Sunset Park Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 2250 29th Street, Santa Monica, California 90405
- CMS Provider Number
- 055748
- Inspections on file
- 39
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Sunset Park Healthcare during CMS and state inspections, most recent first.
A resident with dementia and Alzheimer’s disease, who had severely impaired cognition and required assistance with ADLs, gave an LVN access to a credit card to purchase a cell phone. Over several days, multiple unauthorized charges appeared on the card, including personal purchases at a beauty provider, hotel reservations in another state, and dry cleaning far from the facility. The resident reported not authorizing these expenditures and was upset that someone accessed his wallet and took the card. Another LVN described it as unusual that a charge nurse repeatedly insisted on escorting the resident to the bank, given ongoing staff education not to accept money or gifts from residents. The involved LVN admitted using the resident’s card, including for a hotel reservation, and not promptly returning it, despite having completed abuse prevention and gifts/gratuities training that prohibited misappropriation of resident funds.
A resident with epilepsy, Alzheimer's disease, severe cognitive impairment, high fall risk, and total dependence for ADLs was not provided the documented two-person assist for mobility and transfers as indicated on the MDS and therapy assessments. While being given a shower, the resident slipped on the floor, and afterward was not evaluated or assessed by an RN/LPN in accordance with the facility’s fall clinical protocols and fall risk management policies.
Surveyors found that three residents with cognitive and physical impairments did not have functioning call devices within reach, as required by their care plans and facility policy. One resident was given a table bell as an alternative, while the others had no way to alert staff for assistance due to a malfunctioning call light system.
A resident with severe cognitive impairment and a history of respiratory and mental health conditions was not permitted to receive visitors of their choosing due to restrictions imposed by a family member, despite facility policy and regulations prohibiting such limitations unless there is immediate risk. Staff enforced these restrictions, and no care plan was developed to address the family conflict or visitation issue.
A facility failed to create a comprehensive care plan addressing a resident's visitation rights and ongoing family conflict, despite the resident's impaired cognition and documented disputes among family members. Staff and documentation confirmed that no care plan was developed to manage the situation, contrary to facility policy and regulatory requirements.
The facility did not develop or implement comprehensive care plans for several residents with severe cognitive impairment and complex needs. One resident was placed at risk of entrapment due to improper bed and bedside table placement, while two other residents with behavioral and mobility issues lacked care plans addressing their specific risks. Staff and DON confirmed these omissions, which were not in accordance with facility policy.
A resident with severe hearing loss did not receive timely hearing aids or alternative communication tools, despite documented need and care plan interventions. The resident experienced frustration, difficulty communicating with staff, and inability to watch TV, while staff were unaware of the hearing aid issues and did not follow facility policies for supporting hearing-impaired residents.
Three residents with severe cognitive and physical impairments did not consistently receive physician-ordered restorative nursing treatments, including PROM exercises and use of splints, as required by facility policy. Documentation of these treatments was completed in advance rather than reflecting actual care provided, as confirmed by staff interviews and record review. This failure resulted in a deficiency related to the maintenance and improvement of residents' range of motion.
A resident with dysphagia and cognitive impairment, fully dependent on staff, was found to have multiple broken, missing, and discolored teeth and had not received dental care since admission, despite physician orders and facility policy requiring regular dental services. Staff confirmed the absence of dental records and acknowledged the expectation for routine dental exams.
A dietary staff member failed to use proper measuring utensils when preparing Paprika Beef, instead scooping bouillon powder with a spoon and not following the facility's recipe. The staff member, new to the facility, admitted to not following recipe protocols, and the Dietary Supervisor confirmed that all cooks are required to use measuring utensils and follow recipes to ensure proper meal preparation.
Surveyors identified multiple deficiencies in kitchen food storage and sanitation, including expired and unlabeled food items, improper storage of staff personal items in resident refrigerators, unclean utensils and surfaces, and failure to dispose of expired foods. Dietary staff were unaware of proper storage times, and facility policies for labeling and monitoring food were not followed.
A CNA was observed wearing the same gown, mask, and gloves while providing care to three residents on Enhanced Barrier Precautions, including checking gastrostomy tube sites, without changing PPE or performing hand hygiene between each resident. All three residents were severely cognitively impaired, totally dependent for ADLs, and had physician orders for EBP. Facility policy and the DON confirmed that PPE should be changed and hand hygiene performed between residents to prevent cross-contamination.
A leaking pipe under the kitchen sink was left unrepaired for about one to two weeks, with staff using a bucket to catch the water. Dietary and maintenance staff were aware of the issue, but there was a delay in repair and inconsistent reporting of when the maintenance supervisor was notified. Additionally, required maintenance repair logs and schedules were not maintained as per facility policy.
Nine rooms did not meet the required 80 sq. ft. per resident, with some rooms providing only 75.3 or 77.6 sq. ft. per resident. A resident with multiple chronic conditions was unable to move freely in her room due to the placement of a bariatric bed and bedside table, which further restricted access to the bathroom and safe movement.
A resident with severe cognitive impairment and multiple diagnoses was administered psychotropic medications without complete or signed informed consent forms from the resident or responsible party. Staff confirmed that required documentation was missing, and facility policy mandating written consent prior to administration was not followed.
A bariatric bed and bedside table in a shared room created a crowded environment, limiting a resident's ability to move freely and safely access the bathroom. The resident, who required assistance with mobility and daily activities, reported feeling confined and unable to move around the room without difficulty.
A resident with severe cognitive impairment and total dependence on staff had multiple personal belongings go missing after admission. The facility did not complete an inventory of the resident's property at admission as required by policy, and family reports of missing items were not addressed or resolved by staff.
A resident with severe cognitive impairment and total dependence for ADLs was unnecessarily restrained when a low, sagging bed and a bedside table blocked their ability to get out of bed. Staff confirmed these measures were used to prevent falls, contrary to facility policy, and both the LVN and DON acknowledged that these practices restricted the resident's movement and posed a risk of entrapment.
The facility did not complete required background checks and screenings for two newly hired nurses with direct resident access, as confirmed by staff interviews and review of personnel files. This failure to follow policy placed all residents at risk, especially due to the presence of controlled medications.
A resident with severe cognitive impairment and a tendency to place objects in his mouth was found with hazardous items like cleanser bottles and razors accessible at his bedside, despite staff awareness of his behavior. Another resident with confusion and wandering behaviors was not properly assessed for elopement risk, lacked an appropriate care plan, and required constant supervision. These deficiencies in supervision, environmental safety, and risk assessment increased the risk of injury and accidents.
Staff did not label the open date on foil pouches containing inhalation medications for two residents with severe cognitive impairment and chronic respiratory conditions. During a medication cart inspection, opened pouches of ipratropium-albuterol and albuterol solutions were found without date labels, despite manufacturer instructions requiring use within a set period after opening. The DON and an LVN confirmed that the medications should have been dated according to policy and manufacturer guidelines.
A resident with severe cognitive impairment and total dependence on staff was found with diclofenac cream accessible at bedside, despite not being approved for self-administration. Additionally, a pill cutter on a medication cart was observed to be unclean, with visible residue, contrary to infection control protocols. Staff confirmed these practices did not follow facility policy for medication storage and equipment sanitation.
Surveyors found that two residents were served overcooked and unpalatable food, including hard pork chops and dinner rolls, leading them to request alternative meals. Both residents reported dissatisfaction with the food quality, and one was unable to eat the pork chop due to dental issues. The Dietary Supervisor confirmed the overcooking of the meal components.
A resident with dysphagia, metabolic encephalopathy, and a gastrostomy, requiring 100% feeding assistance and aspiration precautions, was left with another resident's breakfast tray within reach and without staff supervision. Staff interviews revealed a lack of awareness about the incident and the associated risks, and facility policy requiring tray verification was not followed.
A resident with diabetes and other medical conditions did not receive their physician-ordered fortified CCHO diet with double protein portions for breakfast and dinner. The resident's breakfast tray was found on another resident's table, and staff were unaware of the error. Facility policies requiring correct tray identification and timely meal service were not followed, resulting in the resident missing their prescribed meal.
Two residents with significant medical needs and varying cognitive abilities experienced repeated delays in staff response to call lights, sometimes waiting over 30 minutes for assistance with ADLs such as toileting and changing briefs. Both residents expressed anger over these delays. Staff interviews confirmed that call lights are expected to be answered within 3 to 5 minutes, and facility policy requires prompt response.
Facility staff failed to prevent waste equipment from overflowing in the waste disposal area, resulting in garbage spilling onto the ground. A maintenance staff member was observed standing on top of the trash bin to press down the waste, and both the maintenance staff and DON acknowledged that this situation posed environmental and safety hazards, including exposure to pests and infectious diseases. Facility policies requiring a clean, safe, and orderly environment were not followed.
Two resident rooms were found to contain six beds each, exceeding the federal limit of four residents per room. Despite facility documentation and observations indicating sufficient space and freedom of movement for residents and staff, the rooms did not comply with occupancy regulations.
A resident with severe cognitive impairment and a diagnosis of TB repeatedly refused prescribed TB medications, but the facility did not document physician notification of these refusals as required by policy. Staff interviews confirmed that refusals were not consistently reported or recorded in the resident's medical record.
A resident with severe cognitive impairment and major depressive disorder was prescribed mirtazapine, but the required informed consent documentation was incomplete, lacking a physician's signature and proper witness dating. Facility staff confirmed that this did not meet policy requirements for informed consent prior to administering psychotropic medication.
Two residents with cognitive and physical impairments were involved in altercations that were witnessed and documented by staff, but the incidents were not reported to the State Agency or properly documented according to facility policy. Internal investigations lacked documentation, and required notifications to authorities were not made, resulting in delayed external review.
Two residents with significant cognitive and physical impairments were involved in repeated verbal and physical altercations, which were witnessed and documented by staff. Despite this, there was no evidence of a formal investigation or required reporting to authorities, as mandated by facility policy. The DON acknowledged the incidents but could not provide documentation of any investigation or outcome.
A facility failed to properly label and dispose of enteral feeding bottles for a resident, leading to a deficiency. The feeding bottle lacked an infusion start time and was used beyond the 48-hour limit, contrary to guidelines. The DON confirmed that this oversight could lead to pathogen growth and foodborne illness risk.
A resident with COPD and other conditions was observed receiving 5 liters per minute of oxygen instead of the prescribed 2 liters per minute. The LVN could not explain the deviation, and the DON acknowledged the risk of oxygen overdose. The facility's policy specifies oxygen administration at 2 to 3 liters per minute unless otherwise ordered.
A resident in an LTC facility was administered a medication that had fallen onto the floor, contrary to the facility's infection control policy. The resident, with medical conditions including diabetes and hypertension, was given Ativan by an LVN who acknowledged the facility's policy to discard contaminated pills. The DON confirmed the policy, highlighting the risk of administering soiled medication.
A resident with cognitive impairment was verbally abused by an LVN, who admitted to cursing at the resident during an altercation. The incident was documented, and the LVN was terminated for violating the facility's abuse prevention policy.
A resident was transferred from SNF1 to SNF2 without prior notification to the resident or their representative, resulting in aggressive behavior at SNF2. The resident, with a history of encephalopathy, psychosis, depression, and anxiety, exhibited volatile actions, including throwing objects and invading personal space. Staff attempts to manage the situation were unsuccessful, and the resident was returned to SNF1 the same day.
The facility failed to ensure safe food handling practices as Cook 1 was observed not wearing a hairnet and gloves while preparing food for residents. Interviews with the DSS and DON confirmed the requirement for staff to wear protective gear and wash hands before entering the kitchen. The facility's policy also emphasized avoiding bare hand contact with food. This oversight risked harmful bacteria growth and cross-contamination, potentially affecting 41 medically compromised residents.
The facility was found non-compliant with regulations by housing six residents in two rooms, exceeding the allowed capacity of four. Despite residents expressing satisfaction with the space and care, the room configuration did not meet regulatory standards. A waiver request was submitted, noting the rooms' spaciousness and privacy provisions.
The facility did not meet federal regulations for room size, with ten out of thirteen rooms failing to provide the required 80 square feet per resident. Despite this, observations and resident interviews indicated sufficient space for movement and care. A waiver request was submitted, and the Department recommended its continuation.
Failure to Protect Resident From Financial Abuse by LVN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial abuse and misappropriation of property by a staff member, contrary to its abuse prevention and gifts/gratuities policies. The resident was admitted with dementia and Alzheimer’s disease and had severely impaired cognition per the most recent MDS, requiring assistance with activities of daily living and using a wheelchair. The resident had both a debit and a credit card. Over a period in February, multiple charges appeared on the resident’s credit card, including purchases at a beauty enhancement provider, two small charges to an individual, two hotel charges in Las Vegas, and a dry-cleaning purchase located 34 miles from the facility. The resident did not authorize these purchases. In interviews, the resident stated that an LVN had been his nurse for several months, had brought him clothing, and had accompanied him to the bank four or five times. The resident reported giving the LVN his credit card to purchase a new cell phone, which the LVN said she would obtain for him. The resident later learned from facility staff, after they reviewed his bank statements, that the LVN had used his credit card for unauthorized purchases. The resident stated that he did not give the LVN permission to use his card for a trip to Las Vegas or for other personal expenses, and that he was upset that someone had accessed his wallet and taken the credit card. He also stated that the LVN never gave him the cell phone at the time, and that a cell phone arrived several days after the incident came to light. Another LVN reported that it was unusual for a charge nurse to insist on escorting a resident to the bank, noting that escorts were typically provided by activities staff or CNAs and that staff were regularly in-serviced not to accept money or gifts from residents because it could be considered financial abuse. In a phone interview, the LVN involved acknowledged escorting the resident to open a bank account after work, paying for transportation, and buying cigarettes for the resident. She stated that the resident insisted on giving her his card so she could buy items he wanted, including a phone and organizer, and admitted she did not promptly return the card. She further admitted using the resident’s credit card to reserve a hotel and stated she did not remember telling the resident about this use or the amount spent. The discharge planner discovered suspicious charges when assisting the resident with a call to his bank, and the administrator confirmed with the resident that he had not authorized the purchases. Facility records showed that the LVN had previously completed abuse prohibition training and signed acknowledgments of the abuse and gifts/gratuities policies, which define misappropriation and financial abuse as wrongful use of a resident’s money without consent and prohibit employees from accepting or giving anything of value to or from residents.
Failure to Provide Required Two-Person Assist and Post-Fall Nursing Assessment
Penalty
Summary
Surveyors identified a deficiency in accident prevention and supervision related to one resident with significant cognitive and functional impairments. The resident had diagnoses including epilepsy, muscle weakness, gait and mobility abnormalities, and Alzheimer's disease, and the MDS documented severely impaired cognitive skills for daily decisions and total dependence on staff for ADLs, requiring assistance of two or more helpers. Therapy evaluations and care plans showed impaired bed mobility, functional transfers, ambulation, safety awareness, impulsive behavior, attempts to get up unassisted, poor safety awareness, and inability to control body positioning, with bathing documented as requiring total dependence without attempts to initiate. A fall risk assessment scored the resident as high risk for falls. Despite these documented needs, the facility failed to ensure the resident was assisted with at least a two-person assist during mobility and transfers as indicated by the MDS. In addition, after the resident slipped on the floor while being given a shower, the resident was not evaluated and assessed by a licensed nurse as required by the facility’s policies and procedures titled "Falls - Clinical Protocol" and "Falls and Fall Risk, Managing." This failure to follow the resident’s assessed assistance needs and the facility’s fall assessment protocols resulted in the resident’s fall and had the potential to place the resident at risk for recurrent falls.
Failure to Ensure Call Devices Within Reach for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that call devices were within reach for three out of five sampled residents. Observations and interviews revealed that the call light system in the room shared by these residents was not functioning, as evidenced by the lack of illumination at the nurses' station panel. One resident was provided with a table bell as an alternative means to alert staff, while the other two residents had no alternate method to summon assistance. The Registered Nurse Supervisor confirmed that staff would not be aware of residents' needs in a timely manner due to the malfunctioning call light system. Record reviews showed that all three residents had care plans specifying that call lights should be within easy reach and answered promptly, particularly due to their diagnoses and levels of cognitive and physical impairment. The residents involved had conditions such as dementia, Alzheimer's disease, Guillian-Barre syndrome, and severe cognitive impairment, and required varying levels of assistance with activities of daily living. The facility's own policy, revised in October 2024, also required that call lights be within easy reach for residents in bed or confined to a chair.
Failure to Honor Resident Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, as required by both facility policy and federal regulations. The resident, who had a history of respiratory tuberculosis, pneumonia, and depression, and was assessed as having severely impaired cognitive skills, was subject to visitation restrictions imposed by a family member. Specifically, two family members were not allowed to visit the resident unless accompanied by another family member, despite there being no evidence of harm or neglect associated with their visits. This restriction was documented in the Interdisciplinary Team notes and enforced by staff, who contacted the restricting family member when the two visitors arrived. The facility's own policies, as well as regulatory guidance, state that visitation cannot be restricted based on the wishes of family members or healthcare power of attorney unless there is an immediate risk to the resident. The ombudsman notified the facility that such restrictions were not permitted, yet the facility did not develop a care plan to address the family conflict or the visitation issue. Interviews with staff confirmed that the facility did not follow its policies or regulatory requirements regarding residents' visitation rights, and no care plan was in place to address the situation.
Failure to Develop Care Plan for Visitation Rights and Family Conflict
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's visitation rights and the conflict between the resident's family members. The resident, who had diagnoses including respiratory tuberculosis, pneumonia, and depression, was assessed as having severely impaired cognitive skills and required moderate assistance with activities of daily living. Despite documentation in the Interdisciplinary Team (IDT) notes that certain family members were not allowed to visit unless accompanied by another family member, there was no corresponding care plan developed to address this issue. Progress notes indicated that the facility was informed by the Ombudsman that visitation could not be restricted unless there was an immediate risk to the resident, and staff interviews confirmed that no harm or neglect had occurred from the restricted family members. Further review revealed that the facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs, but no such plan was created regarding the visitation conflict. Both the Social Services Director and a Registered Nurse acknowledged the lack of a care plan for the resident's visitation rights and family conflict, confirming that the facility did not follow its own policies and regulatory requirements in this instance.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement and develop comprehensive care plans tailored to the individual needs of several residents, as evidenced by multiple observations and interviews. For one resident with severe cognitive impairment and total dependence for activities of daily living (ADLs), staff placed a bedside table and lowered the bed frame in a manner that restricted movement and created a risk of entrapment. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that these actions were inappropriate and not in line with the resident's care plan, which aimed to prevent signs and symptoms of entrapment. Another resident with unspecified dementia and psychosis, who was nonverbal and required supervision for ADLs, was observed wandering the facility and attempting to enter other residents' rooms. Despite the use of a sitter to monitor this resident's behavior, there was no care plan developed to address the risk of elopement or behavioral concerns. Both the LVN and DON acknowledged the absence of a care plan for this resident's behavior. A third resident, also with severe cognitive impairment and total dependence for ADLs, was observed in uncomfortable and unsafe positions in bed, with a tendency to slide off the bed. Staff interviews indicated the need for frequent monitoring and specific positioning due to tube feeding requirements, but there was no care plan developed to address the resident's behavior of sliding off the bed. The facility's policy requires comprehensive, person-centered care plans with measurable goals and timetables, which were not implemented for these residents.
Failure to Timely Provide Hearing Aids and Communication Support
Penalty
Summary
The facility failed to maintain a resident's hearing at the highest attainable level and did not obtain hearing aids in a timely manner for a resident with severe hearing loss. The resident, who had diagnoses including type 2 diabetes and hypertensive heart disease, was documented as having moderately impaired hearing and was eligible for hearing aids under Medi-Cal. Despite an audiology consult and a care plan that included interventions for hearing impairment, the resident's hearing aids were not functioning properly, and the facility did not provide alternative communication tools such as a communication board or pen. The resident reported not having spoken to the social worker about hearing aid issues or follow-up appointments for months and expressed frustration over the inability to watch TV and difficulty communicating with staff. Observations and interviews revealed that staff were unaware of the resident's hearing aid problems and had not implemented care plan interventions to support communication. The social services staff acknowledged the lack of communication tools and the importance of effective communication for resident care. Facility policies required staff to report hearing aid complaints and assist residents in maintaining effective communication, but these procedures were not followed, resulting in the resident experiencing anger, communication barriers, and reduced ability to engage in daily activities.
Failure to Provide and Accurately Document Range of Motion Services
Penalty
Summary
The facility failed to ensure that three residents with limited range of motion (ROM) and mobility impairments received appropriate treatment and services as ordered by their physicians and in accordance with facility policy. Each of the residents had significant medical conditions, including hemiplegia, contractures, encephalopathy, Parkinsonism, epilepsy, muscle weakness, and abnormal posture, and were totally dependent on staff for activities of daily living. Physician orders for these residents included daily or five times weekly passive range of motion (PROM) exercises, application of splints, and use of handrolls, all intended to maintain or improve their ROM and prevent further decline. Record reviews revealed that these residents did not consistently receive the ordered restorative nursing assistant (RNA) treatments during a specified period. Specifically, documentation showed that from 5/15/2025 to 5/19/2025, the residents did not receive the full complement of RNA treatments as prescribed. Additionally, weekly summary notes for RNA treatments were documented in advance, rather than reflecting the actual care provided during the week. This practice was confirmed by interviews with the RNA, who stated that she completed the weekly summaries ahead of time, and by the DON, who acknowledged that documentation should not be completed in advance and must accurately reflect the care delivered. The facility's policies on Resident Mobility and Range of Motion, as well as Charting and Documentation, require that residents with limited ROM receive appropriate interventions and that documentation be objective, complete, and accurate. The failure to provide the ordered treatments and to document care accurately constituted a deficiency, as it did not meet the facility's own standards or professional practice requirements.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
A resident with a history of dysphagia and essential hypertension, who was totally dependent on staff for activities of daily living and had moderately impaired cognitive skills, was observed to have multiple broken, missing, and discolored teeth. The resident reported not having seen a dentist in several months, although she denied being in pain at the time of the interview. Review of the medical record revealed a physician's order allowing for dental consult and treatment as needed, but there were no dental records or progress notes indicating that the resident had received any dental care since admission. Interviews with facility staff, including the Social Service Director and the Director of Nursing, confirmed that the resident was supposed to receive dental services every 6 to 12 months and as needed, in accordance with facility policy. The lack of documented dental care and absence of dental records for the resident since admission constituted a failure to provide routine and emergency dental services as required by both physician orders and facility policy.
Failure to Follow Dietary Recipe and Measurement Protocols
Penalty
Summary
A deficiency occurred when a dietary staff member failed to follow the facility's recipe for Paprika Beef by not using proper measuring utensils for the Knorr Beef Bouillon. The staff member was observed scooping the bouillon powder with a spoon, without measuring the amount, and adding it directly to the meat. The same spoon was used for stirring the meat and for scooping the bouillon, which could potentially contaminate the bouillon powder. The staff member admitted to not following the recipe and not using measuring cups or spoons as required, and stated she had not received an in-service on following food recipes since being employed at the facility two weeks prior. The Dietary Supervisor confirmed that all dietary cooks are expected to follow recipes and use proper measuring utensils when preparing meals. The supervisor also acknowledged that failure to follow recipes could result in improper seasoning and potential health risks for residents. A review of the facility's job description for cooks and the specific recipe for Paprika Beef further supported the requirement to adhere to established recipes and procedures.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage and preparation practices. Leftover tuna was found stored in the refrigerator past its used-by date, and a plate of salad was present without any used-by or expiration date. Several food items, including a large container of dry spaghetti and sour cream, were found with expired dates, and some items had no expiration or used-by dates at all. Additionally, a staff member's personal water bottle was stored in the residents' kitchen refrigerator, and a leaking pipe under the sink was being managed with a green bucket to catch water. The kitchen also contained a container of sour cream that was curdled with clear liquid, and a container of prepared tuna without an expiration date. Dietary staff interviewed were unaware of proper storage times for prepared tuna and did not know the location of the maintenance log. Further inspection revealed that multiple food items were not labeled with expiration or used-by dates, and expired items were not disposed of as required. The kitchen environment was also found to be unsanitary, with debris collecting on the paper towel dispenser, an unclean handwashing/eye washing station sink, and six cutting knives that were not clean. Eight out of seventeen resident trays were noted to be cracked and chipped. The facility's policy requires all refrigerated and frozen foods to be covered, labeled, and dated, and for foods to be monitored and discarded by their used-by dates, but these procedures were not followed.
Failure to Change PPE Between Residents on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established guidelines for the use of Personal Protective Equipment (PPE) when providing care to three residents who were on Enhanced Barrier Precautions (EBP) due to their medical conditions, including hemiplegia, encephalopathy, muscle weakness, and the presence of gastrostomy tubes. All three residents were severely cognitively impaired and totally dependent on staff for activities of daily living. Physician orders and facility policy required the use of gowns and gloves for high-contact care activities, with PPE to be changed and hand hygiene performed between contact with each resident, especially in multi-bed rooms where each bed space is considered a separate room. During an observation, a Certified Nursing Assistant (CNA) was seen wearing the same gown, mask, and gloves while sequentially checking and touching the gastrostomy tube sites of all three residents in the same room, without changing PPE or performing hand hygiene between residents. The Director of Nursing confirmed that staff were required to don and doff PPE appropriately for each resident on EBP and acknowledged that failure to do so could result in the transfer of infection between residents. Facility policy also specified the need to change gowns and gloves and perform hand hygiene when moving from contact with one resident to another in multi-bed rooms.
Failure to Repair Leaking Pipe and Maintain Maintenance Logs
Penalty
Summary
A leaking pipe under the kitchen sink was observed, with a green bucket placed underneath to catch the water. Dietary staff reported that the leak had been present for about one to two weeks and stated that the maintenance supervisor had been notified the previous week. The maintenance supervisor confirmed being notified but indicated the notification occurred more recently. Both dietary and maintenance staff acknowledged that leaking pipes could lead to mold growth and potential illness among residents. Additionally, the facility failed to maintain maintenance repair logs and schedules as required by its own policy. The Director of Nursing stated that the maintenance supervisor is responsible for keeping these records in his office, but there was no evidence provided that these logs and schedules were being maintained. The facility's policy specifies that maintenance services should ensure all equipment and areas are kept in a safe and operable manner, with records maintained accordingly.
Resident Room Size Deficiency and Impeded Mobility Due to Bariatric Bed
Penalty
Summary
The facility failed to ensure that nine resident rooms met the federal requirement of at least 80 square feet per resident in multiple occupancy rooms. Observations and record reviews revealed that several rooms, each measuring 226 square feet and housing three residents, provided only 75.3 square feet per resident, while two other rooms with six beds each provided only 77.6 square feet per resident. Despite a facility letter stating that room sizes would not interfere with care or safety, direct observation showed that the rooms did not meet the minimum space requirements as outlined by federal regulations. Additionally, the placement of a bariatric bed and bedside table in one room further restricted movement for a resident with multiple chronic conditions, including fibromyalgia, muscle weakness, rheumatoid arthritis, hypertension, and spondylosis. This resident, who was cognitively intact and required varying levels of assistance for mobility and personal care, reported feeling confined and unable to move freely within the room, particularly when accessing the bathroom. The arrangement of furniture and insufficient space impeded the resident's ability to move safely and independently, contrary to regulatory standards.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was fully informed and provided consent prior to the administration of psychotropic medications. Record reviews showed that a resident with diagnoses including metabolic encephalopathy, unspecified dementia, and major depressive disorder was prescribed and administered mirtazapine and trazodone. The Minimum Data Set indicated the resident had severely impaired cognitive skills and required maximal to total assistance with activities of daily living. Despite these conditions, the required informed consent documentation for both medications was either incomplete or missing, lacking signatures and confirmation that the resident or responsible party had been informed and had consented to the treatment. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that informed consent forms for the psychotropic medications were not properly completed prior to administration. The facility's own policy requires that informed written consent be obtained and documented in the resident's medical record before initiating psychotherapeutic drug treatment. However, the resident's health record did not contain the necessary signed consents, and both medications were administered without this documentation.
Bariatric Bed Placement Impedes Resident Mobility
Penalty
Summary
The facility failed to ensure that a bariatric bed did not impede the free movement of staff and a resident. During observation and interview, it was noted that a resident's room was crowded due to the presence of a bariatric bed and a bedside table belonging to the roommate. The resident reported feeling closed in and stated that the size of the bariatric bed made it difficult to move around the room. Specifically, the resident indicated that opening the bathroom door caused it to bump into the foot of the roommate's bed, and she could only safely exit her own bed from one side. The resident expressed frustration about not having enough room to move freely in her room. Record review showed that the resident had intact cognition and required varying levels of assistance for mobility and activities of daily living, including walking, toileting, and dressing. The federal guidance reviewed indicated that the measurement of usable living space in the room should include the swing or arc of any door opening directly into the resident's room. The deficient practice resulted in impeding the free movement of the resident and had the potential to impede the free movement of staff and guests.
Failure to Inventory and Safeguard Resident's Personal Belongings
Penalty
Summary
The facility failed to promptly resolve a grievance regarding missing personal belongings for a resident who was severely cognitively impaired and fully dependent on staff for activities of daily living. Upon review, it was found that the facility did not complete an inventory of the resident's personal belongings at the time of admission, as required by facility policy. The resident's family reported missing clothes and personal items to staff but did not receive any follow-up or resolution regarding the missing items. Interviews with facility staff, including the Social Services Director and Director of Nursing, confirmed that an inventory list was not completed upon admission, and that staff are responsible for documenting and updating residents' personal property records. The facility's policy mandates that an inventory be completed at admission and reviewed regularly, but this was not done in this case, resulting in the resident's belongings being unaccounted for.
Unnecessary Physical Restraint Due to Bed and Bedside Table Placement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and total dependence for activities of daily living was subjected to unnecessary physical restraint. The resident's bed frame was observed to be set very low with a sagging mattress, which restricted the resident's ability to get out of bed. Additionally, a bedside table was positioned alongside the bed, blocking the resident's movement. These conditions were observed on two separate occasions, and staff interviews confirmed that the setup was intended to prevent the resident from getting up due to a high risk of falls. The facility's own policy states that restraints should only be used for medical symptoms and not for staff convenience or fall prevention, and that equipment should not be used to restrict resident mobility. Both the LVN and DON acknowledged that the bed and bedside table placement restricted the resident's movement and could cause entrapment. The care plan for the resident included a goal to prevent signs and symptoms of entrapment, but the observed practices were inconsistent with this goal and the facility's restraint policy.
Failure to Complete Background Checks for Direct Care Staff
Penalty
Summary
The facility failed to complete required background checks and screenings for two employees with direct access to residents, as mandated by its own policies and procedures. Specifically, the personnel files for a registered nurse and a licensed vocational nurse showed no evidence of background checks or screenings being conducted at the time of hire or thereafter. This was confirmed during interviews with the Director of Staff and Development, who acknowledged that no background checks were performed for these employees, and with the Director of Nursing, who stated that such checks are necessary prior to employment to ensure staff do not have histories that could negatively impact residents. A review of the facility's policy on background screening investigations indicated that background, reference, and criminal conviction checks—including fingerprinting as required by state law—must be initiated within two days of an employment offer and completed before the employee begins work. The failure to follow these procedures placed all 41 residents at risk, particularly given the presence of controlled drug medications in the facility.
Failure to Prevent Accident Hazards and Inadequate Elopement Risk Assessment
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident with severe cognitive impairment and a known behavior of placing objects in his mouth. Despite documentation in the care plan and staff awareness of this behavior, the resident was observed with access to potentially hazardous items such as a perineal cleanser bottle and multiple disposable razors in his bedside drawer. On separate occasions, the resident was seen putting a cleanser bottle and a blanket in his mouth. Staff interviews confirmed that the resident was not permitted to keep such items within reach, and that frequent monitoring was necessary due to his behavior. Additionally, the facility did not properly evaluate another resident's risk for elopement. This resident, also with severe cognitive impairment and a history of confusion, was observed wandering the facility and attempting to enter other residents' rooms, requiring constant supervision by a sitter or CNA. Despite these behaviors, the resident's elopement risk assessments did not accurately reflect his risk level, and there was no care plan developed to address his risk of elopement. The DON acknowledged that the assessments were inaccurate and that a care plan should have been in place. Facility policies required the review of incidents and accidents for trends and individual vulnerabilities, as well as accurate and complete documentation. However, the observed deficiencies in supervision, environmental safety, and risk assessment for these residents demonstrated a failure to adhere to these policies, placing residents at increased risk for injury and accidents.
Failure to Label Open Dates on Inhalation Medications
Penalty
Summary
Staff failed to label the open date on inhalation medications for two residents with severe cognitive impairment and chronic respiratory conditions. For one resident with type II diabetes mellitus and chronic respiratory failure, the ipratropium-albuterol inhalation solution was being administered every six hours, but the opened foil pouch containing the unit-dose vials was not labeled with the date it was first opened. Similarly, for another resident with chronic obstructive pulmonary disease, congestive heart failure, and muscle weakness, the albuterol inhalation solution was also being administered every six hours, and the opened foil pouch was not labeled with the date of opening. In both cases, the lack of labeling was observed during a medication cart inspection, and the responsible nurse confirmed that the pouches should have been dated according to manufacturer instructions. Manufacturer guidelines for these medications specify that once the foil pouch is opened, the vials must be used within a specific timeframe (one week for ipratropium-albuterol and two weeks for albuterol). The facility's policy also requires checking expiration dates and returning expired medications to the pharmacy. The DON confirmed that the medications should be dated upon opening and that failure to follow these guidelines could affect medication effectiveness. The deficiency was identified through observation, interview, and record review, with direct evidence that the required labeling was not performed.
Improper Medication Storage and Unsanitary Equipment
Penalty
Summary
Facility staff failed to ensure that a resident's diclofenac cream medication was properly stored and secured according to facility policy. The resident, who had diagnoses including metabolic encephalopathy, muscle weakness, and anxiety disorder, was assessed as having severely impaired cognitive skills and was totally dependent on staff for activities of daily living. The resident was not considered safe for self-administration of medication. Despite this, the diclofenac cream was found in the resident's bedside table drawer, accessible to the resident, who was known to put random objects in his mouth. Both a nurse and the Director of Nursing confirmed that the medication should not have been at the bedside due to the resident's confusion and inability to self-administer medications. Additionally, a pill cutter assigned to one of the medication carts was observed to have whitish and orange particles, indicating it was not cleaned and sanitized as required. Nursing staff acknowledged that pill cutters were supposed to be cleaned before and after each use for infection control purposes. Facility policy required medications to be stored in locked compartments and medication preparation areas to be maintained in a clean, safe, and sanitary manner. The failure to properly store medication and maintain clean medication equipment was confirmed through observation, staff interviews, and review of facility policies.
Unpalatable and Overcooked Food Served to Residents
Penalty
Summary
Surveyors observed that the facility failed to provide palatable and nutritious food to residents, as evidenced during a lunch test tray review. The meal, which included pork chop, baked potato, mixed vegetables, dinner roll, cake, milk, and juice, was found to be overcooked and unappetizing. Specifically, the pork chop was hard and lacked flavor, the baked potato was hard near the edges, the mixed vegetables were not palatable, and the dinner roll was hard and overcooked. These findings were confirmed by the Dietary Supervisor, who acknowledged the overcooking of the meal components. Two residents reported that the food was not palatable and specifically mentioned the pork chops being too hard to eat, leading them to request sandwiches as alternatives. One resident, who had broken teeth, was unable to eat the overcooked pork chop. Both residents expressed dissatisfaction with the quality of the food, indicating that it was not meeting their needs. The facility's policy requires that each resident be provided with a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs, but this standard was not met in these instances.
Failure to Prevent Access to Incorrect Meal Tray for Resident at Aspiration Risk
Penalty
Summary
Facility staff failed to ensure that a resident at risk for aspiration, who required 100% feeding assistance, was not left with a breakfast tray within reach. During a facility tour, a breakfast tray intended for another resident was observed on the bedside table next to the resident at risk, with no staff present in the room. The resident's medical record indicated diagnoses including metabolic encephalopathy, dysphagia, obesity, hearing loss, and a gastrostomy, with dietary orders specifying a mechanical soft diet and enteral feeding, along with strict aspiration precautions and the need for full assistance with feeding. Interviews with staff revealed a lack of awareness regarding the placement of the breakfast tray and the associated risks. The CNA interviewed was unaware of the situation and could not articulate the dangers, while the RN and DON acknowledged the potential for serious harm if the resident consumed the incorrect meal. Facility policy required staff to verify correct diet trays before serving, but this protocol was not followed, resulting in the deficiency.
Failure to Provide Prescribed Diet to Resident with Diabetes
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type 2 diabetes mellitus, anemia, vitamin D deficiency, muscle weakness, abnormal gait, and left-sided hemiplegia and hemiparesis, was not provided with a fortified consistent carbohydrate (CCHO) diet as ordered by the physician. The resident's dietary order specified a regular texture, regular liquid consistency, and double portion protein for breakfast and dinner for weight and nutritional management. During a facility tour, the resident's breakfast tray was found on another resident's bedside table, and the resident reported not recalling having breakfast or being aware that the tray was placed there. No staff were present in the room at the time of observation. Interviews with facility staff revealed a lack of awareness regarding whether the resident had received breakfast, and no explanation was provided for why the tray was misplaced. The facility's policies required proper identification and verification of meal trays to ensure residents received the correct diet, as well as timely meal service. However, these procedures were not followed, resulting in the resident not receiving the prescribed meal in accordance with their dietary needs and physician's orders.
Delayed Call Light Response for Residents Needing ADL Assistance
Penalty
Summary
Facility staff failed to answer call lights in a timely manner for two residents who required assistance with activities of daily living (ADLs). One resident, admitted with diagnoses including type 2 diabetes, essential hypertension, and generalized muscle weakness, was assessed as cognitively intact and at high risk for falls. The resident's care plan required that the call light be kept within reach and answered promptly. During observation and interview, the resident reported frequent delays in call light response on every shift, sometimes waiting so long that she fell back asleep, which caused her anger and frustration when needing assistance to use the bathroom. Another resident, with diagnoses including dysphagia, essential hypertension, and generalized muscle weakness, was assessed as moderately cognitively impaired and totally dependent on staff for ADLs. This resident reported waiting more than 30 minutes for staff to respond to call lights, resulting in delays for assistance with changing adult briefs or obtaining water, which also led to anger. Staff interviews confirmed that call lights are expected to be answered promptly, ideally within 3 to 5 minutes, and that delays could result in resident distress or emergencies. Facility policy also required call lights to be answered as soon as possible, but no later than 5 minutes.
Overflowing Waste Equipment Creates Unsanitary and Unsafe Environment
Penalty
Summary
Facility staff failed to maintain a sanitary and comfortable environment by allowing waste equipment in the waste disposal area to overflow, resulting in waste spilling onto the ground. During a facility tour, surveyors observed overflowing trash bins with garbage spilling out, and a maintenance staff member was seen standing on top of the trash bin attempting to press down the garbage. The maintenance staff member acknowledged that trash was not supposed to overflow and that lids should remain shut to prevent exposure, noting that overflowing waste could attract pests and pose a fire hazard. The Director of Nursing confirmed that maintenance staff should not have climbed on the overflowing waste equipment due to the risk of injury and agreed that overflowing trash was an environmental hazard that could cause unpleasant odors and attract pests, potentially exposing residents, staff, visitors, and the public to infectious diseases. Review of facility policies indicated requirements for maintaining a safe, sanitary, and homelike environment, as well as proper maintenance of buildings and grounds, which were not followed in this instance.
Resident Rooms Exceed Maximum Occupancy Requirement
Penalty
Summary
The facility failed to comply with federal regulations requiring that resident rooms accommodate no more than four residents per room. During observations, interviews, and record reviews, it was found that two resident rooms each contained six beds, exceeding the allowable maximum. The facility had submitted a Request for Room Size Waiver, indicating that these rooms had six beds and asserting that the room sizes would not interfere with daily nursing care, safety, or residents' dignity and privacy. The waiver letter also stated that the space would not adversely affect residents' health and safety or impede their well-being. A review of the Client Accommodations Analysis confirmed that the two rooms in question measured 466 and 475 square feet, respectively, with each resident having approximately 77.6 square feet of space. Observations during the survey period noted that residents in these rooms had ample space to move freely, and there was sufficient room for beds, side tables, and care equipment. Despite these observations, the rooms did not meet the federal requirement limiting occupancy to four residents per room.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to follow its own policy and procedures regarding the notification of a physician when a resident refused prescribed tuberculosis (TB) medications. For one resident with severe cognitive impairment and multiple diagnoses including TB, anemia, hypertension, and mobility issues, there were multiple documented refusals of critical medications such as isoniazid, pyridoxine, and rifampin over several dates. Despite these refusals, there was no documentation in the resident's medical record or progress notes indicating that the physician had been notified of the refusals, as required by facility policy. Interviews with staff revealed that the nurse would attempt to re-administer the medications later and only notify the physician after three consecutive days of refusal, which was not in line with the facility's policy. The DON confirmed that although the physician visited frequently and was verbally informed, the refusals were not documented in the progress notes. The facility's policy specifically required that detailed information about treatment refusals be documented in the medical record and that the healthcare practitioner be notified of any refusal of treatment.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to follow its own policy and procedure regarding informed consent for psychotropic medication administration for one resident diagnosed with major depressive disorder, hypertension, and dysphagia. The resident, who had severe cognitive impairment and required significant assistance with activities of daily living, was prescribed mirtazapine for depression. Review of the informed consent documentation revealed that while the resident's responsible party was provided information about the medication, the consent form lacked the physician's signature and did not include the date when staff witnessed the education being provided. Interviews with facility staff, including an LVN, the Social Services Director, and the Director of Nursing, confirmed that the consent was incomplete and not valid according to facility policy, which requires a physician's signature and proper dating of the witness to ensure that education about the risks and benefits of the medication was provided. The facility's policy also specifies that informed consent must be obtained and renewed every six months, and that the physician's signature may be obtained remotely if necessary. The incomplete documentation resulted in the resident potentially receiving a psychotropic medication without being fully informed as required.
Failure to Timely Report and Document Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its policy regarding the timely reporting and investigation of a resident-to-resident altercation, as well as the submission of a conclusion report within the required timeframe. Two residents were involved in altercations on two separate occasions, with staff witnessing and documenting the incidents in progress notes. Despite these documented events, the incidents were not reported to the State Agency as required by facility policy and regulatory standards. Resident 1, who had a history of bipolar disorder, schizophrenia, and peripheral vascular disease, was noted to have mildly impaired cognitive skills but was otherwise independent in activities of daily living and capable of making decisions. Resident 2, with diagnoses including hemiplegia, aphasia, and major depressive disorder, had severely impaired cognitive skills and required moderate assistance with daily activities. Both residents were involved in altercations, with staff noting physical and verbal aggression, and statements were obtained from witnesses. Interviews with facility staff, including the DON and Administrator, revealed that while the incidents were internally investigated and residents were separated, there was no documentation of the investigation or its outcome. Furthermore, the Administrator was not initially made aware of the incidents, and the required reports to the State Agency and other authorities were not submitted in accordance with the facility's abuse reporting policy. This failure resulted in a delay in external oversight and investigation of the alleged abuse.
Failure to Investigate and Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not investigating a resident-to-resident altercation involving two residents. On two separate occasions, one resident with a history of bipolar disorder and schizophrenia, and another resident with hemiplegia, aphasia, and major depressive disorder, were involved in verbal and physical altercations. Staff witnessed these incidents, including one where a resident became physically aggressive and threatened further altercations, and another where both residents argued about personal space. Despite staff witnessing and documenting the incidents in progress notes, there was no evidence that a formal investigation was conducted or documented as required by the facility's abuse policy. The Director of Nursing (DON) acknowledged the altercations and stated that the residents were separated, but could not provide any documentation of an investigation or its outcome. Additionally, the incidents were not reported to the State Agency as mandated by facility policy. The facility's policies require that all reports of resident abuse, including resident-to-resident altercations, be thoroughly investigated, documented, and reported to appropriate authorities. However, the lack of investigation documentation and failure to report the incidents to the State Agency constituted a failure to follow these procedures, resulting in a deficiency.
Failure to Properly Label and Dispose of Enteral Feeding Bottles
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of enteral feeding bottles for one resident, leading to a deficiency in care. Specifically, the enteral feeding bottle for Resident 3 was observed to be dated but lacked an infusion start time, which is necessary to track the duration of use. This oversight was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that G-tube feedings should be labeled with both date and time to ensure they are changed within the appropriate timeframe. Further investigation revealed that the enteral feeding bottle had been in use beyond the 48-hour maximum hang time as stipulated by both the manufacturer's guidelines and the facility's policy. The Director of Nursing (DON) confirmed that failing to label the feeding with a date and time could result in prolonged administration, increasing the risk of pathogen growth and potential foodborne illness. Resident 3, who was totally dependent for all functional care and had a severely impaired cognition, was at risk due to this deficiency.
Failure to Administer Correct Oxygen Dosage
Penalty
Summary
The facility failed to ensure that a resident received the correct therapeutic dose of oxygen as ordered by the physician. The resident, who was admitted with diagnoses including encephalopathy, dysphagia, depression, and chronic obstructive pulmonary disease (COPD), was observed receiving oxygen at a rate of 5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during an initial tour and confirmed by a Licensed Vocational Nurse (LVN), who was unable to explain the deviation from the prescribed oxygen flow rate. The Director of Nursing (DON) acknowledged the risk of oxygen overdose, which could lead to lung expansion and potentially cause the resident to stop breathing. The facility's policy on oxygen administration, dated October 2010, specifies that oxygen should be administered at a rate of 2 to 3 liters per minute unless otherwise ordered. The failure to adhere to the physician's order placed the resident at risk of oxygen poisoning and could negatively impact their health and well-being.
Infection Control Breach: Contaminated Medication Administered
Penalty
Summary
The facility failed to adhere to its infection control policy when a licensed nurse administered a medication to a resident after it had fallen onto the floor. This incident involved a resident who was admitted with medical diagnoses including diabetes, hypertension, and generalized muscle weakness. The resident, who had moderately intact cognition and required supervisory to partial/moderate staff assistance with activities of daily living, was given Ativan, a medication used to treat anxiety, after it had been picked up from the floor by the nurse. During an observation and interview, the nurse acknowledged that the facility's process for handling a pill that falls to the ground is to discard it due to contamination risks. The Director of Nursing confirmed this policy, emphasizing that a pill on the floor is considered soiled and should not be administered to residents. Despite this, the nurse handed the contaminated pill to the resident, who then ingested it, potentially exposing the resident to gastrointestinal illnesses.
Verbal Abuse Incident Involving LVN and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Licensed Vocational Nurse (LVN). The incident involved a resident with a history of encephalopathy, psychosis, depression, and anxiety disorder, who was admitted to the facility with moderate cognitive impairment. On the day of the incident, the resident was involved in a verbal altercation with the LVN, who admitted to cursing at the resident, violating the facility's abuse prevention policy and code of conduct. The altercation was documented in the resident's situation background assessment and recommendation (SBAR) form, and the resident was placed on 72-hour monitoring. The LVN, who had no previous disciplinary actions and had received initial abuse and code of conduct training, denied verbally abusing the resident but admitted to calling 911 due to the resident's aggressive behavior. The facility's policies clearly state that any form of resident abuse, including verbal abuse, is not condoned. Despite the LVN's denial, the facility's corrective action memo confirmed the LVN's admission of cursing at the resident, leading to the LVN's termination. The facility's failure to prevent this verbal abuse incident resulted in a deficiency report.
Failure to Inform Resident and Representative of Discharge
Penalty
Summary
The facility staff failed to inform a resident and their representative about the discharge from Skilled Nursing Facility 1 (SNF1) to Skilled Nursing Facility 2 (SNF2) before the transfer occurred. This lack of communication led to the resident being transferred to SNF2, where they exhibited aggressive behavior and were difficult to manage. The resident had been admitted to SNF1 with diagnoses including encephalopathy, psychosis, depression, and anxiety disorder, and was noted to have moderate cognitive impairment. Upon arrival at SNF2, the resident became volatile, attempting to elope and exhibiting aggressive behavior towards staff and other residents. Staff at SNF2, including a social services director, licensed vocational nurse, speech therapist, and certified nursing assistant, reported incidents of the resident throwing objects, invading personal space, and being verbally aggressive. Despite attempts to de-escalate the situation and calls for police assistance, the resident's behavior remained unmanageable, leading to their discharge back to SNF1 on the same day.
Failure in Safe Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and handling practices in the kitchen, as observed during a survey. Cook 1 was seen not wearing a hairnet and gloves while preparing food that was to be served directly to residents. This oversight was noted during an initial tour of the kitchen, where Cook 1 admitted to forgetting to wear the necessary protective gear for infection prevention purposes. Interviews with the Dietary Services Supervisor (DSS) and the Director of Nursing (DON) confirmed that all staff were required to wear hairnets and gloves when handling food, as well as wash their hands before entering the kitchen area. The facility's policy and procedures, dated 2018, also indicated that Food & Nutrition employees should avoid bare hand contact with any foods and use suitable utensils or single-use gloves. The failure to adhere to these protocols had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illness to the 41 medically compromised residents receiving food from the kitchen.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with regulations by accommodating more than four residents in two of its rooms, specifically rooms [ROOM NUMBERS], which each housed six residents. This deficiency was identified through observation, interviews, and record reviews. Despite the residents in these rooms expressing satisfaction with the space and their ability to move freely, the configuration did not meet the regulatory requirements. The residents reported no issues with their rooms, and staff were able to provide care without restrictions. A room waiver request was submitted, highlighting that the rooms were spacious, provided ample closet space, and ensured privacy and safety for the residents.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, ten out of thirteen resident rooms did not meet the 80 square feet per resident requirement for multiple occupancy rooms. Nine of these rooms contained three beds each, with only 75.33 square feet per resident, while two rooms contained six beds each, with one room providing only 70.55 square feet per resident and the other 79.16 square feet per resident. The minimum required square footage for a three-bed room is 240 square feet, and for a six-bed room, it is 480 square feet. Despite the deficiency, observations during the survey indicated that residents had ample space to move freely within their rooms, and there was sufficient space for nursing staff to provide care. Interviews with two residents confirmed that they did not experience any issues with room space or receiving care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not interfere with daily nursing care, safety, or the residents' ability to attain their highest practicable well-being. The Department recommended the continuation of the Room Waiver Request.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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