 224 lbs with a loss of 5% or more in the last month or 10% in the last 6 months, while the resident was not on a physician-prescribed weight loss regimen. The resident’s weight log showed a decline from 241 lbs on admission to 236 lbs, then 232 lbs, 224 lbs, and finally 206 lbs on 3/3/2026. An SBAR communication form dated 1/5/2026 documented an eight-pound weight loss and noted the physician recommended a RD evaluation. However, no change of condition form was initiated for the 18 lb weight loss documented on 3/3/2026, and no weight variance IDT was held when the resident experienced the continued weight loss. The resident’s weight loss care plan, initiated 1/5/2026, identified risk for further weight loss related to sporadic refusal of breakfast and included interventions such as notifying the charge nurse of meal refusal, monitoring lunch and dinner intake, and obtaining RD recommendations. The Nutritional Risk care plan, initiated 1/6/2026, addressed significant weight loss and included monthly weights, snacks, and honoring preferences within the meal plan. Both care plans were not updated or revised after the continued weight loss on 3/3/2026. During interview, the RN supervisor stated that a significant weight change should trigger a change in condition, physician notification, and an IDT meeting, and acknowledged that the resident’s nutrition care plans were not updated and the IDT was not held after the significant weight loss was discovered.
Failure to Notify Physician of Abnormal Hemoglobin Result
Penalty
Summary
The facility failed to inform a physician of an abnormal lab result for one of four sampled residents, Resident 61, in accordance with the facility’s policy and procedures for change in condition and lab result notification. Resident 61 had diagnoses that included chronic kidney disease stage 4, iron deficiency anemia, and anemia in chronic kidney disease. The resident’s care plan for anemia, initiated in 2020, identified that the resident was at risk for low hemoglobin, weakness, shortness of breath, and fatigue, and included interventions to administer medications as ordered, assess for increased fatigue and shortness of breath, and notify the physician of lab work results per policy. Resident 61’s lab result from 11/11/2025 showed a hemoglobin level of 8.8 g/dl, which was below the normal reference range of 11 to 18 g/dl and 0.9 points lower than the prior hemoglobin result of 9.7 g/dl from 5/15/2025. During a concurrent interview and record review on 4/3/2026, RN 1 reviewed the resident’s chart and stated the hemoglobin was low and required physician notification. RN 1 also stated there was no evidence in the progress notes or change of condition forms that the physician had been notified of the abnormal lab result. On 11/13/2025, Resident 61 went to a nephrology appointment for regular follow-up and was sent from the appointment to a GACH due to chronic anemia. The ED note stated the resident was being evaluated for chronic anemia and kidney disease, had some chest pain, and that the anemia was due to a gastrointestinal bleed at that time. The resident received IV normal saline and was admitted for continued care and management, including close monitoring and treatment of unstable vital signs, cardiorespiratory status, and neurological status.
Excess Residents in Shared Rooms
Penalty
Summary
The facility failed to ensure that three resident rooms accommodated no more than 4 residents per room. During an initial tour on 3/31/2026 at 10:52 AM, Rooms 3, 4, and 5 were observed; Rooms 3 and 4 each had six beds, and Room 5 had five beds, all with curtains. Resident 28 stated there were no problems with the number of residents in the room and that everyone comes and goes as they please without difficulty. During record review, the facility’s room waiver request letter dated 3/31/2026 stated that the facility serves individuals diagnosed with chronic and persistent mental illnesses, often with significant behavioral and emotional disturbances, and that residents are generally ambulatory, physically stable, and capable of independent egress without staff assistance.
Insufficient room space per resident
Penalty
Summary
The facility failed to meet the requirement of 80 square feet per resident in 17 of 27 resident rooms, including Rooms 1, 3, 5, 7, 8, 9, 13, 15, 17, 18, 20, 21, 23, 24, 25, 26, and 27. During record review, the facility's room waiver letter and client accommodations analysis form completed on 3/31/2026 showed multiple rooms with less than 80 square feet of livable space per resident, including rooms with 2, 3, 5, or 6 beds and per-bed space measurements ranging from 67.2 to 78.8 square feet. During a concurrent observation and interview on 3/31/2026 at 10:52 AM, Resident 28 stated the room gave each resident adequate space. The facility's room waiver request letter, dated 3/31/2026, stated that the facility serves individuals diagnosed with chronic and persistent mental illnesses, often accompanied by significant behavioral and emotional disturbances, and that residents are generally ambulatory, physically stable, and capable of independent egress without staff assistance.
Failure to Protect Resident from Inappropriate Touching by Peer with Known Behavioral Issues
Penalty
Summary
The facility failed to protect a resident from inappropriate touching by another resident, despite being aware of the perpetrator's ongoing behavioral issues. One resident, diagnosed with paranoid schizophrenia and under conservatorship, had a documented history of poor personal boundaries, including repeated incidents of standing too close, touching others, and masturbating in public. Over the course of a year, staff documented hundreds of episodes of intrusive and inappropriate behaviors, including touching both residents and staff without consent. The care plan for this resident included interventions such as behavioral health consultations, participation in a special treatment program, and one-to-one counseling, but these measures did not prevent further incidents. The incident in question involved the resident with a history of boundary violations entering a shared bathroom while another resident was using it and attempting to touch the resident's private area without permission. The victim, also diagnosed with paranoid schizophrenia and under conservatorship, reported feeling scared, uncomfortable, and violated, and responded by physically defending himself. Staff interviews confirmed that the perpetrating resident was known for intrusive behaviors and that redirection and supervision were routinely used, but these interventions were insufficient to prevent the incident. Staff and other residents corroborated the pattern of inappropriate touching and lack of respect for personal boundaries. Documentation and interviews revealed that the psychologist responsible for the resident was not informed of the full extent of the inappropriate behaviors, including public masturbation and attempts to kiss staff. The facility's policy required identification of residents at risk for abusive behaviors and consideration of alternative placement if warranted, but these steps were not fully implemented. The failure to adequately monitor and intervene allowed the incident to occur, resulting in psychological and emotional distress for the victim and increased risk for peer conflict and safety concerns among other residents.
Failure to Notify Psychologist of Repeated Inappropriate Resident Behaviors
Penalty
Summary
The facility failed to notify the psychologist regarding a resident who exhibited repeated inappropriate behaviors, including touching other residents and staff without consent. Despite extensive documentation of these behaviors in the resident's care plan and behavior summaries, which included hundreds of episodes of intense staring, standing too close, intrusiveness, masturbating in public, and inappropriate touching throughout the year, the psychologist was not informed of the severity or frequency of these incidents. The psychologist was also unaware of specific boundary violations, such as the resident attempting to kiss a staff member and entering shared bathrooms while occupied by other residents. The resident in question had a diagnosis of paranoid schizophrenia and was under conservatorship, with a documented history of poor boundaries and inappropriate social behaviors. The care plan included interventions such as encouraging behavioral health consultation and 1:1 counseling, but there was no evidence that the psychologist was kept informed of ongoing or escalating behaviors. Staff interviews confirmed that the resident's inappropriate touching and boundary issues were longstanding and required frequent redirection, but these actions were not effectively communicated to the psychologist for further intervention or adjustment of the treatment plan. Another resident, who was also diagnosed with paranoid schizophrenia and under conservatorship, reported psychological stress and emotional distress after being inappropriately touched by the first resident. This incident led to a physical altercation between the two residents. Staff and other residents corroborated the ongoing issues with the resident's intrusive behaviors. Facility policy required identification and intervention for residents with disruptive behaviors, but the lack of communication with the psychologist represented a failure to provide appropriate treatment and services for residents with mental disorders or psychosocial adjustment difficulties.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Safe Environment and Oversight for Residents Unable to Consent to Sexual Activity
Penalty
Summary
The facility failed to ensure a safe environment and adequate oversight for two residents who were unable to make their own decisions, resulting in one resident experiencing emotional distress and feeling unsafe. Both residents had significant mental health diagnoses, including schizoaffective disorder, anxiety disorder, paranoid schizophrenia, and bipolar disorder, and were under conservatorship, indicating they could not make their own medical decisions but could express their needs. Despite these limitations, the facility did not ensure that staff were aware of or monitored the sexual activities between the two residents. Staff interviews revealed inconsistent awareness and understanding of the residents' relationship and sexual activities. A Certified Nursing Assistant acknowledged the relationship and stated that residents had the privilege to have sex, but also indicated that staff should be alerted if residents were seen together in certain ways. However, a Registered Nurse was unaware of the sexual relationship and had not been informed by the residents or other staff. The Director of Nursing and the Administrator described general monitoring practices but did not demonstrate that specific oversight or interventions were in place for these two residents, who were known to lack decision-making capacity. Following the sexual encounter, one resident exhibited significant emotional and psychological distress, including panic, anxiety, increased pacing, new or worsened delusions or hallucinations, and expressed feeling unsafe and wanting to harm others. The resident was subsequently evaluated by a psychiatric crisis team and transferred to a hospital. The facility was notified by the hospital that the resident alleged her boyfriend was sexually and physically aggressive with her. The facility's investigation confirmed that staff were not fully aware of the sexual activities or the need for closer monitoring of these residents, as required by their conditions and care needs.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident who had a known history of exchanging money for sex while residing at the facility. On the evening of the incident, the resident with a history of sexually inappropriate behavior entered the victim's room without consent, exposed himself, and engaged in non-consensual sexual contact, including touching and sucking on the victim's breasts, despite the victim repeatedly telling him to stop. The victim was unable to consent to sexual activities due to her mental health condition, which included paranoid schizophrenia and a legal conservatorship indicating incapacity to make her own decisions. Prior to the incident, there were documented indications that the perpetrator had been sexually active with multiple residents and had exchanged money for sexual favors. This information was recorded in progress notes and reported to a director who was no longer employed at the facility, but the DON and other key staff were not made aware of these behaviors. The facility did not investigate the allegations of money exchange for sex or the ongoing sexually inappropriate behavior, and staff were unaware of the extent of the perpetrator's actions until after the incident occurred. Interviews and record reviews revealed that staff, including CNAs and RNs, had observed or were aware of a prior relationship between the two residents, but there was no evidence that the facility assessed either resident's capacity to consent to sexual activity or implemented appropriate supervision or interventions to prevent abuse. The facility's policies prohibited abuse, mistreatment, and exploitation, and required immediate reporting and investigation of any allegations or suspicions of sexual abuse, but these procedures were not followed, resulting in the resident experiencing sexual abuse and emotional distress.
Failure to Implement Abuse Prohibition Policy Resulting in Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its Abuse Prohibition Policy and Procedure to prevent, prohibit, and investigate allegations of sexual abuse, specifically in the case involving two residents. One resident, who lacked the capacity to consent to sexual activities and was under a conservatorship, was subjected to non-consensual sexual contact by another resident with a known history of exchanging money for sex within the facility. Despite documentation and staff awareness of the perpetrator's sexually inappropriate behaviors and history, the facility did not take adequate steps to prevent further incidents or investigate prior allegations of exploitation and abuse. The incident occurred when the resident with a history of sexually inappropriate behavior entered the room of the resident lacking capacity, exposed himself, and engaged in sexual acts despite being told to stop multiple times. The victim reported feeling objectified and devalued as a result of the assault. Staff interviews and record reviews revealed that the perpetrator had previously been sexually active with multiple residents and had exchanged money for sexual favors, but these behaviors were not properly reported or investigated by facility leadership, including the DON and administrators. Documentation showed that staff, including a program counselor, were aware of the perpetrator's actions and had reported them to a former director, but the information was not escalated to the DON or administrator as required by policy. The facility's policies clearly defined non-consensual sexual contact and mandated immediate reporting and investigation of any allegations or suspicions of abuse. However, the facility failed to follow these procedures, resulting in the occurrence of sexual abuse and the lack of protection for vulnerable residents.
Failure to Prevent Transmission of Sexually Transmitted Infections Among Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in preventing the transmission of sexually transmitted infections (STIs) among residents. Three residents, all under conservatorship and lacking capacity to make their own decisions, engaged in unprotected sexual activity with each other. One resident with a confirmed diagnosis of a sexually transmitted virus had unprotected sex with another resident, who subsequently had unprotected sex with a third resident. Documentation showed that these interactions occurred on multiple occasions, and staff were aware of the sexual activities but did not implement adequate precautions to prevent STI transmission. Medical records indicated that the residents involved had significant mental health diagnoses, including schizophrenia and schizoaffective disorder, and were considered gravely disabled, requiring conservatorship for placement and decision-making. Despite these vulnerabilities, the facility's staff allowed residents to engage in sexual activity during designated free time without ensuring the use of condoms or verifying consent capacity. Staff interviews revealed a lack of knowledge and procedures regarding monitoring or promoting safe sex practices among residents, and there was no evidence of consistent implementation of infection control measures specific to sexual activity. The facility's own infection prevention and control policy referenced adherence to CDC guidelines, which recommend condom use to prevent the spread of HIV and other STIs. However, interviews with staff, including the infection preventionist, DON, and counselors, demonstrated that the facility did not have effective systems in place to ensure these guidelines were followed. The failure to implement appropriate precautions and monitor sexual activity among residents with known or suspected STIs resulted in a deficiency in the facility's infection prevention and control program.
Failure to Protect Residents from Physical Abuse by Staff and Peers
Penalty
Summary
The facility failed to protect residents from physical abuse in two separate incidents involving both staff-to-resident and resident-to-resident altercations. In the first incident, a resident with schizoaffective and bipolar disorder, who was cognitively intact and independent in activities of daily living, was involved in a physical fight with a primary counselor inside the resident's assigned room. The resident initially reported a fall but later disclosed the altercation, which was corroborated by the roommate and another staff member. The resident sustained a swollen right palm and an abdominal bruise as a result of the incident. The facility's investigation confirmed that the physical altercation occurred in the presence of another staff member who did not intervene. In the second incident, two residents with intact cognition and independence in daily activities engaged in a physical altercation after a verbal dispute escalated. One resident approached the other in the hallway, and after an exchange of words, initiated physical contact by hitting the other resident, who then retaliated. Staff interviews revealed that although staff were present and heard the argument, they did not intervene until the altercation became physical. Both residents required x-rays following the incident, and one resident reported nasal pain as a result of being struck in the nose. The facility's policies defined physical abuse to include hitting and other forms of corporal punishment, and required protection of residents from such harm. In both cases, staff failed to prevent or promptly intervene in the altercations, resulting in residents being subjected to physical abuse and requiring medical evaluation. The incidents were substantiated by resident and staff interviews, as well as medical records documenting the injuries sustained.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its policy and procedures by not allowing a resident to return after hospitalization, despite the resident being medically cleared for discharge. The resident, who had been admitted to the facility with diagnoses including paranoid schizophrenia and diabetes mellitus, was transferred to a General Acute Care Hospital (GACH) for abdominal pain and shortness of breath. During the hospital stay, the resident was diagnosed with pneumonia, fecal impaction, and developmental delay. The resident's physician orders indicated a plan to discharge the resident back to the facility on oral antibiotics, but the facility did not permit the return, citing the need for isolation due to MSSA, despite no isolation order being present. The Assistant Admissions Coordinator (AAC) and the Director of Nursing (DON) were involved in the decision-making process. The AAC was informed by the Social Worker (SW) that the resident might be discharged on the seventh day of the bed-hold period. However, the DON decided against readmission due to the resident's need for isolation and ongoing IV antibiotics, which were later changed to oral antibiotics. Despite the change, the resident was not readmitted, and the bed was given to a new resident. This resulted in the resident remaining in the hospital longer than necessary, potentially affecting their psychosocial wellbeing.
Residents Denied Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents could easily access the results of the most recent survey and any plan of correction. This deficiency was observed for four residents, all of whom had intact cognition and were capable of performing activities of daily living independently. These residents expressed interest in reviewing the survey results but were unaware of where the information was located. Interviews with the residents revealed their desire to understand the facility's performance and any issues identified in the survey. The survey results were found to be located in a binder placed in a quarantined area, which was inaccessible to residents. The area was marked with yellow and black tape to prevent residents from wandering near the exit door, and the binder was not visible from behind the quarantine tape. Staff members, including the Program Manager, Assistant Administrator, and Administrator, confirmed that the survey binder was in this restricted area, and residents were not permitted to enter. The facility's policy on resident rights indicated that residents should have access to information regarding their care, including survey results. However, the placement of the survey binder in a quarantined area effectively denied residents this right. The facility's failure to provide residents with access to the survey results was a violation of their rights to information about their care while in the facility.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as observed during a kitchen tour and interviews with dietary staff. A container of cooked leftover chicken was found in the refrigerator without a date, and opened, unboxed bags of meatballs, egg rolls, and other meats in the kitchen's freezer were not labeled or dated. Additionally, a pan of uncooked chicken was improperly stored on top of raw vegetables in the refrigerator. These practices were contrary to the facility's policy, which requires all foods to be dated, labeled, and stored in a manner that prevents contamination. Interviews with the Dietary Supervisor and a dietary staff member revealed a lack of adherence to the facility's food handling policies. The Dietary Supervisor was unaware of which staff member stored the cooked chicken, and both he and the dietary staff member acknowledged that storing raw chicken on top of vegetables could lead to contamination and illness. The facility's policy mandates that uncooked and raw animal products be stored separately and below ready-to-eat foods to prevent contamination, a guideline that was not followed in this instance.
Inadequate Infection Control Measures and Expired PPE
Penalty
Summary
The facility failed to use an appropriate cleaning agent to prevent the spread of infection. During an observation, a bottle of rapid multi-surface disinfectant cleaner was found on the housekeeping cart, but it did not indicate its effectiveness against bacteria or viruses. The Housekeeping Supervisor admitted to not being trained or having completed an infection control competency with the contracted cleaning service or the facility. The Administrator confirmed that the Housekeeping Supervisor should be knowledgeable about the cleaning supplies to ensure the facility uses the right disinfectant to prevent infections. Additionally, the facility did not maintain an adequate supply of N95 masks, as all available masks were expired. The Maintenance Supervisor acknowledged the expired status of the masks and stated that a new supply would be ordered. The Director of Nursing also confirmed the expiration of the masks and emphasized the need for non-expired masks to ensure resident safety and prevent disease spread during a respiratory outbreak. The facility's policy indicated that personal protective equipment should be available at all times, but this was not adhered to in the case of the N95 masks.
Facility Fails to Maintain Kitchen Equipment and Infrastructure
Penalty
Summary
The facility failed to maintain essential kitchen equipment and infrastructure, leading to several deficiencies. During an inspection, it was observed that there was a leaking pipe under the kitchen sink, with a red bucket placed underneath to catch the water. The Dietary Supervisor was unaware of the leak, which posed a risk of staff slipping and potential mold growth. Additionally, the entire wall panel from the sink was completely separated from the wall, creating gaps that could allow pests and rodents to enter the kitchen. The Maintenance Director, who had been employed for five months, was also unaware of these issues and did not maintain a log of kitchen inspections. The inspection further revealed improper food storage practices, including unlabelled and undated opened bags of meat and a pan of uncooked chicken placed on top of raw vegetables. There was also a container of cooked chicken without a date and no documentation on the cooling down log for the cooked chicken stored in the refrigerator. The facility's pest control invoice from the previous month had already highlighted the structural concerns, yet no action had been taken to address them. The facility's maintenance policy requires regular inspections and maintenance of the building and equipment, but these were not effectively implemented, leading to the observed deficiencies.
MDS Coding and Submission Deficiencies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding antipsychotic medication use. Resident 48, who was admitted with diagnoses including paranoid schizophrenia, was prescribed Zyprexa, an antipsychotic medication, since 2021. However, the MDS incorrectly indicated that the resident was not taking any antipsychotic medication, despite the Medication Administration Record showing daily administration of Zyprexa. The Director of Nursing acknowledged the error, stating that the MDS should accurately reflect the care the resident was receiving. Additionally, the facility did not transmit the quarterly and annual assessments for two residents within the required 14-day period after completion. Resident 45, admitted with schizophrenia and anemia, and Resident 52, admitted with schizophrenia, both had completed MDS assessments that were not transmitted. The Director of Nursing noted that the MDS nurse is responsible for timely submission, but the assessments were not marked as accepted in the system, indicating they were not transmitted. The facility's policy and procedures require that resident assessments be submitted in accordance with federal and state guidelines. The Assessment Coordinator or designee is responsible for ensuring timely submission to the CMS' QIES Assessment Submission and Processing system. The failure to accurately code and timely transmit MDS assessments could lead to incorrect reflection of residents' care plans and services received.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for two residents, leading to potential risks of suboptimal care. Resident 16 was admitted with diagnoses including herpes viral infection and immunodeficiency virus. Despite being cognitively intact and not requiring assistance with activities of daily living, the baseline care plan for Resident 16 did not include interventions or goals for managing genital herpes. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed that the facility did not comply with its policy of developing and implementing a baseline care plan within 48 hours of admission. Resident 14, admitted with schizophrenia, anxiety disorder, and pain, was prescribed Buspirone for anxiety. However, the care plan for Resident 14 lacked individualized, person-centered objectives, monitoring, and a timetable to address the use of Buspirone. The Registered Nurse Supervisor confirmed the absence of a care plan for the psychotropic medication, which is necessary to monitor potential side effects. The Director of Nursing acknowledged the importance of care planning for psychotropic medications to ensure resident safety. The facility's policies and procedures require the interdisciplinary team to develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes. The failure to adhere to these policies for Residents 14 and 16 indicates a deficiency in providing effective and person-centered care, potentially compromising their physical, mental, and psychosocial well-being.
Inadequate Infection Control Training for Housekeeping Staff
Penalty
Summary
The facility failed to ensure that staff, particularly those in housekeeping, were competent in infection control practices, which could potentially lead to the spread of infections among residents. During an interview, the Housekeeping Supervisor (HS) admitted that the disinfectant used in the facility did not specify which bacteria, infections, or viruses it was effective against. Furthermore, the HS had not received any in-service training or completed an infection control competency since being employed, either with the contracted cleaning service or the facility itself. Additionally, the Director of Staff Development (DSD) stated that she did not maintain files for the housekeepers, as they were contracted employees, and that the Administrator kept the HS's employee file. The contracted company was responsible for the other housekeepers' files. The DSD also mentioned that all housekeepers' annual competencies were completed online with the contracted company. A review of the HS's employee file revealed no records of infection control in-service, competency, or training. The facility's policy required all staff, including contracted personnel, to participate in regular in-service education, including training on infection prevention and control program standards.
Failure to Post Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a visible and prominent place daily, as required by their policy. During an observation, the Daily Nurse Staffing form, which indicated the number of CNAs, LVNs, and RNs scheduled for each shift, was found in an area secured by quarantine tape, inaccessible to residents. This area was near the staff restroom and exit, which residents were not permitted to enter. The Director of Staff Development confirmed that the staffing information was posted by the time clock, in a location not accessible to residents, and acknowledged that residents could not read the posting from its position. Interviews with residents and staff further highlighted the deficiency. A resident expressed interest in knowing the number of staff on duty, stating that such information was not available to them. The Director of Nursing also confirmed that residents were not allowed in the area where the staffing hours were posted, making it impossible for them to see the information. The facility's policy, revised in August 2022, required that staffing numbers be posted in a prominent location accessible to residents and visitors, which was not adhered to, leading to the deficiency.
Facility Exceeds Resident Room Capacity
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as three of the 27 resident rooms exceeded the maximum capacity. Specifically, two rooms housed seven residents each, and one room housed five residents. This was observed during a facility tour, where it was noted that some beds had curtains closed around them, and some residents were not present in the room. Despite the overcrowding, a resident interviewed stated that the room provided adequate space. The facility had submitted a room waiver request, indicating that their resident population, diagnosed with chronic and persistent mental illness, were healthy, ambulatory, and capable of egress without staff assistance. The waiver claimed that the room arrangements did not adversely affect residents' health and safety or impede their ability to achieve their highest practicable well-being.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to meet the requirement of providing at least 80 square feet per resident in six out of 27 resident rooms. Specifically, Rooms 1, 3, 5, 7, 8, and 9 did not meet the required space per resident, with room sizes ranging from 67.2 to 78.1 square feet per bed. This deficiency was identified through observation, interview, and record review, including a room waiver letter and client accommodations analysis form completed by the facility. During an interview, a resident stated that the room provided adequate space, despite the documented deficiency.
Failure to Investigate Alleged Sexual Abuse by LVN
Penalty
Summary
The facility failed to thoroughly investigate an allegation of non-consensual sexual abuse involving a Licensed Vocational Nurse (LVN) and a resident. The incident was first reported to the Director of Nursing (DON) on November 28, 2024, although the alleged abuse occurred around October 2024. The resident reported that the LVN entered her room, kissed her, and touched her inappropriately, later instructing her to meet him in the chart room where further inappropriate contact occurred. Despite the resident's intact cognition, the facility did not take immediate action to ensure her safety or conduct a comprehensive investigation. Interviews with various staff members, including the Program Director, Social Services, and the Primary Counselor, revealed inconsistencies in the handling of the report. The resident initially confided in the Primary Counselor, who then informed the Program Manager, DON, and Administrator. However, the facility did not promptly report the incident to the Department of Public Health, nor did they take the resident to a hospital for further examination. The LVN involved admitted to being alone with the resident in the chart room and providing her with food, which is against facility policy. The facility's policies prohibit staff from being alone with residents in non-resident areas like the chart room and from providing outside food or clothing without proper authorization. Despite these policies, the LVN admitted to purchasing clothes and food for residents, further violating facility guidelines. The failure to adhere to these policies and the lack of a timely and thorough investigation into the allegations left the resident feeling unsafe and unwilling to remain in the facility.
Deficiency in Nursing Staff Competency Evaluations
Penalty
Summary
The facility failed to ensure that the nursing staff met the required skills and competency evaluations, as evidenced by the lack of updated documentation in the employee files for four staff members, including two Licensed Vocational Nurses (LVNs) and two Certified Nursing Assistants (CNAs). During a review of these files, it was found that there were no current LVN licenses, updated CPR cards, annual competencies, or updated background checks. Additionally, there was no evidence of CNA licenses, CPR care, annual competencies, or abuse training. The Director of Nursing (DON) acknowledged that these documents should be current and present in the employee files, and that annual competencies, including abuse training, are mandatory at the facility. Interviews with the nursing staff further highlighted the deficiency. One LVN admitted to not having completed abuse training since being hired and could not recall the last time he underwent annual competency training. Another LVN also could not remember when he last received training for abuse, annual competencies, sexual harassment, or a background check, indicating that these were only completed upon hiring. Both staff members emphasized the importance of annual competencies to ensure they do not forget how to properly care for residents or complete essential tasks. The facility's policy and procedures require competency evaluations upon hire, annually, and as necessary, but these were not adhered to, leading to a potential deficit in knowledge, training, and certification among the nursing staff.
Failure to Supervise Residents Leading to Physical Altercation
Penalty
Summary
The facility failed to follow its Abuse Prohibition Policy and Procedure by not supervising two residents, Resident 1 and Resident 2, while they were in the facility's staircase. This lack of supervision led to an incident where Resident 2 pushed Resident 1, placing Resident 1 at risk for serious injury, harm, or death. The incident occurred on 5/10/2024 at 10:40 AM when both residents were exiting the staircase after being excused from a group session due to a verbal argument. Resident 1, who has a diagnosis of paranoid schizophrenia and exhibits symptoms of psychosis, was admitted to the facility with a care plan that included monitoring for medical conditions contributing to psychosis and encouraging participation in special treatment programs. Despite these interventions, Resident 1 had episodes of labile moods and suspicious behavior leading up to the incident. On the day of the incident, Resident 1 reported being pushed multiple times by Resident 2 in the staircase. Resident 2, also diagnosed with paranoid schizophrenia and exhibiting risk for distressed mood symptoms, had a care plan that included encouraging participation in special treatment programs and providing support for distressed moods. Resident 2 had episodes of intrusiveness and disorganized thought processes leading up to the incident. During the incident, Resident 2 reported pushing Resident 1 out of the way because she felt threatened. Staff interviews revealed that the stairwell was often left unsupervised, and there was no specific person designated to supervise the stairs, leading to the altercation between the two 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
