Temecula Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Temecula, California.
- Location
- 44280 Campanula Way, Temecula, California 92592
- CMS Provider Number
- 555923
- Inspections on file
- 29
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Temecula Healthcare Center during CMS and state inspections, most recent first.
A resident with hypertensive heart disease, heart failure, and morbid obesity, who required partial/moderate assistance with multiple ADLs and mobility, was planned for discharge home with support from informal caregivers. The care team, including the CM and DOR, identified the need for home health, a caregiver, and equipment such as a bariatric FWW, wheelchair, and oxygen, and the physician ordered discharge home. However, there was no documented evidence that caregiver training on required care and ADLs was completed for the responsible party or any designated caregiver, nor that missed training was rescheduled. On the planned discharge day, staff confirmed the resident still needed assistance with daily activities, and the responsible party expressed uncertainty about being able to provide the necessary care, contrary to facility policy requiring verification of caregiver capacity for a safe discharge.
A resident with hypertensive heart disease with HF and morbid obesity was initially scheduled for discharge home, and a written Notice of Proposed Transfer/Discharge was issued reflecting that plan. Later, a physician order and discharge summary documented a change in the discharge destination to a board and care facility, but the facility did not issue a new written notice reflecting this change to the resident, the resident representative, or the Ombudsman. Interviews with the CM and DON confirmed that the process requires a new notice when the discharge plan changes and that the SSD or CM should provide and review the notice and send a copy to the Ombudsman, but there was no documentation that this occurred, contrary to facility policy requiring a new notice for significant changes such as a change in discharge destination.
Two residents were involved in a hallway altercation in which one resident alleged being choked and the other admitted to pushing the complainant away after a verbal dispute involving an LVN. Staff intervened, assessed the alleged victim, and documented the incident, including that the alleged victim reported choking and the alleged aggressor denied choking but admitted pushing. Despite staff knowledge that resident physical altercations must be reported within two hours, the incident was not reported to the SSA until the following morning, well beyond the facility policy’s definition of “immediately” (within two hours for abuse allegations), resulting in a failure to comply with required abuse reporting timeframes.
A resident with surgical aftercare needs and mental health diagnoses developed persistent loose, watery diarrhea after a clinician recommended a stool culture for C-diff, but staff instead processed only a generic stool culture and never completed the specific C-diff test. Over the following week, documentation showed ongoing diarrhea without evidence that the physician was informed the ordered C-diff test was not done or that treatment for the diarrhea was initiated. Later, the resident experienced significant weight loss and a critically elevated WBC, which was received by staff but communicated to the physician only by text, with no documented follow-up or new orders despite facility policy calling for immediate, direct notification for critical results. The resident’s condition deteriorated overnight, with hypotension, respiratory distress, and altered mental status, leading to a 911 call and transfer, after which the resident died in transit; the physician later reported not being told that the C-diff culture had not been performed and was unaware of any delay in transfer.
A nurse used a wound cleanser containing sorbitol to clean the peristomal skin of a resident with a colostomy, contrary to facility protocols and professional guidelines that require gentle cleansing with normal saline or water. The resident experienced severe pain and burning during the procedure, and staff interviews confirmed that wound cleansers should not be used for ostomy care.
A physical therapist transferred a resident with hemiplegia and Parkinson's disease using a Hoyer lift without a second staff member, contrary to facility policy and the resident's care plan, which required two-person assistance for safe transfers.
A resident with a history of stroke-related monoplegia was involved in a verbal altercation after being moved to a new room, displaying agitated behaviors and making threatening statements. The incident caused emotional distress to the new roommate, who was subsequently relocated. Despite facility policy requiring documentation of such events, staff interviews and record reviews confirmed that the incident was not documented in the resident's medical record.
A resident with multiple medical conditions was found by staff with a bleeding head wound, severe pain, and confusion, with no explanation for the injury. Staff discovered the incident in the early morning, observed significant blood loss and an overturned walker, and transferred the resident to the hospital, where serious head injuries were diagnosed. Despite policy requiring notification within two hours, the DON reported the incident to the SSA more than twelve hours later.
A resident who was alert and oriented was discharged after their health improved, but the facility did not send the discharge notice to the LTC Ombudsman at the same time it was provided to the resident and their representative, as required by policy. The notice to the Ombudsman was sent several days later, contrary to facility procedures.
Surveyors found that the internal release mechanisms on the walk-in refrigerator and freezer doors were not functioning, preventing staff from being able to open the doors from the inside. The Director of Maintenance was unaware of the issue until it was identified during the inspection.
Surveyors found that the generator enclosure, which houses the diesel fuel storage area, lacked a portable fire extinguisher within the required travel distance. The closest extinguisher was located inside the facility, across a courtyard, rather than within 30 or 50 feet of the enclosure as required by NFPA 10. This deficiency affected all residents and smoke compartments.
Two kitchen staff members were found to be unaware of proper response protocols for grease fires and reported not having received training on this topic. This deficiency was observed during a facility tour and interview with the DOM and Kitchen Lead Staff, affecting one of four smoke compartments.
Multiple lapses in food safety and sanitation were observed, including an expired sandwich left in the refrigerator, a dispensing scoop stored in direct contact with mashed potato powder, a kitchen door left open near the garbage area for an extended period, and uncovered dumpsters. These deficiencies were confirmed by dietary staff and were not in accordance with facility policy or professional standards.
The facility did not ensure that residents or their representatives were provided with follow-up information or documentation regarding Advance Directives (ADs). Multiple residents, including those with intact and moderately impaired cognition, were unsure if they had an AD or if information was offered. Record reviews showed missing documentation of education or follow-up about ADs, despite facility policy requiring this. The deficiency was confirmed through interviews and record reviews, with the Social Service Director acknowledging the lack of required documentation.
Two residents received improper respiratory care when one was given oxygen at a higher flow rate than ordered without proper assessment or documentation, and another used unlabeled oxygen tubing, contrary to facility policy. Staff interviews and record reviews confirmed that oxygen administration and equipment labeling protocols were not followed.
A dietary aide did not follow the manufacturer's instructions when testing the Quat sanitizer solution, dipping the test strip for only four seconds instead of the required ten. This deviation from procedure was acknowledged by the aide and confirmed by the RD, with facility policy also requiring adherence to manufacturer guidelines.
A resident with a right below knee amputation and moderate cognitive impairment was found with their call light on the floor and out of reach, despite care plan and facility policy requiring accessibility. Staff interviews confirmed the call light should have been within reach to allow the resident to request assistance as needed.
A resident with dementia was exposed to a chemical hazard when a housekeeper left a cup containing toilet cleaning solution and a brush on the bedside table near the resident's drinking cup. The cleaning solution was accessible to the resident, and staff interviews confirmed that such chemicals should be secured away from resident areas according to facility policy.
The facility did not effectively use its QAPI program to resolve an ongoing issue with missing covers on all three dumpsters. Despite identifying the problem and making multiple attempts to contact the waste management company, the bins remained uncovered, and no interim solutions were implemented. The daily supervisor rounds checklist consistently showed the task for closing and cleaning trash lids was not completed.
A nurse did not follow manufacturer instructions for disinfecting a shared blood pressure cuff, failing to keep the surface wet with a disposable wipe for the required one-minute contact time after use on a resident. Interviews with the IP and ADON confirmed staff are expected to follow these instructions, and facility policy requires equipment to be cleaned per manufacturer guidelines.
A resident's legal representative requested medical records, but the facility failed to provide them within the specified two working days. The Medical Records Director forwarded the request to the legal team, causing a delay. The facility's policy requires records to be provided within two days for current residents or 15 days for discharged residents, which was not adhered to in this case.
A resident with atrial flutter was transferred to a hospital without a physician order after becoming unresponsive. Despite the facility's policy requiring physician notification and an order for hospital transfers, staff failed to follow this protocol, as confirmed by interviews with the RN and ADON.
A facility failed to maintain accurate medical records for a resident, resulting in inconsistencies in the timeline of an alleged financial abuse incident. The resident's daughter reported the abuse to the Case Manager, but the eINTERACT SBAR Summary inaccurately documented the incident time. The RN who documented the note was not present during the incident and was instructed by the DON to create a late entry, leading to confusion and inaccuracies. The facility lacked a specific policy on late charting, although standard practice discouraged documentation by staff not on duty.
A resident with a history of falls and severe cognitive impairment was observed without a bed alarm, despite it being a recommended intervention. The care plan was not implemented, and the fall risk assessment was not updated. Staff interviews revealed a lack of communication and adherence to the care plan, leading to potential fall risks.
A resident with Bipolar Disorder alleged physical abuse by a CNA during a shower, reporting pain from hair pulling. The incident was not reported to CDPH within the required two-hour timeframe, as confirmed by interviews with facility staff. The report was delayed by 14 hours, contrary to the facility's policy for immediate reporting of abuse allegations.
The facility failed to notify the Ombudsman prior to the discharges of two residents, as required by policy. One resident with hemiplegia and another with multiple health issues were discharged without timely notification to the Ombudsman, which is necessary for advocacy support. The facility's practice of sending discharge notices monthly resulted in delays, contrary to the policy requiring simultaneous notification to the Ombudsman and the resident.
A resident, identified as a fall risk, did not have bilateral floor mats in place as ordered, posing a potential injury risk. Observations revealed only one mat was present, despite orders for mats on both sides of the bed. Interviews with a CNA and the ADON confirmed the deficiency, highlighting a lapse in following the facility's fall prevention protocol.
A facility failed to provide medical records within two business days after receiving a request from an attorney for a resident with severe cognitive impairment. The request, received on August 20, 2024, was sent to the corporate office, which instructed not to respond, indicating the facility's attorney would handle it. As of the survey date, seven business days had passed without fulfilling the request, violating the facility's policy for timely provision of protected health information.
The facility failed to provide adequate supervision for two residents, resulting in separate elopement incidents. Both residents, identified as elopement risks, managed to leave the facility undetected despite having personal alarms. Staff interviews and care plan reviews confirmed that the residents were not properly monitored.
The facility failed to maintain an infection prevention and control program during a COVID-19 outbreak by not conducting contact tracing and testing for staff and residents, believing that N95 respirators negated the need for such measures. This led to the spread of COVID-19 among residents and staff, affecting all four units.
The facility failed to thaw chicken safely for 106 of 113 sampled residents. The chicken was found in a sink without a continuous flow of cold water, contrary to the facility's policy. Cook #33 admitted to using hot water to thaw the chicken more quickly. The Dietary Supervisor instructed the chicken to be discarded, and interviews confirmed the expectation for staff to follow food safety guidelines.
The facility failed to follow up with the local authority for a Level II PASARR evaluation for a resident with schizophrenia and anxiety disorder. Despite a positive Level I screen, the ADON did not ensure the evaluation was completed, leading to the resident not receiving necessary services.
The facility failed to submit a Level I PASARR for a resident with bipolar disorder and anxiety disorder who remained in the facility longer than 30 days. Staff interviews revealed a lack of awareness and understanding of the requirement to resubmit the Level I evaluation, leading to non-compliance with the facility's policy and state instructions.
The facility failed to schedule physician-ordered follow-up appointments for two residents, leading to a deficiency in meeting professional standards of quality. Despite documented orders, the necessary appointments were not scheduled, as confirmed by staff interviews.
The facility failed to ensure that a pharmacy recommendation for a resident with heart failure and dementia was reviewed by the physician. The recommendation for a primidone level was not documented as reviewed or responded to by the physician, leading to a lack of evidence of follow-up. The DON and a quality assurance nurse were involved in the process, but documentation was incomplete.
Failure to Provide Caregiver Training Prior to Planned Home Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective discharge planning and caregiver training prior to a planned discharge home. The resident was admitted with hypertensive heart disease with heart failure and morbid obesity, and MDS assessments showed the resident was cognitively intact but required partial/moderate assistance for toileting hygiene, bathing, dressing, footwear, bed mobility, and toilet transfers. Case management notes documented that the resident and the designated DPOA agreed the resident would return home, with assistance from a family member and a close friend for ADLs, mobility, personal care, meals, and supervision. A physician order set a discharge date to the resident’s home, and the physical therapist recommended home health, a caregiver, bariatric front wheel walker, wheelchair, and oxygen upon discharge. Despite these identified needs and the plan for home discharge with caregiver support, there was no documented evidence that caregiver training was provided to the responsible party or any designated caregiver prior to the planned discharge date. There was also no documentation that caregiver training was rescheduled when it was not completed before the planned discharge. On the planned discharge day, the CNA confirmed the resident required assistance with daily activities, and the responsible party reported uncertainty about being able to provide the necessary care after discharge. The DOR confirmed there was no documentation of caregiver training or appointments to coordinate such training, and the CM stated caregiver training had been offered but not completed. The DON stated that rehab was responsible for caregiver training for ADLs and that the caregiver or any designated caregiver should have been trained to ensure a safe discharge home, and that without completed caregiver training, discharge home would not be considered safe. The facility’s discharge policy required discharge planning to ensure a safe transition and to determine if appropriate and adequate support, including caregiver capacity, was in place.
Failure to Issue Revised Transfer/Discharge Notice After Change in Discharge Destination
Penalty
Summary
The facility failed to provide a new written notice of proposed transfer or discharge when a resident’s discharge destination changed from home to a board and care facility. The resident, admitted with hypertensive heart disease with heart failure and morbid obesity, had an initial physician order dated February 4, 2026, indicating Medicare benefit exhaustion on February 6 and discharge on February 7 to the resident’s home address. A corresponding Notice of Proposed Transfer/Discharge dated February 4 documented an effective discharge date of February 7 and listed the home address as the transfer/discharge destination. Subsequently, a physician order dated February 13 changed the discharge plan to a board and care facility, and the Discharge/Transfer Summary dated February 13 documented that the resident was discharged to a board and care. Despite this change in discharge destination, there was no documented evidence that a new written notice of proposed transfer/discharge reflecting the board and care destination was provided to the resident, the resident representative, or the Ombudsman. During interviews, the Case Manager stated that she provides a new written notice when there are changes in the discharge plan but acknowledged she did not provide a new copy to the Ombudsman for this resident. The DON stated that the SSD or Case Manager should review the notice with the resident and/or representative, complete the written notice, and fax it to the Ombudsman, and confirmed that a new notice should have been prepared for the revised discharge date and destination but there was no documentation that this occurred. The facility’s policy on Transfer or Discharge Notices required written notification to residents or representatives, a copy to the State Long-Term Care Ombudsman, and issuance of a new notice for significant changes such as a change in discharge destination, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Physical Abuse Allegation to SSA
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged incident of physical abuse between two residents to the state survey agency (SSA) within the required two-hour timeframe. On January 4, 2026, at approximately 6:30 p.m., a physical altercation occurred in the hallway of Station 3 between Resident 1 and Resident 2. Resident 2 reported that Resident 1 choked him, stating, "He choked me, but I managed to get out," while Resident 1 stated that Resident 2 came very close to his face, prompting him to push Resident 2 away. Staff, including an LVN, intervened to separate the residents and assessed Resident 2 for skin issues or injuries, and the physician was notified. Resident 1’s medical record showed admission with multiple diagnoses including peripheral vascular disease, anxiety disorder, right below-knee amputation, type 2 diabetes mellitus, orthopedic aftercare following amputation, osteomyelitis, cellulitis of the left lower limb, and MRSA infection. A history and physical dated January 1, 2026, indicated no neuro focal deficits. Resident 2’s record indicated admission with diagnoses including opioid use, anxiety disorder, a displaced bicondylar fracture of the left tibia status post ORIF, and injuries from a pedestrian–vehicle collision, with a history and physical dated January 5, 2026, documenting that Resident 2 was oriented to person, place, and time. Progress notes and eINTERACT SBAR summaries documented that Resident 2 admitted to using profanity toward an LVN related to a prior incident, that Resident 1 witnessed this verbal altercation, intervened, and that Resident 2 alleged choking while Resident 1 denied choking and reported only pushing Resident 2 away. Interviews with staff confirmed both the occurrence of the altercation and the delay in reporting it to the SSA. LVN 1 stated that when two residents have a physical altercation, the RN should be notified immediately and that such altercations should be reported within two hours. The Social Services Director and the Director of Nursing both confirmed that the altercation occurred at 6:30 p.m. on January 4, 2026, and that the SSA was not notified until 9:15 a.m. on January 5, 2026. The DON acknowledged that the altercation was considered abuse and should have been reported immediately. Review of the facility’s abuse, neglect, exploitation, and misappropriation reporting policy, revised September 2022, showed that suspected abuse must be reported immediately to the administrator and appropriate agencies, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. The facility did not adhere to this policy or the regulatory requirement for timely reporting.
Failure to Perform Ordered C-diff Test and Respond to Critical Lab Result for Resident With Persistent Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered laboratory test was correctly carried out and that critical results and ongoing symptoms were appropriately communicated and addressed. A resident was admitted with diagnoses including encounter for surgical aftercare following digestive system surgery, major depressive disorder, and bipolar disorder, and had a POLST specifying comfort-focused treatment and transfer to the hospital only if comfort needs could not be met in the facility. On December 25, 2025, an SBAR form documented a change in condition with the onset of diarrhea and a primary clinician recommendation for a stool culture for C-diff. However, the order summary for that date showed only a generic stool culture was sent, and the facility did not complete the specific C-diff test that had been recommended. From December 26 through December 31, 2025, bowel continence/movement records showed the resident repeatedly had loose and watery stools, with multiple entries documenting incontinence or continent episodes with large, medium, or small amounts of loose or watery stool. A stool culture result dated December 28, 2025, showed no salmonella or shigella, but there was no documentation that the physician was notified that the ordered C-diff culture had not been performed, nor that the resident continued to have loose stool over this seven-day period. Progress notes did not indicate any treatment for the resident’s ongoing loose stool. Facility staff, including an LVN and the ADON, later confirmed that a stool culture for C-diff is a different test from a routine stool culture and that the physician should have been notified when the wrong laboratory test was completed. On December 31, 2025, an SBAR documented that the resident had significant weight loss over one week and drowsiness, with a recommendation for CBC and CMP. Laboratory results showed the resident’s WBC increased from 8.44 on December 23, 2025, to a critically elevated 36.91 on December 31, 2025. An SBAR at 11:39 p.m. recorded receipt of the critical WBC result but did not document any recommendations or interventions from the physician. RN 1 reported that she texted the physician with the critical value, received a question about the admission date, provided that information, and received no further response, and she endorsed the critical value to LVN 3. LVN 3 stated that a critical lab value is considered an emergency requiring an immediate phone call to the physician rather than a text message. The ADON confirmed that a WBC of 36.91 is a critical value, that the physician should have been notified, and that RN 1 should have followed up with the physician after the initial text response. During the night shift spanning December 31, 2025, to January 1, 2026, LVN 3 monitored the resident every 30 minutes due to the critical lab value, performed a bladder scan, and noted the resident was easily aroused and not in distress around midnight. Later, he observed that the resident’s breathing became fast and labored, and he notified RN 1 and a CNA. An SBAR dated January 1, 2026, at 2:05 a.m. documented hypotension, bradycardia, tachypnea, and low oxygen saturation, with staff noting that the resident was initially without shortness of breath or distress around 12:45 a.m., but by around 2:00 a.m. had fast and labored breathing, prompting immediate RN assessment and a 911 call. Progress notes from January 1, 2026, described initiation of oxygen via non-rebreather mask, altered mental status, and the call to 911 at approximately 2:12 a.m., with transfer to the hospital and subsequent notification that the resident died in the ambulance at 2:38 a.m. The physician later stated he was not informed that the C-diff culture ordered on December 25, 2025, had not been performed and that, if the resident continued to have loose watery stool, a C-diff culture would have been important because a positive result would have led to antibiotic orders. The physician also stated he ordered the resident’s transfer to the hospital but was unaware of any delay in the transfer. The facility’s own policies required correct processing of lab orders, prompt physician notification of significant condition changes and critical lab results, and direct voice communication for results requiring immediate notification, which were not followed in this case.
Improper Use of Wound Cleanser During Ostomy Care Causes Resident Pain
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow professional standards of practice for ostomy care by using a wound cleanser containing sorbitol to clean the peristomal skin of a resident with a colostomy. The resident, who had multiple diagnoses including surgical aftercare following digestive system surgery, pneumonitis, pressure ulcer, and type 2 diabetes, experienced severe pain during the procedure. The LVN used the wound cleanser after the resident's colostomy bag was found leaking, despite facility practice and physician orders indicating that the peristomal area should be cleansed with normal saline or warm water and not with harsh chemicals or alcohol-based products. Interviews with facility staff, including the Director of Nursing, Registered Nurse, and Treatment Nurse, confirmed that wound cleansers are not appropriate for peristomal skin due to the risk of burning and irritation. The resident reported significant pain and burning sensation when the cleanser was applied, describing the spray as smelling strong and feeling like alcohol. Documentation in the resident's medical record and facility guidelines further supported that only gentle cleansing agents should be used for ostomy care, and the use of the wound cleanser was inconsistent with established protocols.
Failure to Use Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a physical therapist (PT) operated a Hoyer lift to transfer a resident from bed to wheelchair without the assistance of a second staff member. Observation confirmed that the PT performed the transfer alone, despite the resident being in the lift and requiring maximum assistance for bed transfers. Interviews with both a CNA and the PT confirmed that facility policy requires two staff members to operate the Hoyer lift for safety during transfers. The resident involved had a history of hemiplegia and Parkinson's disease, resulting in substantial to maximal assistance needs for mobility and transfers. The resident's care plan and functional assessment documented these needs, and the facility's policy, revised in July 2017, specified that at least two nursing assistants are required for safe use of a mechanical lift. The PT acknowledged operating the lift alone, which was inconsistent with both the resident's care requirements and facility policy.
Failure to Document Resident Altercation and Related Behaviors
Penalty
Summary
The facility failed to ensure accurate documentation of an incident involving a verbal altercation and related behaviors between two residents. One resident, who had a history of monoplegia following a stroke, was moved to a new room after a previous altercation. Upon being placed with a new roommate, the resident was observed by staff and the new roommate to be agitated, bumping her wheelchair into objects, and making threatening statements over the phone. The new roommate became emotionally distressed, activated her call light, and was subsequently moved to another room by staff. Interviews with staff, including a CNA, LVN, ADON, and DON, confirmed that the incident was not documented in the medical record of the resident who made the threatening statements. The facility's policy requires that all changes in a resident's condition, as well as events, incidents, or accidents, be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, there was no evidence of documentation in the medical record regarding the incident involving the verbal altercation and the resident's behaviors. Record reviews showed that while some documentation existed in the new roommate's records, including an SBAR summary and an IDT note describing the emotional distress and the events that occurred, there was a lack of corresponding documentation in the record of the resident who was the source of the altercation. This omission was confirmed by the DON during a review of the progress notes, indicating a failure to comply with the facility's documentation policy.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident to the State Survey Agency (SSA) within the required two-hour timeframe. The incident occurred when a resident, who had a history of intertrochanteric femur fracture, arterial aneurysm, and rheumatoid arthritis, was found by staff in the early morning hours with a bleeding wound on the right posterior scalp. The resident was visibly distressed, in severe pain, and unable to explain the cause of the injury. Staff observed a large pool of blood on the floor, the resident's walker overturned, and the resident using her bedside table for support. The resident was transferred to an acute care hospital, where she was diagnosed with trace pneumocephalus, subarachnoid hemorrhage, and subdural hematoma, and admitted to the ICU for further monitoring. Interviews with facility staff revealed that the injury was discovered at approximately 3 a.m., but the SSA was not notified until 4:38 p.m., more than twelve hours after the incident. The facility's policy requires that injuries of unknown origin, especially those resulting in serious bodily injury, be reported to the SSA, Ombudsman, and law enforcement within two hours. Staff acknowledged awareness of this policy and the reporting requirements, but the notification was delayed significantly beyond the mandated timeframe. Record reviews confirmed the timeline of events, including the initial discovery of the injury, the resident's transfer to the hospital, and the late reporting to authorities. Documentation showed that the required SOC 341 form was sent to the appropriate agencies and law enforcement was notified, but only after a substantial delay. The failure to report the injury promptly constituted a breach of the facility's own policy and regulatory requirements regarding timely reporting of suspected abuse, neglect, or injuries of unknown origin.
Failure to Timely Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that a copy of the discharge notice for a resident was sent to the Long-Term Care (LTC) Ombudsman at the same time it was provided to the resident and their representative. According to interviews and record review, the discharge notice was given to the resident and their family member on April 22, 2025, but was not sent to the LTC Ombudsman until April 25, 2025. Facility policy requires that the notice be sent to the Ombudsman simultaneously with the notice to the resident and representative. The resident involved was alert and oriented to person, place, and time, and was being discharged because their health had improved sufficiently to no longer require services from the facility. Documentation confirmed the discharge process and the timing of notifications, as well as the facility's policy on transfer or discharge notices. The delay in notifying the LTC Ombudsman was confirmed through staff interviews and review of the discharge notice and progress notes.
Non-Functioning Internal Door Releases on Walk-In Refrigerator and Freezer
Penalty
Summary
Surveyors observed that the facility failed to maintain proper means of egress as required by NFPA 101, Life Safety Code. During a tour, it was found that both the walk-in refrigerator and freezer, located towards the back of the walk-in refrigerator, were equipped with deadbolt locks and internal release knobs intended to allow individuals to open the doors from the inside. However, when the Director of Maintenance (DOM) attempted to operate the internal release mechanisms from inside both units, the mechanisms failed to function. The deficiency was identified through direct observation and interview with the DOM, who stated he was unaware that the internal release knobs were not working. This issue was present in one of four smoke compartments within the facility. The report specifically notes that the non-functioning internal door release mechanisms could result in staff becoming trapped inside the walk-in units. No information was provided in the report regarding any residents being directly involved or affected at the time of the deficiency. The findings were limited to the staff's ability to exit the walk-in refrigerator and freezer in the event of an emergency, as observed during the facility tour.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The facility immediately addressed the non-functioning internal door release mechanism in the walk-in refrigerator and freezer doors. The doors were repaired to function properly so that no potential entrapment could occur. 2. How the facility will identify other residents having the potential to be affected. Staff who utilize the walk-in refrigerator and freezers have the potential to be affected. No residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the dietary staffs were in-serviced by the Environmental Service Director regarding "Means of Egress requirements." The Dietary Supervisor will monitor the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress weekly. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with members of the Safety Committee the weekly monitor in place for the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress. The findings will be reported to the QA/QAPI Committee at least quarterly for analysis, review, modification and/or correction. The utilization of portable fire extinguishers and their locations to hazardous areas. The Environmental Services Director and/or designee will verify monthly that the portable fire extinguishers within the building are in compliance and within the appropriate distance of hazardous areas. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor at least quarterly the monthly monitoring conducted by the Environmental Services Director that the portable fire extinguishers within the building comply and are within the appropriate distance of hazardous areas. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. K711. 1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The Environmental Services Director immediately discussed with the two staff who were unaware of the protocols for addressing a grease fire and made them aware of the appropriate procedures to address such an occurrence.
Failure to Provide Fire Extinguisher in Generator Enclosure
Penalty
Summary
The facility failed to properly equip the generator enclosure with the required fire safety equipment, specifically a portable fire extinguisher. During a tour and interview with the Director of Maintenance, it was observed that the diesel fuel storage area, located in an external concrete enclosure with the generator, did not have a fire extinguisher installed within the minimum required travel distance. The closest fire extinguisher was found to be inside the facility, across a courtyard, rather than within 30 or 50 feet of the diesel fuel storage enclosure as required by NFPA 10 standards for Class B hazards. This deficiency was identified during an inspection and affected all 114 residents and four smoke compartments in the facility. The absence of a fire extinguisher in the specified location was directly observed, and the Director of Maintenance confirmed the lack of appropriate fire safety equipment in the generator enclosure area.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. A fire extinguisher was put in place within the diesel fuel storage area. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and Environmental Service Director. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and/or Maintenance Director regarding "The protocols for addressing a grease fire and the appropriate procedures to address such an occurrence." The DSD and/or Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction.
Kitchen Staff Lacked Training on Grease Fire Response
Penalty
Summary
During a facility tour and interview with the Director of Maintenance, it was observed that kitchen staff were not aware of the proper response protocols for addressing a grease fire in the cooking facilities. Two kitchen staff members were specifically asked about the procedures to follow if a grease fire were to occur on the griddle or stove top. Both staff members stated that they did not know the appropriate response protocols and confirmed that they had not received training on how to respond to a grease fire. The deficiency was identified in one of four smoke compartments and was witnessed by the Director of Maintenance and the Kitchen Lead Staff during the interview. The lack of staff knowledge and training regarding grease fire response was cited as a failure to maintain the cooking facilities in accordance with NFPA 101: Life Safety Code, which requires employees to be instructed in life safety procedures and devices.
Deficient Food Safety and Sanitation Practices in Kitchen Operations
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices as evidenced by several observed deficiencies. One expired peanut butter and jelly sandwich was found in the snacks refrigerator, despite facility policy requiring items to be clearly marked with a use-by date and discarded accordingly. Both the Assistant Dietary Supervisor (ADS) and the Registered Dietician (RD) confirmed that the sandwich was past its expiration date and should not have been available for consumption. Additionally, a dispensing scoop was observed stored inside a container of mashed potato powder, in direct contact with the food product, contrary to professional standards and FDA Food Code, which require utensils to be stored with handles above the food to prevent cross-contamination. Further observations revealed that the kitchen door near the garbage area was left open for approximately 20 minutes, which the ADS acknowledged could allow insects and dust to enter, increasing the risk of cross-contamination. Three large dumpsters were also found without tight-fitting covers, a violation of facility policy and food safety standards, as this could attract insects and rodents. These lapses in food safety and sanitation practices were observed in a facility serving 112 out of 115 residents who received food prepared in the kitchen.
Failure to Provide and Document Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to ensure that a copy of each resident's Advance Directive (AD) was available and that residents or their representatives were provided with follow-up information regarding the formulation of an AD. This deficiency was identified in 11 out of 14 residents reviewed for ADs. Multiple residents, during interviews, expressed uncertainty about whether they had an AD, whether they had been asked about creating one, or whether they had received information or follow-up on the topic. Record reviews for these residents consistently showed either the absence of an executed AD or lack of documentation that information or education about ADs was provided or followed up. For each resident cited, the admission records, Advance Directive Acknowledgment forms, POLST forms, and care conference documentation were reviewed. In all cases, the documentation either indicated that the resident had not executed an AD or did not mention an AD at all. Care conference records typically had a check mark for "Advance Directive/POLST/code status order," but there was no evidence that residents or their representatives were given information or education about their right to formulate an AD, nor was there documentation of follow-up discussions. Interviews with the Social Service Director confirmed that such documentation was missing and should have been present. Residents involved in the deficiency included those with both intact and moderately impaired cognitive function, as indicated by their BIMS scores. Several residents stated they would like to have an AD or wanted more information, while others were unsure if the facility had followed up with them. The facility's policy required that residents or their representatives be provided with written information about ADs and that staff document offers of assistance and the resident's decision. However, the required documentation and follow-up were not found in the records reviewed for the cited residents.
Failure to Follow Oxygen Administration Policies for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following established policies and procedures for oxygen administration. One resident with a diagnosis of COPD was observed receiving continuous oxygen at six liters per minute via nasal cannula, which exceeded the physician's order of 2-4 liters per minute as needed to maintain oxygen saturation above 90%. There was no documentation or assessment of the resident's oxygen use that morning, and staff did not report the increased oxygen level or assess the resident's condition as required. Facility staff, including an LVN and RN Supervisor, acknowledged that the oxygen was set incorrectly and that the resident's condition and oxygen use had not been properly monitored or documented. Another resident, admitted with acute respiratory failure and pleural effusion, was observed using an unlabeled nasal cannula for oxygen delivery. The tubing was not labeled with the date as required by facility policy, which mandates that oxygen tubing be changed and labeled every seven days and as needed. Staff confirmed that the tubing should have been labeled to prevent infection, and the physician's order specified regular changes and labeling of the oxygen equipment. These failures were directly observed and confirmed through staff interviews and record reviews.
Dietary Staff Failed to Follow Manufacturer's Instructions for Sanitizer Testing
Penalty
Summary
A deficiency was identified when a dietary aide (DA) failed to follow the manufacturer's instructions for testing the Quaternary ammonium compound (Quat) sanitizer solution in the facility's three-compartment sink. During observation, the DA dipped the Quat test strip into the sanitizing solution for only four seconds before comparing it to the color chart, instead of the required ten seconds as specified by the manufacturer's directions. The DA acknowledged during an interview that the correct procedure was not followed and that this could result in inaccurate readings of the sanitizer concentration. The facility's policy and procedure manual also indicated that the manufacturer's instructions should be followed for proper sanitation.
Call Light Not Accessible to Resident with Mobility Impairment
Penalty
Summary
A deficiency was identified when a resident with a right below knee amputation and moderate cognitive impairment was observed with their call light button on the floor and not within reach. The resident stated they could not reach the call light and needed it to be closer in order to call for assistance. The resident's care plan specifically indicated that the call light should be within reach to encourage its use for assistance with activities of daily living. During interviews, a Licensed Vocational Nurse, the Director of Staff Development, and the Assistant Director of Nursing all confirmed that the call light should not have been on the floor and should have been accessible to the resident. Facility policy also requires that call lights be accessible to residents in various locations, including in bed. The failure to ensure the call light was within reach constituted a lack of reasonable accommodation for the resident's needs and preferences.
Resident Exposed to Chemical Hazard Due to Improper Storage of Cleaning Solution
Penalty
Summary
A housekeeper left a cup containing a pink toilet cleaning solution and a brush on the bedside table of a resident diagnosed with dementia and unable to make medical decisions. The cleaning solution was placed near the resident's drinking cup, making it accessible to the resident. The family member discovered the cleaning solution and reported it to the nurse, who confirmed the substance was a toilet cleaner. Interviews with staff, including a Licensed Vocational Nurse and the Housekeeping Supervisor, confirmed that cleaning chemicals should not be left in resident areas and should be properly secured. The facility's policy requires that cleaning supplies be maintained in a safe manner and stored away from resident areas. The housekeeper admitted to leaving the cleaning solution in the resident's room and acknowledged that it should have been stored in the proper storage area. This incident resulted in the resident being exposed to a chemical hazard, contrary to facility policy and expectations for resident safety.
Failure to Address Missing Dumpster Covers Through QAPI
Penalty
Summary
The facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to address an ongoing issue with missing covers on all three dumpsters. Review of the Food & Nutrition Services: Daily Supervisor Rounds Checklist showed that the task 'Trash Lids closed and clean' was not checked off on any day between March 2, 2025, and April 17, 2025. During an interview and record review, the Administrator confirmed that replacing the dumpster covers was a current QAPI project, but the bins remained uncovered due to repeated cancellations by the waste management company. Although temporary measures were considered, no interim solutions were implemented to prevent animal access or potential contamination. The facility's QAPI policy requires ongoing monitoring and problem resolution, but the issue persisted without effective action.
Improper Disinfection of Shared Blood Pressure Cuff
Penalty
Summary
A licensed nurse failed to properly disinfect a shared manual blood pressure cuff after use on a resident. During a medication pass observation, the nurse was seen wiping the cuff with a disposable disinfectant wipe but did not allow the surface to remain wet for the full one-minute contact time required by the manufacturer's instructions. The nurse initially stated the cuff should have air dried for three minutes, but upon reviewing the manufacturer's instructions, acknowledged that the required contact time was one minute. Interviews with the Infection Preventionist and the Assistant Director of Nursing confirmed that the facility's expectation was for staff to clean and disinfect shared resident equipment, such as blood pressure cuffs, according to the manufacturer's instructions. The facility's policy also required reusable resident care equipment to be decontaminated between residents per manufacturer guidelines. The failure to follow these procedures was directly observed and confirmed through staff interviews and policy review.
Failure to Timely Provide Medical Records
Penalty
Summary
The facility failed to provide access to personal and medical records within two working days upon request by a resident's legal representative. Resident 1 was admitted to the facility and later discharged on January 29, 2025. A request for the release of Resident 1's medical records was made on February 11, 2025, by the resident's legal representative, specifying that the records be made available within two working days. However, the Medical Records Director (MRD) forwarded the request to the facility's legal team, which delayed the process. The MRD received the request on February 11, 2025, and forwarded it to the legal team, but the records were not released within the requested timeframe. On February 14, 2025, the legal representative followed up, but the MRD had not provided an update or followed up with the legal team since then. The facility's policy states that records should be provided within two days for current residents or within 15 days for discharged residents. The failure to release the records within the specified time frame was a deviation from the facility's policy and resulted in a deficiency.
Failure to Obtain Physician Order Before Hospital Transfer
Penalty
Summary
The facility failed to ensure that a physician order was obtained prior to the hospital transfer of a resident, identified as Resident 2. On February 19, 2025, Resident 2, who had been admitted with a diagnosis of atrial flutter, experienced a medical emergency while using the bathroom. The resident became unresponsive, prompting the staff to call American Medical Response (AMR), which resulted in the resident being transported to a hospital for further assessment. However, the transfer was conducted without obtaining a necessary physician order, as confirmed by the review of Resident 2's medical records and interviews with the facility's staff. During interviews conducted on March 3, 2025, both a Registered Nurse (RN) and the Assistant Director of Nursing (ADON) acknowledged that the standard procedure for a change in a resident's condition includes notifying the physician and obtaining a transfer order before hospital transfer. The facility's policy, dated 2001, also mandates that the attending physician or physician on call be notified when a transfer is needed. The failure to secure a physician's order before transferring Resident 2 to the hospital was a deviation from these established protocols, potentially impacting the resident's safety and appropriateness of care.
Inaccurate Documentation of Financial Abuse Incident
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, leading to inconsistencies in the reporting timeline of an alleged financial abuse incident. The resident, who had moderate cognitive impairment, was involved in an allegation against his wife for financial abuse. The incident was reported by the resident's daughter to the Case Manager at 2 p.m. on February 18, 2025. However, the eINTERACT SBAR Summary for Providers inaccurately documented the time of the incident as 7:49 a.m., which was not consistent with the actual time of reporting. The Registered Nurse (RN) who documented the note was not present at the facility when the incident occurred and was instructed by the Director of Nursing (DON) to create a late entry note. The RN admitted to documenting the incident without firsthand knowledge, which led to confusion and inaccuracies in the resident's medical records. The DON acknowledged the mistake and stated that the facility lacked a specific policy on late charting, although it was standard practice for staff not to document in a resident's medical record if they were not scheduled to work. The facility's policy on charting and documentation emphasized the need for objective, complete, and accurate documentation.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident who was at risk for falls. The resident, who had a history of repeated falls and severe cognitive impairment, was observed without a bed alarm, which was a recommended intervention following a fall. The resident's care plan, which included the use of a bed alarm as a fall prevention measure, was not implemented, and the fall risk assessment was not updated to reflect newly identified risks discussed during an interdisciplinary team meeting. Interviews with facility staff, including a CNA and RN Supervisor, revealed that the bed alarm was not in place, and the CNA was not informed of the need for it. The RN Supervisor acknowledged that the care plan should have been implemented and updated to reflect the current fall risks. The Director of Nursing confirmed that the post-fall evaluation was not conducted as per facility policy, which required updating the fall evaluation after a resident experiences a fall to determine current risks and needs.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe to the California Department of Public Health (CDPH) after being made aware of the incident involving a resident. The resident, who was cognitively intact and diagnosed with Bipolar Disorder, reported that during a scheduled shower, a Certified Nurse Assistant (CNA) pulled her hair hard, causing pain. The resident informed a Licensed Vocational Nurse (LVN) about the incident, but the LVN did not take immediate action to report the abuse allegation. The incident occurred in the late afternoon, but the report to CDPH was not made until the following morning, approximately 14 hours later. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the involved LVN, confirmed that the abuse allegation should have been reported within two hours to ensure the resident's safety and prevent further abuse. The facility's policy mandates immediate reporting of abuse allegations to local, state, and federal agencies, which was not adhered to in this case.
Failure to Notify Ombudsman Prior to Resident Discharges
Penalty
Summary
The facility failed to ensure timely notification to the Ombudsman regarding the discharge of two residents, which is a requirement to provide advocacy support for residents being transferred or discharged. Resident 4, who was admitted with hemiplegia and hemiparesis following a stroke, was discharged on October 9, 2024, without the Ombudsman being notified prior to the discharge. The Social Service Designee (SSD) 1 stated that discharge notices are sent to the Ombudsman by email on the first of the month, indicating a delay in notification. This practice resulted in Resident 4's discharge notice not being sent to the Ombudsman office before the discharge occurred. Similarly, Resident 5, who had diagnoses including aftercare cervical decompression, type 2 diabetes mellitus, dementia, and multiple rib fractures, was discharged on September 11, 2024. The discharge notice for Resident 5 was also sent to the Ombudsman on October 1, 2024, after the discharge had already taken place. The facility's policy requires that a copy of the discharge notice be sent to the Ombudsman at the same time it is provided to the resident and their representative, which was not adhered to in these cases. This failure to follow protocol potentially deprived the residents of advocacy support prior to their discharges.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident had bilateral floor mats in place as ordered, which had the potential to result in an injury due to a fall. During an unannounced visit, it was observed that the resident, who was identified as a fall risk, only had a floor mat on the right side of her bed, despite the order specifying that floor mats should be placed on both sides. The resident's medical records indicated she was admitted with multiple diagnoses, including dementia, hemiplegia, and hemiparesis following a stroke, which affected her ability to make decisions. Interviews conducted with the resident, a CNA, and the ADON confirmed the deficiency. The CNA, responsible for the resident's care, acknowledged that the resident was a fall risk and confirmed that there should be a floor mat on each side of the bed. The ADON also stated that if there was an order for bilateral floor mats, they should be in place on both sides of the bed. The facility's policy on falls indicated that staff and physicians should identify interventions to prevent falls and address the risks of significant consequences from falling.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide copies of medical records upon request and within two business days after receiving a request from an attorney on behalf of a resident, identified as Resident 3. This deficiency was identified during an unannounced visit to investigate a complaint allegation. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Medical Records (MR) personnel, revealed that the facility's standard procedure was to fulfill medical record requests within 24 to 48 hours. However, the request for Resident 3's records, which was received on August 20, 2024, was not fulfilled within this timeframe. The MR personnel stated that the request for Resident 3's records was sent to the corporate office on the same day it was received, and the corporate office instructed not to respond to the request, indicating that the facility's attorney would handle it. The Administrator confirmed that the facility's legal department dealt with requests from attorneys, but he was unsure of the timeline for fulfilling such requests. As of the date of the survey, it had been seven business days since the request was received, and the records had not been provided. Resident 3 had been admitted to the facility with diagnoses including a fracture of the left thigh and diabetes mellitus and had severe cognitive impairment. The resident was transferred to a general acute care hospital and did not return to the facility. The request for records was made by the resident's attorney, with an authorization signed by a family member, requesting all writings related to the resident for legal matters. The facility's policy required timely provision of requested protected health information, which was not adhered to in this case.
Inadequate Supervision Leading to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for two residents, resulting in separate elopement incidents. Resident 1, who was admitted with diagnoses including cerebral infarction and cognitive communication deficit, eloped on March 26, 2024. Despite having a Wanderguard, Resident 1 was able to leave the facility undetected and was found outside by a family member. Interviews with staff revealed that Resident 1 was not properly monitored, despite being identified as an elopement risk in her care plan and elopement risk assessment. Similarly, Resident 2, who was admitted with diagnoses including psychosis, anxiety, and depression, eloped on March 22, 2024. Resident 2 also had a personal alarm due to her elopement risk but managed to leave the facility and was later found outside. Staff interviews indicated that Resident 2 was not adequately supervised, and her alarm was not responded to in a timely manner. Both residents' care plans and elopement risk assessments indicated they were at risk for elopement and should not leave the facility unattended. The Director of Nursing confirmed that the elopement episodes were due to inadequate monitoring for safety.
Failure to Conduct Contact Tracing and Testing During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of COVID-19 to staff and residents on all four units. Specifically, the facility did not conduct contact tracing for staff during a COVID-19 outbreak, believing that the use of N95 respirators negated the need for testing individuals exposed to COVID-19. This led to the failure to test all residents and staff who had been in close contact with others who had COVID-19, and the facility did not conduct broad-based COVID-19 testing when contact tracing failed to halt transmission. This deficiency had the potential to affect all 111 residents in the facility, with eight residents and two staff testing positive for COVID-19 as of the report date. The issue began when a resident tested positive for COVID-19, and the facility did not perform appropriate contact tracing and testing of everyone who had contact with the infected resident. Subsequently, several other residents across different units tested positive for COVID-19. The facility's policy required immediate investigation and contact tracing when a COVID-19 positive individual was identified, but this was not followed. Interviews with the Infection Preventionist (IP), Director of Nursing (DON), and other staff revealed a misunderstanding that the use of N95 respirators by staff prevented the need for further testing and contact tracing. Further review of the facility's COVID-19 Outbreak Log and interviews with staff indicated that the facility did not test any residents or staff who had been in contact with COVID-19 positive individuals, relying instead on the use of N95 respirators as a protective measure. This approach was contrary to CDC guidelines, which recommend testing and contact tracing regardless of the use of source control measures like N95 respirators. The facility's failure to follow these guidelines and its own policies led to the spread of COVID-19 among residents and staff, resulting in an Immediate Jeopardy situation that required immediate corrective action.
Removal Plan
- Immediate testing of staff and residents and reaching out to unscheduled staff for testing and in-service.
- Review and update of care plans based on residents' needs.
- In-service and instruction on updated facility mitigation plan and general infection control.
- In-service of all staff on revised mitigation plan and guidelines, including contact tracing and testing procedures.
- QAPI Committee meeting to review and approve QAPI plan addressing the issue.
- COVID-19 testing of all residents and staff using antigen testing/POC.
- Random assessment of staff competency in screening visitors and wearing PPE.
- In-service of all staff on new mitigation plan and infection control procedures.
- Daily rounds to ensure compliance with infection control procedures.
- Monitoring and review of compliance by QAPI Committee until significant compliance is demonstrated for three consecutive months.
Improper Thawing of Chicken in Kitchen
Penalty
Summary
The facility failed to thaw chicken in a safe manner for 106 of 113 sampled residents who received food from the kitchen. The facility's policy on safe thawing practices, as outlined in their General HACCP Guidelines for Food Safety, requires meat, fish, and poultry to be thawed in a refrigerator in a drip-proof container, under clean running water, in a microwave if cooked immediately, or as part of the cooking process. However, during an observation, four bags of chicken were found in a sink without a continuous flow of cold water. The Dietary Aide/Assistant Supervisor (DA/AS) #35 confirmed that the chicken was placed in the sink by Cook #33, who admitted to using hot water to thaw the chicken more quickly, contrary to the facility's policy. The Dietary Supervisor was informed of the improper thawing method and instructed DA/AS #35 to discard the chicken. Interviews with the Dietary Supervisor, Director of Nursing, and the Administrator confirmed that the expectation was for kitchen staff to follow the facility's food safety guidelines. Despite this, Cook #33 did not adhere to the proper thawing procedures, leading to a potential risk of cross-contamination and foodborne illness for the residents receiving food from the kitchen.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to follow up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR) for one resident. The facility's policy required a Level II Full Evaluation by a state-designated authority when a Level I screen identified a resident with mental illness or intellectual disability. Resident #93, who was admitted with diagnoses including schizophrenia and anxiety disorder, had a positive Level I screen necessitating a Level II evaluation. Despite this, the facility did not ensure the completion of the Level II evaluation, as evidenced by a letter from the State Department of Health Care Services indicating the resident was unable to participate in the evaluation and subsequent interviews with facility staff confirming the lack of follow-up. Interviews with the Director of Medical Records, the Assistant Director of Nursing (ADON), the MDS Registered Nurse (RN), and the Director of Nursing (DON) revealed a breakdown in communication and responsibility. The ADON, who was responsible for the PASARR process, did not notify the local authority to reschedule the Level II evaluation for Resident #93. The MDS RN was unaware of the missed evaluation, and the DON confirmed that the ADON should have taken immediate action to ensure the resident received the appropriate treatment services. This failure resulted in the resident not receiving the necessary evaluation and potentially appropriate services for their mental health conditions.
Failure to Submit Level I PASARR for Resident with Mental Disorders
Penalty
Summary
The facility failed to submit a Level I Preadmission Screening and Resident Review (PASARR) for a resident with mental disorders or intellectual disabilities. The resident, who had diagnoses including bipolar disorder and anxiety disorder, was originally admitted on 07/26/2023 and readmitted on 12/19/2023. Despite the resident's active diagnosis of bipolar disorder and the requirement to submit a new Level I screening if the resident remained in the facility longer than 30 days, the facility did not comply with this requirement. The facility's policy indicated that a Resident Review should be submitted by the 40th calendar day after admission for cases exceeding the 30-day exempted hospital discharge, but this was not done for the resident in question. Interviews with facility staff revealed a lack of awareness and understanding of the requirement to resubmit a Level I evaluation. The Assistant Director of Nursing (ADON) acknowledged that a new Level I screening was not submitted because she was unaware of the instructions in the letter from the State of California-Health and Human Services Agency Department of Health Care Services. The MDS Registered Nurse (RN) also admitted to not being aware of the letter specifying the need for a new Level I evaluation on the 31st day. The Director of Nursing confirmed that the ADON was responsible for the submission of the Level I screening, and the Administrator stated that the facility should have ensured the completion of the Level I screening on the 31st day.
Failure to Schedule Physician-Ordered Follow-Up Appointments
Penalty
Summary
The facility failed to schedule physician-ordered follow-up appointments for two residents, leading to a deficiency in meeting professional standards of quality. Resident #111, admitted with a displaced fracture of the left clavicle and a dislocation of the right ulnohumeral joint, had an order for a post-operation follow-up with an orthopedic surgeon. Despite the order being placed in the electronic medical record and the case manager's slot, the appointment was not scheduled. Interviews with the Administrative Assistant/Case Manager Assistant (AA/CMA) and the Director of Nursing (DON) confirmed that the appointment was missed and should have been scheduled upon the resident's admission to the facility. Similarly, Resident #188, admitted with diagnoses including acute kidney failure and hydronephrosis, had multiple follow-up appointments ordered, including with an internal medical doctor, oncologist, urologist, and hematologist/oncologist. Despite these orders being documented, the resident reported that no follow-up appointments had been scheduled. The AA/CMA stated that he had not received any instructions from the case manager to schedule these appointments. The Administrator confirmed that staff were expected to handle appointments according to the facility policy, which was not followed in these cases.
Failure to Document Physician Review of Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation was reviewed by the physician for a resident with heart failure and dementia. The resident was admitted on 01/15/2024, and a medication regimen review (MRR) conducted between 02/01/2024 and 02/07/2024 included a recommendation for a primidone level. However, there was no documentation to indicate that the physician reviewed or responded to this recommendation. The Director of Nursing (DON) delegated the follow-up of pharmacy recommendations to a quality assurance nurse, who in turn sent the recommendations via text message to the physician. The nurse only documented responses when the physician agreed with the recommendations and made changes, but did not document when the physician disagreed or did not respond. This led to a lack of evidence that the physician reviewed the pharmacist's recommendation for the resident's laboratory request. Interviews with the DON and the quality assurance nurse revealed that the nurse did not recall if the physician responded to the recommendation for the resident's laboratory request and acknowledged the absence of documentation. The DON stated that the physician addressed the recommendation but failed to document it, and the nurse followed up but did not document the outcome. The Administrator expected accurate and complete documentation of pharmacy recommendations and physician responses, including whether the physician agreed or disagreed with the pharmacist's recommendation, in the resident's progress notes.
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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