Rocky Point Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakeport, California.
- Location
- 625 16th Street, Lakeport, California 95453
- CMS Provider Number
- 055499
- Inspections on file
- 29
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Rocky Point Care Center during CMS and state inspections, most recent first.
Two residents with multiple chronic conditions, including dementia, chronic pain, respiratory failure, CKD, CHF, and other comorbidities, were transferred to a hospital/ER for changes in condition, including uncontrolled pain, altered mental status, unresponsiveness, and panicked rapid breathing. In both cases, the facility did not provide written bed-hold notices to the residents or their responsible parties at the time of transfer, despite facility policy requiring written information on bed-hold policies at admission and again at transfer (or within 24 hours for emergency transfers). The DSD acknowledged that bed-hold information was only given verbally by phone, and the DON confirmed there was no documentation in either resident’s record that written bed-hold notices were provided.
A resident with dementia, behavioral disturbance, chronic pain, encephalopathy, anxiety, insomnia, cerebral palsy, and recurrent depressive disorder was hospitalized for uncontrolled pain and a change in mental status and later deemed stable for transfer back to a SNF. Despite repeated requests from the family and hospital case management, the facility refused readmission, citing unspecified needs and behaviors and inquiring if the family could pay for a 24-hour private sitter, without clearly identifying which care needs could not be met or documenting a change in condition requiring a different level of care. The DON reported that residents are permitted to return after hospitalization, while the Administrator stated the facility could not manage the resident’s care, referenced worsening behaviors, and acknowledged that the decision not to readmit was made by non-clinical corporate staff, contrary to the facility’s bed-hold and return policy requiring evaluation based on the resident’s current condition.
The facility did not ensure that resident bedrooms met the required minimum of 80 square feet of living space per resident in shared rooms and 100 square feet in single rooms, with 23 of 31 rooms found to be undersized. Measurements taken by the Maintenance Director showed individual living spaces as small as 7 by 8 feet, and the Maintenance Director acknowledged not knowing there was a minimum room size requirement. A resident reported that a three-person room was too small, and another resident stated the room was too small to maneuver in and spent more time in the halls. The Administrator also reported being unaware of the 80-square-foot per resident requirement.
Surveyors observed multiple medication administration errors that produced a 14.71% error rate. In separate passes, an LPN gave an oral hypoglycemic after a meal instead of 30 minutes before, and administered Basaglar insulin without holding the pen to the skin for the manufacturer-required 5 seconds. Another LPN underdosed a resident’s fluticasone nasal spray by giving only one spray per nostril instead of two. A third LPN administered Humalog insulin but held the pen in place for only 3 seconds, and gave metformin before dinner trays were served despite an order to give it with breakfast and dinner. These errors did not follow MD orders, manufacturer instructions, or facility policy.
Dietary staff did not ensure that meals were palatable or properly prepared, as evidenced by resident council complaints over several months about poor food quality, inedible textures, and feeling rushed during meals, and by a resident stating the food was poor and vegetables were overcooked. Observations showed canned vegetables and pureed meats were prepared and placed on the steam table well over an hour before service, then held for extended periods. A test tray later revealed that regular and pureed items, including roast beef, scalloped potatoes, corn, and bread, were bland, gummy, and gray in appearance. Facility recipes for key items lacked any seasonings, despite policies requiring vegetables to be prepared close to serving time with appropriate seasonings and garnishes to maintain nutritive value and appeal.
Staff failed to clean and maintain oxygen concentrators used for oxygen therapy for several residents with COPD, chronic respiratory failure, hypoxemia, dementia, and dependence on supplemental O2. Surveyors observed concentrators with heavy dust buildup on exterior vents and within internal filter compartments, including discolored and visibly dirty filters, while residents were receiving continuous O2 via NC. The Maintenance Supervisor and IP repeatedly confirmed that filters needed changing and machines needed cleaning, and one resident reported that no one had been cleaning the concentrator. There were no maintenance or cleaning logs for facility-owned concentrators, oxygen concentrators were not included on housekeeping cleaning guides, and vendor maintenance records could not be located, despite facility policy and the manufacturer’s manual requiring routine cleaning and filter maintenance, especially for continuously operated equipment.
Nursing staff failed to follow manufacturer instructions for insulin pen administration for two residents by not maintaining the required hold time after injection, despite prior education from the pharmacy consultant and acknowledgment by the DON that this was necessary to ensure full dosing. Another resident with alcoholic cirrhosis and portal hypertension had an order for rifaximin 550 mg BID for hepatic encephalopathy prophylaxis, but MAR review showed 36 missed doses documented as "medication not available," along with seven doses incorrectly recorded as given even though the drug had not been supplied. The resident reported that his liver medication had been stopped because it was too expensive and described feeling abnormal and excessively sleepy, while chart review revealed no documentation that the MD or DON had been notified of the ongoing omission, contrary to facility policy requiring prompt provider notification of significant medication errors.
Two residents with COPD and chronic respiratory conditions did not receive oxygen therapy as ordered by their physicians. One resident, care planned for risk of respiratory distress and ordered continuous O2 at 3 L/min via nasal cannula, was observed receiving only 2 L/min, despite the MAR documenting 3 L/min and no progress note explanation or MD notification. Another resident, ordered continuous O2 at 2 L/min with scheduled changes of disposable prefilled humidifiers, was observed receiving 1.5 L/min without a humidifier attached, and had no care plan addressing oxygen therapy. Facility policies required verification and prompt implementation of MD orders for oxygen, but these were not followed.
Surveyors found that a resident with hypertensive heart disease, chronic kidney disease, a history of falls, and documented use of bilateral hearing aids did not have a care plan addressing hearing impairment, despite the MDS noting use of hearing appliances and moderate cognitive impairment. The resident reported difficulty hearing, stated her hearing aids were not working and needed servicing, and said she had not received help scheduling service or an appointment with her ear doctor. An LN acknowledged the resident was hard of hearing and required loud, slow speech but was unaware she had hearing aids, while the MD noted her hearing had declined but felt she still understood conversations. These findings conflicted with facility policy requiring the IDT to develop a comprehensive, person-centered care plan that specifies needed services and responsible professional disciplines.
Surveyors found that pharmaceutical delivery receipts for multiple dates were not signed by pharmacy or facility licensed staff, contrary to facility policy requiring reconciliation and signature to document acceptance of medications. The DON acknowledged that receipts were not reconciled and signed as expected. In a separate incident, a resident with moderate cognitive impairment was observed repeatedly spitting out a pill, with three pills left on the bedside table, after an LPN had left acetaminophen, calcium, and Vitamin B complex at the bedside without supervision. Review of orders confirmed there was no authorization for the resident to self-administer medications, and the DON stated that leaving medications at the bedside without physician approval was a safety concern.
A resident with anxiety and depression, who frequently yelled for help, was repeatedly subjected to verbal abuse and threats from another cognitively intact resident with depression. On multiple occasions, the aggressor resident approached the yelling resident in her room and at the nurses’ station, yelled profanities, called her a “bitch,” and made statements such as “suffocate the bitch,” “I’m going to choke you out,” and “I’m going to slap that bitch.” Nursing staff observed the incidents, noted that the victim appeared scared and reported being afraid, and confirmed the accuracy of the documented threats. The aggressor resident later stated he went to the other resident with the intention of making her “shut up,” despite a facility abuse policy that defines and prohibits verbal abuse, including threats and derogatory language toward residents.
The facility failed to report allegations of verbal abuse within the required two-hour timeframe after one cognitively intact resident repeatedly entered another resident’s room and common areas, yelling profanities and making explicit threats to choke, slap, and harm her. Nursing staff documented the incidents in progress notes, SBAR, and the 24-hour report log and notified the DON and ADM, including via text, but the DON told a nurse that an SBAR was not needed because it was only yelling and no one was touched, and instructed that the word “abuse” not be used in documentation. The ADM acknowledged that the incident was not reported to CDPH until the following day by fax, and records show the abuse report form was faxed after multiple episodes of resident-to-resident verbal aggression and threats, contrary to facility policy requiring all alleged abuse to be reported immediately but no later than two hours.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not procure food from approved sources or ensure that food was stored, prepared, distributed, and served according to professional standards, as observed by surveyors.
Surveyors found that the facility did not provide a homelike, clean, and safe environment, as evidenced by worn and stained carpeting throughout the hallways and damaged walls with exposed drywall in multiple resident rooms. Several residents confirmed the long-standing nature of the damage, and the administrator acknowledged both the wall and carpet issues, noting that the carpeting also hindered wheelchair and equipment movement.
A resident with moderately impaired cognition was physically pushed by another resident during an argument over TV channels, resulting in a fall and injuries to the forearm. The incident occurred when one resident's remote changed both TVs in the room, and no staff were present. The aggressor admitted to the action, and the facility was aware of issues with the TV system but had not addressed them.
A resident with chronic pain syndrome and a tibial fracture reported severe pain but was administered medication for moderate pain, contrary to the Physician's Order. On multiple occasions, the resident received Hydrocodone-Acetaminophen for moderate pain when severe pain was reported, and Acetaminophen for mild pain when moderate pain was reported. This discrepancy was confirmed by several staff members and the MDS Coordinator, highlighting a failure to follow the facility's pain management policy.
The facility failed to serve food that was palatable and at the correct temperature, affecting four residents. One resident with severely impaired cognition and three with intact cognition reported issues with the food being tasteless and cold. Staff confirmed these issues, and a test tray revealed food temperatures below acceptable levels. The facility lacked a policy for acceptable food temperature ranges, contrary to its policy of providing a nourishing and palatable diet.
The facility failed to label and date refrigerated food items, including vanilla extract, chocolate syrup, and sandwiches, which could compromise food safety. Staff confirmed that all food items should be labeled with open and discard dates to prevent serving spoiled food, as per facility policy.
The facility failed to label and date perishable food items brought in by family members for residents, leading to potential safety risks. Observations revealed unlabeled and undated items in the refrigerator, confirmed by the DON. Staff interviews highlighted inconsistencies in understanding the policy, which requires labeling with residents' names and dates to prevent cross-contamination and ensure safety. The facility's policy mandates discarding opened items after three days.
The facility failed to provide proper hand hygiene for residents before and after meals and did not maintain sanitary conditions for utensils and dishes. Observations showed that residents were not offered hand hygiene, and kitchen utensils were stored wet, with a plate found with dried food residue. Staff confirmed these practices violated facility policies, posing a risk of infection.
The facility failed to report abuse allegations within the required timeframe in two separate incidents. In one case, a physical altercation between two residents was reported late, and in another, a family member's report of potential abuse was delayed. Staff interviews revealed inconsistencies in understanding the reporting process, with some unaware of the two-hour requirement for cases involving injury. The facility's policy mandates immediate reporting, but both incidents were reported late.
A facility failed to provide a resident with the required SNF ABN and NOMNC before discharge. The deficiency was identified when the SNF Beneficiary Notification Review Form for the resident was found incomplete, lacking necessary documentation and explanations for the absence of these notices. The Regional Director confirmed the oversight, highlighting a lapse in the notification process.
The facility failed to complete Baseline Care Plans (BCPs) within the required 48-hour timeframe for three residents, leading to potential delays in care. Interviews revealed staff confusion about the BCP completion timeframe, with varying responses from 24 to 72 hours, despite the facility's policy requiring completion within 48 hours. This inconsistency contributed to the late completion of BCPs, potentially affecting resident safety and care.
Three residents experienced significant delays in receiving assistance after activating call lights, with waits ranging from ten minutes to an hour. These delays occurred despite the facility's policies on timely responses and repositioning to prevent skin breakdown. The residents, all with intact cognition, reported waiting for repositioning, incontinence care, and assistance with a bedside commode, potentially affecting their physical and emotional well-being.
A resident with documented dislikes for breaded food was served breaded fried chicken, contrary to his preferences. This oversight was confirmed by dietary staff and the Registered Dietician, who acknowledged the importance of adhering to residents' food preferences to prevent weight loss and malnutrition. The facility's policy requires consideration of residents' dietary preferences, which was not followed in this case.
The facility failed to maintain the kitchen floor in good repair, with the linoleum coming apart in several areas, posing infection control and safety hazards. Staff confirmed the floor's poor condition, which hindered proper cleaning and sanitation, and acknowledged the risk of tripping. The Administrator recognized the need for repairs, aligning with the facility's maintenance policy.
The facility failed to maintain a pest-free kitchen environment, as flies were observed by staff, including the Dietary Supervisor and Registered Dietitian. Staff acknowledged the health risks posed by flies, which could contaminate food and cause illness. The Administrator identified a broken Plexiglas as a potential entry point for the flies, but the facility did not provide a pest control policy when requested.
Failure to Provide Required Written Bed-Hold Notices at Time of Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of its bed-hold policies to residents or their responsible parties at the time of transfer. For one resident with severe dementia with behavioral disturbance, hiatal hernia, chronic pain, encephalopathy, anxiety, insomnia, cerebral palsy, and recurrent depressive disorder, the face sheet showed admission to the facility with these diagnoses. An SBAR Communication Form and Progress Note dated 2/5/26 documented uncontrolled pain and a change in mental status, with a family-requested transfer to the ER. The responsible party reported not receiving any written bed-hold notice or paperwork at the time of this transfer, and the DON confirmed there was no record in the medical chart that a written bed-hold policy was provided for this ER transfer. A second resident, admitted with acute respiratory failure, chronic kidney disease, chronic pain, unspecified dementia, and congestive heart failure, was transferred to a general acute care hospital for periods of unresponsiveness and panicked rapid breathing, as documented in a Progress Note dated 3/19/26. During interviews, the DSD stated that no written bed-hold notifications were provided to residents or responsible parties during transfers and that bed-hold policies were only communicated verbally via phone calls. Concurrent record review with the DON confirmed there was no documentation that written bed-hold policies were provided to this resident at the time of transfer. Review of the facility’s “Bed-Holds and Returns” policy dated 2/2026 showed that all residents or representatives were to receive written information about bed-hold policies at admission and again at the time of transfer (or within 24 hours for emergency transfers), which did not occur for these two residents.
Failure to Readmit Hospitalized Resident Based on Current Condition and Clearly Identified Needs
Penalty
Summary
The deficiency involves the facility’s failure to readmit a resident after hospitalization, despite the resident being deemed stable for transfer back to a SNF and having no documented change in health care needs that would prevent return. The resident had multiple diagnoses, including severe dementia with behavioral disturbance, hiatal hernia, chronic pain, encephalopathy, anxiety, insomnia, cerebral palsy, and recurrent depressive disorder. Prior to hospitalization, the resident had a 1:1 sitter in place at the facility. On 2/05/26, an SBAR and progress note documented uncontrolled pain and a change in mental status, and the family requested transfer to the ER. The hospitalist discharge summary later indicated the resident was in stable condition for transfer to a SNF. Following the hospitalization, the resident’s responsible party and hospital case management repeatedly contacted the facility to arrange readmission. The responsible party reported that the hospital first requested readmission on 2/13/26 and that the facility cited issues with medications as a barrier, even after the hospital physician adjusted the medications. Care coordination notes from the hospital documented multiple calls to the facility on 2/18/26, 2/19/26, and 2/20/26, during which the facility stated it could not meet the resident’s needs but did not specify which needs. When the case manager requested clarification on what needs could not be met, the question went unanswered. On 2/25/26, the facility Administrator visited the resident in the hospital, requested additional information for a nursing consultant, and again did not answer when asked which needs could not be met. The responsible party and hospital staff documented that the Administrator asked if the family could pay for a 24-hour private sitter as a condition of readmission, and when the family stated they could not, the facility continued to refuse readmission without clearly identifying the unmet needs. On 2/26/26, the hospital social worker documented that the Administrator stated the facility was unable to accept the resident because they could not meet her needs, citing her behaviors and stating they were only going to get worse. In interviews, the DON stated all residents were permitted to return after hospitalization and was not aware of the specifics of this transfer, while the Administrator stated the facility could not manage the resident’s care at their current level, referenced worsening behavior, and noted the facility did not have a psychiatric or locked unit. The Administrator also stated that the refusal decision was made by corporate staff who were not physicians or nurses and could not recall if a physician was consulted, despite the facility’s own bed-hold and return policy requiring residents be permitted to return after hospitalization and that concerns be based on the resident’s current condition rather than pre-hospitalization status.
Resident Rooms Below Required Minimum Square Footage
Penalty
Summary
The facility failed to ensure resident bedrooms met the minimum required 80 square feet of living space per resident in multiple-occupancy rooms and 100 square feet for single rooms, affecting 23 of 31 resident rooms. During observation and measurement, the Maintenance Director measured one room and confirmed each resident’s living space was 7 feet by 8 feet, which did not meet the minimum requirement, and acknowledged not knowing there was a minimum room size requirement for residents. The Maintenance Director later confirmed that the square footage listed on the facility map was correct and that the circled numbers indicated the number of residents assigned to each room, amending rooms where the numbers were incorrect. One resident reported that the room was small for three people, and another resident stated the room was a bit small to maneuver in and that they were mainly out in the halls. The Administrator stated he was unaware that each resident was required to have 80 square feet of living space. These observations, measurements, and interviews demonstrated that the facility did not provide the required minimum square footage of living space per resident in a majority of its resident rooms, resulting in bedrooms that did not meet regulatory size standards.
Multiple Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as five errors were observed during 34 medication passes, resulting in a 14.71% error rate. During a morning medication pass, a nurse administered glipizide 5 mg by mouth to a resident after the resident had already eaten breakfast, despite the physician’s order specifying that glipizide be given 30 minutes before meals. In the same encounter, the nurse administered Basaglar insulin via kwik-pen to the resident’s right lower abdomen but immediately withdrew the pen without holding it against the skin for the five seconds required by the manufacturer’s instructions. In another observed medication pass, a nurse administered only one spray of fluticasone nasal spray into each nostril of a resident, while the physician’s order required two sprays in both nostrils once daily. During an afternoon medication pass, a different nurse administered Humalog insulin via kwik-pen to another resident and held the pen against the skin for only three seconds instead of the five seconds specified in the manufacturer’s instructions. At the same time, the nurse administered metformin 1000 mg to this resident before dinner trays had been served, contrary to the physician’s order to give the medication with breakfast and dinner. These actions did not follow physician orders, manufacturer instructions, or the facility’s policies on administering medications safely, timely, and in accordance with accepted professional standards.
Failure to Maintain Palatable and Properly Prepared Meals for Residents
Penalty
Summary
Dietary staff failed to ensure that food served to residents was palatable, attractive, and maintained at an appetizing temperature, affecting 60 residents who received lunch from the kitchen on the identified date. Resident council meeting minutes from multiple months documented repeated complaints about poor food quality, inedible textures, and residents feeling rushed during meals. In interviews, a resident reported that the food was not of good quality and that vegetables were overcooked. During a resident council meeting observed by surveyors, attending residents again voiced complaints that the food was of poor quality, not palatable, and overall not good. Surveyors observed meal preparation in the kitchen, where canned corn was opened at 9:00 a.m., cooked, and placed on the steam table at 9:50 a.m., and pureed roast beef with thickener was prepared and placed on the steam table at 10:30 a.m., although lunch service was scheduled for 12:00 p.m. A test tray evaluated at approximately 12:56 p.m. with both regular and pureed roast beef, scalloped potatoes, buttered corn, and a bread roll revealed that the regular corn was bland, and the pureed beef, corn, potatoes, and bread roll were bland and gummy, with all foods appearing gray in color. The Corporate Registered Dietician acknowledged they would look more closely at pureed food preparation, and the Dietary Manager stated food was expected to be held on the steam table for about 45 minutes, which contrasted with the observed holding times of 1.5 to 2 hours. Review of facility recipes for scalloped potatoes and pureed cream-style corn showed only basic ingredients (mix, margarine, water, canned corn, thickener) with no seasonings, despite facility policies stating that vegetables should be prepared close to serving time, with care to preserve nutritive value, and that proper seasonings and garnishes should be used to make foods more appealing and flavorful.
Failure to Clean and Maintain Oxygen Concentrators Used for Resident Oxygen Therapy
Penalty
Summary
Nursing and maintenance staff failed to ensure that oxygen concentrators used by multiple residents were kept clean and properly maintained, resulting in visibly dirty equipment with dust and debris on vents and internal filters. For one resident with dementia and breast cancer receiving continuous O2 at 2 L/min via nasal cannula for shortness of breath, surveyors observed dust on the outside vent and large areas of dust buildup inside the concentrator’s filter compartment. The Maintenance Supervisor confirmed the internal filter needed to be changed and the concentrator needed overall cleaning, and the Infection Preventionist agreed the concentrator needed cleaning and filter change and stated it could be harmful to use the compressor when the filter was so dirty. Another resident with COPD, hypoxemia, and a history of recurrent pneumonia had an order for continuous O2 at 2 L/min via nasal cannula. During observation, dust buildup was seen on the outside vent and covering the outside of the concentrator. Later, when the filter compartment was opened, scattered areas of dust buildup were found inside, and both the Maintenance Supervisor and Infection Preventionist confirmed the internal filter needed to be changed and the concentrator cleaned. A third resident dependent on supplemental oxygen with an order for continuous O2 at 2 L/min via nasal cannula was observed using a concentrator with dust buildup on the outside vents; when opened, the internal compartment had a layer of white dust and debris throughout and a discolored internal filter. The Maintenance Supervisor confirmed the filter needed to be changed, the Infection Preventionist stated a dirty concentrator was not good for a resident receiving oxygen therapy, and the resident reported that no one had been cleaning the concentrator. A fourth resident with COPD and chronic respiratory failure with hypoxia, ordered to receive continuous O2 at 3 L/min via nasal cannula, was observed receiving O2 at 2 L/min from a concentrator that felt hot to the touch and had a large amount of dust buildup on the outside vent and dust covering the entire machine. When the concentrator’s filter compartment was opened, one side filter hidden by a screwed-in plate and the internal compartment both had a thick layer of dust buildup. The Maintenance Supervisor stated this concentrator belonged to the facility and that it was his responsibility to ensure facility-owned equipment was operating effectively and in clean condition. He later stated his department had no cleaning logs for facility-owned concentrators, oxygen concentrators were not listed on the housekeeping daily cleaning guide, and he could not find vendor maintenance and cleaning logs. The Administrator reported two facility-owned concentrators had been delivered the prior year, there was no record of which machine was placed for this resident or when, and the Maintenance Supervisor later stated the concentrator for this resident had been in place since delivery. The facility’s policy and the owner’s manual required routine exterior cleaning and regular filter maintenance, including more frequent cleaning and filter changes when operated continuously, which were not documented or demonstrated in practice. The Infection Preventionist stated the dusty concentrators posed an infection risk because dust and debris can hold bacteria, spores, and other pathogens that can enter the resident’s respiratory system, placing residents at risk for chronic cough, delayed healing, or other respiratory diseases.
Failure to Properly Administer Insulin and Provide Ordered Rifaximin Therapy
Penalty
Summary
Licensed nurses failed to ensure residents were free from significant medication errors related to insulin administration and critical medication omissions. During a medication pass observation, one nurse administered 20 units of glargine via an insulin pen to a resident’s abdomen but removed the pen immediately after injection without maintaining the needle in place for the required duration per manufacturer instructions. In a separate observation, another nurse administered 4 units of lispro via an insulin pen to a different resident’s abdomen and withdrew the pen after only 5 seconds, despite being aware this was earlier than required. The DON acknowledged that insulin pens require a specific hold time on the skin to ensure the full dose is delivered and that this topic had been covered in a prior in‑service by the pharmacy consultant, who had instructed staff that long‑acting insulins require at least a 10‑second hold and short‑acting insulins at least 6 seconds. A third resident, admitted with alcoholic cirrhosis and portal hypertension, had a physician’s order for rifaximin 550 mg by mouth twice daily for prophylaxis of hepatic encephalopathy. Review of the MAR showed multiple entries coded as “medication not available,” with 15 missed doses in one month and an additional 14 missed doses in the following month, along with seven doses incorrectly documented as administered despite the medication not being supplied by the pharmacy since an earlier date. The resident reported that staff had stopped giving his liver medication about a month earlier because it was too expensive and stated he was receiving other liver medications that were only part of his full treatment. He also reported feeling that his ammonia level was rising and that he was feeling “weird” and falling asleep at abnormal times during the day. Further record review showed no nursing progress notes indicating that the physician or DON had been notified about the repeated unavailability and omission of rifaximin, despite the facility’s policy defining omission of an ordered drug as a medication error and requiring prompt provider notification of significant errors. The DON later confirmed that there were no notes documenting MD notification, that the seven doses marked as given on the MAR were documented in error, and that a total of 36 doses of rifaximin had been missed. The physician stated that the resident was on the maximum dose of lactulose and that there was nothing more that could be done to stop the decline without rifaximin, emphasizing the necessity of that medication.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The deficiency involves failures to follow physician orders and facility policy for oxygen administration for two residents with COPD and chronic respiratory conditions. One resident had an admission diagnosis of COPD and chronic respiratory failure with hypoxia and a care plan identifying risk for respiratory distress, with a goal to maintain comfort and avoid respiratory complications through oxygen therapy as ordered by the MD. The physician order directed continuous oxygen at 3 L/min via nasal cannula. On observation, the resident was receiving oxygen at 2 L/min, and a licensed nurse confirmed the concentrator was set at 2 L/min despite the 3 L/min order and stated an RN would be needed to adjust it. The MAR for the month showed documentation that continuous oxygen at 3 L/min had been administered each day, and progress notes contained no explanation for the deviation from the order or any physician notification regarding the discrepancy. The DON confirmed staff were expected to follow all physician orders, including oxygen administration, and acknowledged the failure to provide oxygen as ordered. The second resident, admitted with COPD, had physician orders for continuous oxygen at 2 L/min via nasal cannula, along with orders to change disposable prefilled oxygen humidifiers when consumed or when bubbles were no longer visible and to replace them every Sunday night shift. The resident’s care plan did not include a care plan for oxygen therapy. During observation, the resident was receiving oxygen at 1.5 L/min, and there was no humidifier attached to the oxygen concentrator. The Infection Preventionist confirmed the absence of a humidifier. Facility policies on oxygen administration and physician orders required verification of physician orders, starting oxygen at the ordered flow, ensuring all care is provided in accordance with timely, complete physician orders, and prompt implementation of orders, with licensed nurses responsible to identify changes, notify physicians, document accurately, and implement orders. These requirements were not met in the observed oxygen administration for this resident.
Failure to Care Plan and Arrange Services for Resident’s Hearing Impairment
Penalty
Summary
Surveyors identified that the facility’s Interdisciplinary Team (IDT) did not develop a comprehensive care plan addressing a resident’s known hearing impairment and did not ensure access to needed hearing services. The resident was admitted with diagnoses including hypertensive heart disease, chronic kidney disease, and a history of falling. The admission inventory documented that the resident had right and left hearing aids, and the MDS assessment indicated the resident used a hearing aid or appliance, had adequate hearing with the device, and had a BIMS score of 11, reflecting moderate cognitive impairment. Despite this information, the care plans dated 12/30/25 contained no care plan for hearing impairment, and there was no documented plan describing services or professional responsibilities related to managing the resident’s hearing needs. During observation and interviews, the resident reported difficulty hearing and requested that the surveyor speak loudly, stating that her hearing aids were not working, needed servicing, and that she had not been able to have them serviced or obtain an appointment with her ear doctor. She stated the facility was not helping her schedule such an appointment. A licensed nurse acknowledged the resident was hard of hearing, required slow and loud speech, and admitted being unaware that the resident had hearing aids, though he stated staff could arrange an audiology appointment. The physician reported the resident’s hearing had declined but felt she still understood conversations and “gets by.” These findings contrasted with the facility’s written policy requiring a comprehensive, person-centered care plan, developed by the IDT within specified timeframes, to describe services needed to attain or maintain each resident’s highest practicable well-being, including which professional services are responsible for each element of care.
Unsigned Medication Deliveries and Improper Bedside Medication Administration
Penalty
Summary
The deficiency involves failures in pharmaceutical services and medication management. Surveyors reviewed the facility’s pharmaceutical delivery receipts with a licensed nurse and the DON and found that delivery receipts for multiple dates in March 2026 lacked signatures from both pharmacy staff and facility licensed staff. LN 4 confirmed that there were no signatures on the receipts for those dates and stated that a signed receipt is used to prove that medications have been delivered and placed in the medication cart. The DON confirmed that the receipts were unsigned and stated that the facility’s expectation was that medications received from the pharmacy would be immediately reconciled against the delivery ticket, any errors noted, and then signed to indicate acceptance of the delivery. The facility’s policy on accepting delivery of medications required nurses to reconcile medications with the delivery ticket before signing and to keep a copy of the delivery ticket. The DON stated that unsigned pharmaceutical delivery receipts placed the facility at increased risk for diversion. A second deficiency was identified involving medication administration practices for one resident. The resident had diagnoses including spondylolisthesis and disorders of bone density and had a BIMS score of 11/15, indicating moderate cognitive impairment. During an observation in the resident’s room, the surveyor saw the resident attempt to swallow a pill and spit it out, with two additional pills left on the bedside table. The resident attempted to take the same pill two more times, spitting it out each time and leaving it on the bedside table with the other pills. LN 1 later confirmed that leaving medications at the bedside could be a safety issue but stated he felt the resident was capable of taking medications without supervision. Review of the physician’s orders with LN 1 confirmed there were no orders authorizing the resident to self-administer medications. LN 1 identified the pills as acetaminophen, calcium, and Vitamin B complex. The DON confirmed that medications left at any resident’s bedside without physician approval was a safety concern, and facility policy stated that residents may self-administer medications only if the physician and interdisciplinary team determine they have the decision-making capacity to do so safely.
Failure to Prevent Repeated Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse when another resident repeatedly directed profanities and threats toward her. Resident 1, admitted with anxiety disorder and depression and having a BIMS score of 12 indicating moderate cognitive ability, frequently yelled for help while at the nurses’ station or in her room. Resident 2, admitted with depression and a BIMS score of 15 indicating no cognitive impairment, wheeled himself into Resident 1’s room on one occasion and yelled at her to “shut up” and not yell for help if she did not need it, then stated “suffocate the bitch.” On a later date, while Resident 1 was at the nurses’ station yelling as her baseline, Resident 2 became agitated and verbally aggressive, yelling “Shut the fuck up bitch, there is no reason to be yelling on New Year’s Eve, I’m going to choke you out. Somebody should choke you, I’m going to slap that bitch,” which staff present identified as a threat and as verbal abuse. On another documented occasion, Resident 2 again approached the nurses’ station while Resident 1 was yelling “Help me” and told her to “shut up,” stating “I don’t pay money to hear your bullshit. Tell her to shut up,” and “I’ll tell that bitch to shut up,” after which Resident 1 became quiet. Staff interviews confirmed these events, with one nurse stating Resident 1 looked scared and reported being afraid of Resident 2 after he yelled at her and threatened to choke and slap her, and another nurse confirming the accuracy of the documentation of Resident 2’s prior verbal aggression. Resident 2 acknowledged hearing Resident 1 yell for help daily and stated he went to her with the intention of making her “shut up.” These incidents occurred despite a facility policy on elder/dependent adult abuse that defines verbal abuse as the use of oral or gestured language including threats and disparaging or derogatory terms to or about residents within hearing distance, and requires protection of each resident’s rights, safety, and well-being against all forms of abuse.
Failure to Timely Report Repeated Verbal Abuse Allegations to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of verbal abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. Resident 1, who had anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive ability, was the target of repeated verbal aggression and threats from Resident 2, who had no cognitive impairment (BIMS 15). On 12/25/25, progress notes and an SBAR form documented that Resident 2, alert and oriented x4, wheeled into Resident 1’s room, yelled at her to “shut up” for calling out for help, and stated “suffocate the bitch.” The SBAR and 24-hour report log were completed by LN 2, and the DON was expected to review these daily. On 12/31/25, progress notes documented that Resident 1 was at the nurse’s station yelling when Resident 2 approached, became agitated, and verbally threatened her, saying “Shut the fuck up bitch, there is no reason to be yelling on New Year’s Eve, I’m going to choke you out. Somebody should choke you, I’m going to slap that bitch.” LN 1 intervened and notified the DON and Administrator (ADM). LN 3 later confirmed she texted the DON and ADM that Resident 2 had gotten in Resident 1’s face, screamed profanities, and made threats to choke and slap her, and that she asked what else needed to be done. According to LN 3, the DON responded that an SBAR was not needed because there was no change of condition and that the incident was “yelling and no one was touched,” despite LN 3’s statement that it was a verbal threat to harm. On 1/7/26, progress notes showed that Resident 2 again approached Resident 1 at the nurse’s station, told her to “shut up,” complained about paying money to hear her “bullshit,” and stated “I’ll tell that bitch to shut up,” after which Resident 1 became quiet. The ADM acknowledged he reported the incident that happened on 1/7/26 to CDPH but not until the following day via fax, and that no call was made to CDPH within the two-hour window. A SOC 341 form shows the verbal abuse incidents were faxed to CDPH on 1/8/26 at 4:14 p.m. The DON and ADM later confirmed they were aware of the 12/31/25 incident via text and that the initial text described Resident 2’s threats to choke and slap Resident 1. LN 2 stated the DON had called her after the 12/25/25 incident and instructed her not to use the word “abuse” in her progress notes. The facility’s policy required all alleged violations involving any type of abuse to be reported immediately, but not later than two hours, which did not occur in these events.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Maintain Homelike and Clean Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for its 57 residents. During multiple observations, carpeting throughout the hallways was found to be worn, matted with dirt, and stained in various sizes and colors, particularly at doorway entries. In several resident rooms, torn wallpaper and wall damage with exposed drywall were noted. Residents interviewed confirmed that the damage had been present for a long time and expressed dissatisfaction with the appearance of their rooms. The facility administrator acknowledged that most resident rooms had wall damage and torn wallpaper, attributing the damage to bed heads hitting the walls. The administrator also confirmed awareness of the old, stained carpeting and stated that the maintenance team was directed to clean it monthly. Additionally, the administrator recognized that the carpeting made it difficult for residents to propel their wheelchairs and for staff to move patient care equipment. The facility's own policy requires a clean, sanitary, and orderly environment to maximize a homelike setting, which was not met according to the findings.
Failure to Protect Resident from Physical Abuse During Altercation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident during an altercation over television control in their shared room. Resident 2, whose cognition was moderately intact, deliberately placed his hands on Resident 1's chest and pushed him, causing Resident 1, who had moderately impaired cognition, to fall and sustain a skin tear and abrasion on his left forearm. The incident occurred when Resident 1 changed the television channel using his remote, which also affected Resident 2's television due to the shared control system. There were no staff present in the room at the time of the incident, and the altercation was witnessed by another resident. Interviews and documentation confirmed that Resident 2 admitted to pushing Resident 1 because of the television channel change, and staff acknowledged that the TV remote system allowed one resident's remote to control multiple TVs in the room. The facility's maintenance supervisor was aware of previous complaints about the TV system, but it had remained unchanged. The facility's policy requires protection of residents from all forms of abuse, but this was not upheld in this instance, resulting in physical harm to Resident 1.
Inappropriate Pain Medication Administration
Penalty
Summary
The facility failed to ensure that nurses were following the Physician's Order for pain medication for a resident, identified as Resident 37. The nurses administered pain medication that was not appropriate for the pain level reported by the resident. Specifically, Resident 37, who had diagnoses including Chronic Pain Syndrome, Essential Hypertension, and a right Tibial fracture, reported severe pain levels on multiple occasions, yet was administered medication intended for moderate pain. This discrepancy was noted on several dates in May and June 2024, where the resident reported pain levels of 7 to 10, but received Hydrocodone-Acetaminophen intended for moderate pain levels of 4 to 6. Additionally, there were instances where Resident 37 reported moderate pain levels, yet was administered Acetaminophen intended for mild pain. This occurred on various dates in May and June 2024, where the resident's pain levels were reported between 4 and 6, but the medication given was for pain levels of 1 to 3. The failure to administer the correct medication according to the pain level reported by the resident was verified by multiple licensed staff members and the Minimum Data Set Coordinator during interviews and record reviews. The facility's policy and procedure on Pain Assessment and Management, revised in February 2024, indicated that the medication regimen should be implemented as ordered, with careful documentation of the intervention's result. However, the staff did not adhere to this policy, as evidenced by the repeated administration of inappropriate pain medication. This failure to follow the Physician's Order could result in unrelieved pain and decreased quality of life for the resident, as noted by the licensed staff and the Minimum Data Set Coordinator.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food items served to residents were palatable and at the correct temperature, affecting four sampled residents. Resident 30, with severely impaired cognition, reported that the food was tasteless and cold. Residents 6, 38, and 43, all with intact cognition, also expressed dissatisfaction with the food, describing it as unpalatable, cold, and lacking taste. Observations and interviews with staff confirmed these issues, with staff acknowledging the importance of serving food at the right temperature to prevent weight loss and malnutrition. During a test tray with the Dietary Supervisor, it was found that the temperature of the breaded fried chicken and pureed breaded fried chicken with gravy was below the acceptable range, and the spinach was bland and not at the required temperature. The Registered Dietician noted the absence of an acceptable temperature range policy for food served at meal times. The facility's policy indicated that residents should receive a nourishing, palatable, and well-balanced diet, but this was not adhered to, as evidenced by the findings.
Failure to Label and Date Refrigerated Food Items
Penalty
Summary
The facility failed to ensure that refrigerated items in the kitchen were clearly labeled, easily identified, and dated, which could compromise food safety. During an observation and interview, the Dietary Supervisor verified that several items in the refrigerator, including vanilla extract, chocolate syrup, yellow mustard, and a tub of macaroni salad, had no use-by or discard dates. Additionally, a bin containing sandwiches for lunch alternates was found without labels or dates. The Dietary Supervisor also identified unlabeled items in the freezer, such as pork ribs and crabby cakes, which had been removed from their original packaging and lacked open or discard-by dates. Interviews with various staff members, including a Dietary Aide and a Registered Dietician, confirmed that all food items in the refrigerator and freezer should be clearly labeled with open and discard dates, as per facility policy. The staff emphasized the importance of labeling to ensure the right food is served to residents and to prevent serving spoiled food, which could lead to illnesses such as Salmonella and food poisoning. A review of the facility's policy on food receiving and storage indicated that all food stored in the refrigerator or freezer should be labeled, covered, and dated, highlighting the facility's failure to adhere to its own policies.
Failure to Label and Date Perishable Food Items
Penalty
Summary
The facility failed to ensure that perishable food items brought in by family members and stored in the refrigerator for residents were properly labeled and dated. During an observation, it was noted that several food items, including ice cream, whipped topping, grapes, and nutritional drinks, were not labeled with residents' names or dates of opening and discard. The Director of Nursing (DON) confirmed these items were not labeled correctly and acknowledged that an opened bottle of ranch dressing was past its discard date. Interviews with staff members revealed inconsistencies in their understanding of the facility's policy regarding labeling and discarding perishable food items. Staff members, including unlicensed staff and the Infection Preventionist, emphasized the importance of labeling food with residents' names and dates to prevent cross-contamination and ensure food safety. The Registered Dietician also stated that food items should be discarded after three days to prevent spoilage. The facility's policy, titled "Food from Home," requires that perishable food be labeled with the resident's name and dates of receipt, opening, and discard, and that opened items be discarded after three days. The failure to adhere to this policy poses a risk of serving spoiled or incorrect food to residents.
Inadequate Hand Hygiene and Utensil Sanitation
Penalty
Summary
The facility failed to ensure proper hand hygiene was offered and provided to seven sampled residents before and after meals. Observations on June 17, 2024, revealed that Residents 18, 29, 28, 10, 54, 1, and 14 were not offered or provided hand hygiene prior to or after eating their meals. Interviews with various staff members, including the Central Supply/Medical Records Assistant, Unlicensed Staff, Licensed Staff, and the Infection Preventionist, confirmed that the facility's policy was not followed, which required hand hygiene to be performed before and after meals to prevent infections. Additionally, the facility did not maintain sanitary conditions for utensils and dishes. Observations on June 17 and June 19, 2024, showed that kitchen utensils were stored while still wet, and a plate on the plate warmer had dried food residue. Staff members, including the Dietary Supervisor, Dietary Aide, and Registered Dietician, acknowledged that storing wet utensils and using unclean plates posed a health hazard and could lead to contamination and illness among residents. The facility lacked a specific infection policy and procedure for dishwashing and storing utensils. The report highlights the facility's failure to adhere to its own policies regarding hand hygiene and utensil sanitation, which are critical in preventing the spread of infections. The lack of compliance with these protocols was confirmed through staff interviews and direct observations, indicating a systemic issue in maintaining infection control standards.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations, as evidenced by two incidents involving residents. In the first incident, a physical altercation occurred between two residents, one with bipolar disorder and cerebellar ataxia, and the other with vascular dementia and Alzheimer's disease. The altercation was not reported to the California Department of Public Health (CDPH), the Ombudsman, and the local Police Department until the following day, exceeding the facility's policy requirement of reporting within two hours if there is an injury. In the second incident, a family member reported a potential abuse case involving a resident with hypertension, depression, and anxiety. The facility delayed reporting this allegation to the CDPH, the Ombudsman, and the local Police Department until the next day, again failing to meet the two-hour reporting requirement outlined in their policy. Interviews with various staff members revealed inconsistencies in their understanding of the reporting process and timeframes, with some staff believing that reporting could occur within 24 hours, while others were aware of the two-hour requirement for cases involving injury. The Director of Nursing and the Administrator confirmed that the facility's policy mandates reporting abuse allegations within two hours if there is an injury. However, both incidents were reported late, indicating a failure to adhere to the policy. The facility's policy, revised in April 2021, clearly states that all alleged violations of abuse, neglect, exploitation, or mistreatment should be reported immediately, but not later than two hours if the alleged violation involves abuse.
Failure to Provide Required Medicare Notifications Before Discharge
Penalty
Summary
The facility failed to provide necessary notifications to a resident prior to discharge, specifically the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC). This deficiency was identified during a survey when the Administrator was presented with three SNF Beneficiary Notification Review Forms, one of which, pertaining to Resident 220, was incomplete. The form is intended to document the issuance of these notices or provide an explanation if they were not required. Further investigation revealed that the SNF Beneficiary Protection Notification Review for Resident 220 was not filled out correctly. The Regional Director of Operations confirmed that the necessary documentation, including the Medicare Part A skilled services episode start date and the last covered day of Part A services, was missing. Additionally, there was no documentation to explain why the SNF ABN and NOMNC were not acknowledged by the resident or their representative, indicating a lapse in the facility's notification process.
Failure to Timely Complete Baseline Care Plans
Penalty
Summary
The facility failed to ensure that staff were aware of the Baseline Care Plan (BCP) completion timeframe, resulting in the late completion of BCPs for three sampled residents. Resident 54, who was admitted with diagnoses including muscle weakness, lymphedema, and dysphagia, had a BCP completed late. Similarly, Resident 60, with diagnoses of primary hypertension, type II diabetes mellitus, and muscle weakness, also had a BCP completed late. Resident 28, who had primary hypertension, muscle weakness, and hyperlipidemia, and exhibited both short-term and long-term memory impairment, experienced the same issue. These delays in completing BCPs had the potential to lead to delayed or omitted care, missed medications or treatments, medical complications, and deconditioning. Interviews with various staff members revealed inconsistencies in their understanding of the BCP completion timeframe. The Director of Nursing was unsure of the facility's policy, while other staff members provided varying timeframes ranging from 24 to 72 hours. The facility's policy, however, clearly stated that a baseline plan of care should be developed within 48 hours of admission. This lack of awareness and adherence to the policy contributed to the deficiencies observed in the timely completion of BCPs for the residents, potentially compromising their safety and care.
Delayed Response to Call Lights and Care Needs
Penalty
Summary
The facility failed to provide timely assistance to three residents, leading to unmet physical, mental, and emotional needs. Resident 2, with a BIMS score indicating intact cognition, reported waiting up to an hour for repositioning assistance after activating the call light. This delay was confirmed by her observation of a wall clock. Resident 38, also with intact cognition, experienced delays ranging from ten minutes to an hour when requesting help to use a bedside commode, although she did not have accidents, she sometimes lost the urgency for a bowel movement. Resident 51, with no cognitive impairment, reported waiting 45 minutes to an hour for incontinence care during the night shift. The facility's Director of Nursing acknowledged the expectation for prompt response to call lights, which was not met according to the facility's policies on answering call lights and repositioning. The policies emphasized timely responses to residents' needs and repositioning as a preventive measure against skin breakdown. The observed delays in responding to call lights and providing necessary care could potentially lead to adverse outcomes, such as skin breakdown and emotional distress, as residents were left in soiled conditions or in the same position for extended periods.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 117, received meals that accommodated his food preferences, specifically his dislike for breaded food items. On June 19, 2024, during lunch, Resident 117 was served breaded fried chicken despite his documented preference against breaded foods. This oversight was confirmed through observations, interviews, and record reviews. The dietary staff member responsible for plating the meal acknowledged the error and confirmed that the meal tray had already been placed in the meal cart before the mistake was realized. Interviews with the Registered Dietician, another staff member, and the Dietary Supervisor further confirmed that Resident 117's dislike for breaded food was known and documented. They emphasized the importance of adhering to residents' food preferences to prevent issues such as weight loss and malnutrition. The facility's policy on Food and Nutrition Services also mandates that residents' dietary preferences be considered to ensure their nutritional needs are met. However, in this instance, the policy was not followed, leading to the deficiency.
Kitchen Floor Disrepair Poses Infection Control and Safety Hazards
Penalty
Summary
The facility failed to maintain the kitchen floor in good repair, as observed by surveyors and confirmed through multiple interviews. The linoleum floor in various parts of the kitchen, including areas by the gas stove, the door leading to the hallway, and the sink, was coming apart with raised edges. This condition was identified as a potential infection control issue due to the difficulty in ensuring the floor was adequately cleaned and sanitized. Additionally, it posed a safety hazard as staff members reported tripping over the damaged flooring. Interviews with various staff members, including a Dietary Supervisor and a Dietary Aide, confirmed the observations. They acknowledged that the deteriorating floor condition was unacceptable for maintaining a clean and sanitary kitchen environment, which is crucial for preventing resident illness. The Administrator also recognized the need for floor repairs, citing the safety hazard it posed to staff. The facility's policy and procedure on maintenance, revised in August 2022, indicated that the Maintenance Department is responsible for keeping the building in good repair, which was not adhered to in this instance.
Presence of Flies in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as evidenced by the presence of flies. During an observation, both the Dietary Supervisor and the Registered Dietitian confirmed the presence of a fly in the kitchen. Further observations and interviews with staff members, including a dietary aide and another staff member, revealed that flies were seen in the kitchen from time to time, which was acknowledged as unacceptable due to the potential for contamination of food. The staff expressed concerns about the health risks associated with flies, noting that they carry germs and bacteria that could lead to residents getting sick if the flies contaminated the food. The Administrator was aware of the issue and identified a broken Plexiglas above the air conditioning unit as a possible entry point for the flies. Despite the acknowledgment of the problem, the facility did not provide a policy and procedure for pest control and management when requested. The presence of flies in the kitchen was recognized as a sanitation and infection control issue, with the potential to cause gastrointestinal illness among residents if the flies contaminated their food.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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