Failure to Report Unusual Occurrence After Resident Fall With Head Laceration
Summary
The facility failed to report an unusual occurrence to the California Department of Public Health within 24 hours after Resident 4 had an unwitnessed fall and sustained lacerations to the back of the head that required two staples before being sent to an acute care hospital. Resident 4 was admitted in November 2025 with diagnoses of a right femur fracture, abnormalities of gait and mobility, and mild cognitive impairment. During an interview, Resident 4 stated the fall occurred in the shared bathroom when a family member from the other room suddenly opened the door while holding the doorknob, causing the resident to lose balance and fall. During record review and interview, the ADON stated the incident was not reported because the fall was believed to have been witnessed by a family member and therefore did not require reporting to CDPH. However, the EHR documented the event as an unwitnessed fall with injury, and the ADON acknowledged that the resident’s head injury required two staples. The facility policy titled Unusual Occurrence Reporting stated that unusual occurrences are to be reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility converted a former staff break room into a resident room and assigned two residents there without obtaining prior written approval from HCAI and CDPH. The ADM, DON, and Maintenance staff described removing furniture, adding beds and curtains, and making other room changes, while stating they did not know approval was required before the renovation. The room already had a restroom, sink, closets, call light system, sliding doors, electricity, and sprinklers.
Unqualified Social Services Director: The facility failed to ensure the social services dept was staffed and supervised by a qualified social worker, affecting all 123 residents. The SSD was responsible for admission assessments, discharge planning, and helping residents with dental, optometry, podiatry, and psych appts, but record review showed the SSD did not meet the education requirements in the job descriptions and had only a high school education. HR stated the SSD was hired without the required qualifications, and the ADM stated there were no social workers and no plan to hire one, despite the facility policy and facility assessment identifying a qualified social worker role.
A RN failed to follow safe med administration practices when another resident’s meds were placed on a breakfast tray used to pass trays, and a cognitively impaired resident took them. The meds included antihypertensives, an anticoagulant, antidiabetic meds, an antipsychotic, an antidepressant, an anti-anxiety med, and other routine meds. The resident had dementia and other chronic conditions, was sent to the ER for monitoring, and later returned stable.
Failure to Protect PHI: The facility failed to maintain an ongoing educational program on confidentiality of patient information after a staff member admitted using the facility computer to access her ex-husband's hospital records for personal reasons. The breach involved PHI including the patient's name, MRN, DOB, phone number, and clinical notes, while the DON stated staff are expected to access only files related to residents the facility is planning to care for.
The facility was cited for failing to obtain a required county electrical permit for Spider Boxes hard wired into electrical panels during HVAC-related work, failing to complete the State CHOW license application, and therefore not completing the CMS CHOW certification process. The report also found untimely SSA notification of multiple Administrator changes, including periods when the listed Administrator was absent, an acting Administrator was covering, and administrator licensing records were not accurate.
The facility failed to notify police when a resident with dementia and severe cognitive impairment was discovered missing from the facility. Staff initiated a search when the resident could not be found and later located the resident about a mile away, but the medical record did not show police notification. The DON confirmed the facility did not call police because the resident was found quickly.
Renovation of resident room completed without required state approval
Penalty
Summary
The facility failed to ensure renovations to a shared resident room followed State regulations when it converted a former employee break room back into a resident room without obtaining prior written approval from HCAI and CDPH. During observation, the room contained two resident beds, privacy curtains, chairs, closets, one restroom, one sink, a working call light system, electricity, and water sprinklers. The Administrator stated the facility did not inform HCAI and CDPH before starting the renovations because the facility did not know approval was required. Interviews with staff showed the room had been used as a staff break room for several years before being converted into a resident room, with different staff giving estimates of when the change occurred. The DON stated in-house staff removed tables, chairs, and a refrigerator, placed two beds and new curtains in the room, and that the room already had a restroom, sink, closets, call light system, and sliding doors. The Maintenance Assistant stated maintenance staff removed furniture, replaced overbed lights and call light covers, and added curtains, while the Maintenance Director stated prior approval was not obtained because it was not believed to be necessary and the ADM did not instruct him to seek it. The facility policy stated maintenance services were to keep the building in compliance with applicable laws, regulations, and guidelines.
Unqualified Social Services Director
Penalty
Summary
The facility failed to follow Title 22 regulations by not ensuring the social services department was staffed and supervised by a qualified and competent social worker, affecting all 123 residents. During interview and record review, the Social Services Director stated they were responsible for admission assessments, discharge planning, and assisting residents with dental, optometry, podiatry, and psychiatric appointments to support residents’ physical, mental, and psychosocial needs, and had worked at the facility since 5/2025. Record review and staff interviews showed the Social Services Director did not meet the qualifications listed in the job descriptions reviewed by the Director of Staff Development and Human Resources. The resume did not list education, and the education registration form indicated a high school education. Human Resources stated the Social Services Director was hired without the required qualifications, and the facility created a different job description after the hire. The Administrator stated the facility did not have social workers, had no plan to hire a qualified social worker, and the Social Services Director was the only supervisor of the department, despite the facility policy stating the director of social services was a qualified social worker and the facility assessment identifying a full-time social worker on AM and PM shifts.
Medication Administration Error Involving Another Resident’s Medications
Penalty
Summary
The facility failed to follow nursing standards of practice for safe medication administration when a registered nurse placed another resident’s medications on a breakfast tray that was used to pass other trays, and the tray was then placed in front of a cognitively impaired resident who took the medications. The medications involved included amlodipine 10 mg, atenolol 50 mg, Eliquis 5 mg, Jardiance 12.5 mg, lisinopril 20 mg, olanzapine 2.5 mg, Lexapro 10 mg, Ativan 0.5 mg, metformin 500 mg, Certavite, and Zyrtec. The nurse’s witness statement indicated she pulled one resident’s medication and placed it on a tray used to pass other trays, then left to assist another patient, and upon return was informed that the resident had taken the medication on the tray. Resident R1 had diagnoses including dementia, left hip replacement, high blood pressure, diabetes, asthma, and osteoporosis, and was cognitively impaired with confusion at baseline. Nursing notes and practitioner documentation stated the resident took another resident’s medications and was sent to the hospital for monitoring and evaluation. The practitioner noted the resident had risk of hypotension, hypoglycemia, lethargy, delirium, and bleeding, and the resident was transported by 911, evaluated in the ER, remained clinically stable, and returned to the facility after a 24-hour review.
Failure to Protect PHI
Penalty
Summary
The facility failed to meet State licensure requirements for Staff Development - Confidentiality of patient information when it did not effectively provide an ongoing educational program to ensure staff had the necessary skills and knowledge regarding the confidentiality and appropriate use of PHI. An investigation into a facility-reported incident confirmed that a staff member admitted to using the facility computer to access her ex-husband's hospital records for personal reasons rather than for patient care purposes. The facility report titled Notice of Breach of Protected Health Information (PHI) indicated that the breach occurred on multiple dates and involved access to a patient's name, medical record, date of birth, phone number, and clinical notes, including hospital notes, labs, and patient status. During interview, the DON stated staff are expected not to access patient files that do not apply to the facility and that staff had annual HIPAA training, but the staff member still accessed the PHI for personal use. The DON stated staff should only access files for residents the facility is planning on caring for.
Unpermitted electrical work, incomplete CHOW licensing, and untimely Administrator notifications
Penalty
Summary
The facility failed to establish compliance with applicable Federal, State, and local laws, regulations, and codes in several areas identified during observation, interview, and document review. The report states that the facility did not obtain the proper local building department permit for electrical wiring changes related to temporary Spider Boxes that were hard wired into electrical panels on the first and second floors of the north housing section. These Spider Boxes were used to add electrical capacity for portable air conditioning units in resident rooms and hallways while a new HVAC system was being installed. A county building department manager confirmed that an electrical permit would be required for this type of work and found no permit on record for the electrical panel modifications associated with the Spider Boxes. The facility also did not complete the State Survey Agency change of ownership licensing application after the proposed new owners submitted a CHOW application. The report states that the sale had occurred, but as of the date of the writing, the CHOW license application remained incomplete and the license was still under the previous licensee. Because the state licensing application was not completed, the federal certification change of ownership process also could not be completed. The report notes that the previous licensee remained exposed to the new owner's actions past the CHOW license completion date. In addition, the facility did not timely notify the State Survey Agency of Administrator changes. The report describes multiple Administrator transitions, including periods when Administrator A had left without the required 10-day notification, Administrator B was acting at the facility while covering another facility and before the temporary license for this facility went into effect, and Administrator C was not present while listed as Administrator of record during survey activity. Administrator D later began work and was onsite for a subsequent survey date. The report also notes that the facility's Administrator licensing information was not accurate with the Nevada Board of Administrators and that the CHOW application had not been closed, with administrator-related documentation still needing to be included with dates of service.
Police Not Notified When Missing Resident Was Found
Penalty
Summary
The facility failed to ensure the police department was notified when Resident 1 was discovered missing from the facility. Facility policy titled "Leave of Absence without Notice" stated that the procedure for locating a missing resident included providing police with a description and information about the resident, including any photos. Resident 1 was admitted to the facility and had diagnoses including dementia. The resident's H&P and MDS showed severe cognitive impairment. According to the Change in Condition Evaluation, Resident 1 was unable to be found at approximately 1600 hours and a search was initiated. The resident was later found about a mile away from the facility at approximately 1640 hours. Review of the medical record did not show documented evidence that the police department was notified when the resident was discovered missing. During interview, the DON verified the finding and stated the facility did not call the police because Resident 1 was found so quickly.
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