Bethel Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Selma, California.
- Location
- 2280 Dockery Avenue, Selma, California 93662
- CMS Provider Number
- 555924
- Inspections on file
- 15
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Bethel Lutheran Home during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific actions or events involved.
A nurse attempted to obtain a urine specimen from a resident by straight catheterization without a physician's order, making two unsuccessful attempts before collecting the specimen via bedpan. The resident, who was cognitively intact and had significant medical conditions, was confused and nervous during the procedure. The nurse did not notify the physician or responsible party and was unaware that a physician's order was required, contrary to facility policy and expectations.
A male CNA violated the privacy and dignity of two residents by laying in bed with one resident, which was observed by her roommate. The incident was confirmed through interviews and video footage, revealing the CNA's inappropriate behavior. Both residents were cognitively intact and expressed discomfort, highlighting a breach of their rights to dignity and freedom from abuse.
The facility failed to ensure thorough and complete orientation and education documentation for two CNAs, as verified by the DSD. Records for both CNAs were missing signatures, dates, and other necessary information to confirm completion of required training. The Administrator confirmed these deficiencies, highlighting a lack of supervision and verification in the training process.
A facility failed to ensure a CNA received thorough education on Resident Rights, as required by its policies. The DSD did not complete or verify the necessary training, leaving the Employee Orientation document unsigned. This led to CNA 1 working without proper instruction on Resident Rights, resulting in their termination for violating these rights.
The facility failed to maintain food safety standards, with issues including freezer-burned meat, unlabeled staff food, and improperly dated yogurt in storage areas. Additionally, food items brought by family members for two residents were not labeled with dates, risking the consumption of expired food. These deficiencies were acknowledged by the Dietary Service Supervisor and Registered Dietitian, highlighting the potential for foodborne illnesses.
A facility failed to ensure privacy for two residents during medical treatments. An LVN did not pull curtains or close the door while performing a blood glucose test and administering insulin to a cognitively intact resident, exposing him to view. In another instance, the same LVN administered eye drops to a resident with severe cognitive impairment without drawing the curtains, allowing the roommate to observe. Staff interviews and facility policies confirmed the importance of maintaining privacy, which was not upheld in these cases.
A resident experienced pain and discomfort during a transfer from a wheelchair to a bed due to the improper use of a Hoyer lift sling by CNAs. The resident, with a history of muscle contracture and back surgery, was lifted in a sitting position instead of a reclined position, contrary to the manufacturer's guidelines. Staff interviews revealed a lack of awareness of the correct procedure, and the Director of Nursing confirmed the guidelines were not followed.
The facility failed to ensure proper labeling and storage of medications, with issues including missing expiration dates on pill packets, unlabeled medication containers inside boxes, and a medication refrigerator below the required temperature range. Staff acknowledged these deficiencies, and the DON emphasized the importance of correct labeling and storage to prevent harm and maintain medication potency.
The facility failed to ensure that residents received food at a safe and appetizing temperature. The Dietary Cook did not check the temperature of food on the steam table before serving, which is crucial for food safety and palatability. The absence of temperature checks was confirmed by the Dietary Services Supervisor and the Registered Dietitian, highlighting a breach in the facility's policy requiring food to be held at a minimum of 140 degrees Fahrenheit.
The facility failed to maintain the B-wing medication refrigerator at a safe temperature, risking medication safety. The refrigerator was observed at 32°F, below the acceptable range, potentially damaging medications. Staff acknowledged the issue, and the Maintenance Director noted a lack of regular checks and maintenance logs for the refrigerator.
A resident with chronic pain conditions did not receive prescribed analgesics before physical therapy sessions, as outlined in their care plan. Despite frequent complaints of pain, staff failed to administer pain medication, resulting in unmanaged pain during therapy. Interviews with staff, including an LVN and the MDS Nurse Coordinator, confirmed the oversight, highlighting a lack of adherence to the care plan.
A resident with chronic pain conditions was not given prescribed analgesia before physical therapy, leading to significant discomfort during transfers and therapy sessions. Despite a care plan specifying the need for pain management, staff failed to administer the medication, resulting in the resident experiencing unnecessary pain. The oversight was acknowledged by multiple staff members, including the DON, who confirmed the care plan was not followed.
A resident with multiple medical conditions, including diabetes and hypertension, was served an incorrect portion size due to the dietary staff using a larger scoop than prescribed. This failure to follow the physician's order for a small portion diet was observed during a tray line in the kitchen, and confirmed by both the Dietary Services Supervisor and the Registered Dietitian.
A resident with diverticulitis and malnutrition was served meals not aligned with her preferences, including chicken with skin and beets, despite her dietary restrictions. Staff interviews revealed a lack of proper checks and communication regarding meal preferences, with responsibilities shared between nurses and CNAs. The facility's policy emphasized the importance of aligning meals with residents' informed choices and treatment goals.
A resident with severe cognitive impairment was at risk due to incomplete antipsychotic consent forms, as the physician's signatures were not dated. The DON and LVN acknowledged the oversight, emphasizing the importance of dated signatures to verify informed consent before medication administration. The facility's policies and job descriptions underscored the need for accurate and complete medical records.
A contractor technician failed to wash his hands upon entering the kitchen and scooped ice from the ice machine, potentially causing cross-contamination and foodborne illnesses for 56 residents, staff, and visitors. Interviews with the DSS and RD confirmed the importance of handwashing to prevent the spread of germs, as outlined in the facility's infection control policy.
The facility failed to meet the minimum space requirement of 80 square feet per resident in multiple rooms, with 22 rooms measuring only 154 square feet for two residents each. Despite this, staff and residents reported no issues with room size, privacy, or care space. Observations confirmed adequate privacy and space for care, and a waiver continuation was recommended.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved. No further information about the circumstances, individuals affected, or specific observations is included in the report.
Urine Catheterization Performed Without Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN) attempted to obtain a urine specimen from a resident by performing a straight catheterization without a physician's order. The resident, who was cognitively intact and had a history of hemiplegia, metabolic encephalopathy, and malignant neoplasm of the brain, recalled being confused and nervous during the procedure, as she had previously been able to provide urine specimens using a hat. The LVN made two unsuccessful attempts to insert the catheter before ultimately collecting the specimen via bedpan, without notifying the physician or the resident's responsible party. The LVN stated she was unaware that a physician's order was required for this procedure, as it had been standard practice at her previous place of employment for incontinent residents. Facility policy and procedure documents reviewed indicated that a physician's order is required for invasive procedures such as straight catheterization and for obtaining urine specimens. The Director of Nursing confirmed that the LVN had attempted the procedure without an order and acknowledged that straight catheterization is considered invasive. The facility's administrator also acknowledged that the LVN's actions were not in line with facility expectations, which require staff to follow physician orders, adhere to policy, and document all interactions and communications.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to respect the rights of two residents to a dignified private and personal space when a male CNA laid down on the bed with one of the residents, Resident 1, and took a nap. This incident was observed by Resident 1's roommate, Resident 2, leading to potential psychosocial harm such as emotional distress for both residents. The incident was confirmed through interviews and video footage review, which showed the CNA entering and remaining in the room for approximately 16 non-consecutive minutes. Resident 2, who is cognitively intact, reported the incident to the Administrator, stating that she saw the CNA in Resident 1's bed under the blankets. Resident 1, also cognitively intact, confirmed the CNA's presence in her bed and expressed discomfort about the situation. The facility's documentation and interviews with other CNAs corroborated the incident, with one CNA expressing regret for not reporting the behavior sooner. The facility's Resident Rights document emphasizes the right to dignity and freedom from abuse and neglect, which were violated in this incident. The CNA's actions were not aligned with these rights, as they compromised the residents' dignity and personal space. The facility's response included an investigation and interviews with involved staff and residents, confirming the inappropriate behavior of the CNA.
Incomplete Staff Training Documentation
Penalty
Summary
The facility failed to ensure that the orientation and education documentation for two Certified Nursing Assistants (CNAs) was thorough and completed by the Director of Staff Development (DSD). During a review of CNA 1's education records, it was found that several documents, including a training record and an employee orientation checklist, were incomplete. These documents lacked signatures, dates, and other necessary information to verify that the required training and orientation had been completed. The DSD admitted to not signing the training record, and the employee orientation checklist was entirely blank. Similarly, CNA 3's education records were reviewed and found to be incomplete. A training record was missing the name of the instructor, and the employee orientation checklist was unsigned and undated. The Administrator confirmed these findings and stated that it was expected for new hire education to be supervised and verified by the DSD. This lack of documentation and verification could potentially lead to inadequately trained staff working with residents.
Failure to Educate CNA on Resident Rights
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 1) received thorough education on Resident Rights, as required by the facility's policies and procedures. The Director of Staff Development (DSD) did not complete or verify the necessary training for CNA 1, which was evident from the incomplete Employee Orientation document. This document, which should have been signed by CNA 1 and a licensed nurse, was left blank, indicating that CNA 1 had not been properly instructed in Resident Rights before assuming direct-care responsibilities. The deficiency was further highlighted by a letter from the facility, dated November 14, 2024, which terminated CNA 1's employment due to a violation of resident rights. The Administrator confirmed that it was expected for new hires to have their in-service education supervised and precepted by the DSD. The facility's policy clearly stated that staff must receive appropriate in-service training on resident rights prior to providing direct care, which was not adhered to in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by several observations in the kitchen and resident rooms. In the walk-in freezer, a bag of beef stew meat was found with ice crystals, indicating freezer burn, which the Dietary Service Supervisor (DSS) acknowledged should have been discarded. The Registered Dietitian (RD) confirmed that the freezer-burned meat could potentially harbor bacteria and cause food poisoning. Additionally, a foam cup with a staff member's name but no date was found in the walk-in refrigerator, improperly stored alongside resident food, which could lead to cross-contamination. Further inspection revealed an open yogurt container in the walk-in refrigerator without an open date, which the DSS and RD agreed should have been labeled to prevent serving expired food to residents. In the storage pantry, a bin of oats lacked both an opened and received date, contrary to the facility's policy, which could result in residents consuming expired oats. These lapses in labeling and storage practices were acknowledged by the DSS and RD, who emphasized the importance of proper labeling to prevent foodborne illnesses. In resident rooms, items brought by family members, such as cookies, snacks, and sodas, were found without labels indicating the date received or opened. This oversight was noted in the rooms of two residents, one with conditions including hypertension, Alzheimer's disease, and diabetes, and another with Parkinson's disease and malnutrition. Staff interviews confirmed that these items should have been labeled to prevent residents from consuming expired food, which could lead to health issues. The facility's policy requires food brought by family members to be labeled with the resident's name and a 'use by' date to ensure safety.
Failure to Ensure Resident Privacy During Medical Treatments
Penalty
Summary
The facility failed to ensure privacy and confidentiality for two residents during medical treatments. In the first instance, a Licensed Vocational Nurse (LVN) did not pull the curtains or close the door while performing a blood glucose test and administering insulin to a resident. This resident, who was cognitively intact, was exposed to the view of anyone passing by the open doorway, compromising his privacy during the procedure. In the second instance, the same LVN administered eye drops to another resident without pulling the curtains, allowing the resident's roommate to observe the procedure. This resident had severe cognitive impairment, but the lack of privacy during the medication administration was still a concern. The LVN acknowledged that the curtains should have been drawn to provide privacy. Interviews with other staff members, including another LVN, a Certified Nursing Assistant (CNA), and the Director of Nursing (DON), confirmed the importance of maintaining resident privacy during care. The facility's policies and job descriptions also emphasized the need for privacy and confidentiality, highlighting a failure to adhere to these standards during the observed incidents.
Improper Use of Hoyer Lift Sling Causes Resident Discomfort
Penalty
Summary
The facility failed to provide services that met professional standards of quality of care for a resident when a Hoyer lift sling was used incorrectly during a transfer from a wheelchair to a bed. The resident, who had conditions including muscle contracture, generalized weakness, and abdominal pain, experienced pain and discomfort during the transfer. The Certified Nursing Assistants (CNAs) used the shortest hooks near the resident's shoulders and the longest hooks near the legs, causing the resident to be lifted in a sitting position, which was contrary to the proper procedure for transferring from a chair to a bed. Interviews with the CNAs and other staff revealed a lack of awareness and adherence to the correct procedure for using the Hoyer lift sling. The Director of Staff Development and a Licensed Vocational Nurse confirmed that the staff should have positioned the resident in a more reclined position during the transfer to the bed. The Owner's Manual and Instruction Guide for the Hoyer lift also indicated the need for a reclined position during such transfers. The Director of Nursing acknowledged that the resident should not have experienced discomfort and that the manufacturer's guidelines should have been followed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate labeling and storage of medications, which was observed during a survey. One of the medication carts had two out of 199 pill packets without visible expiration dates. The Licensed Vocational Nurse (LVN) acknowledged that the expiration dates should have been visible and stated that if they were not, the medication should not be administered. The Director of Nursing (DON) confirmed that labeling medications correctly was a facility policy and emphasized the importance of visible expiration dates to prevent administering expired medications, which could lose potency and be ineffective. Additionally, the facility did not label the inside containers of boxed medications with resident information. During observations, it was noted that seven boxed medications lacked labels on the medication containers inside. LVNs stated that if the medication came out of the unlabeled box, it could be given to the wrong resident, leading to medication errors. The DON reiterated the importance of labeling medication containers with the resident's name to prevent harm. The facility also failed to maintain proper storage temperatures for medications. One of the medication refrigerators was observed to be below the required temperature range, which could damage the medications and make them unsafe for use. The Minimum Data Set Nurse (MDSN) and the Assistant Director of Nursing (ADON) acknowledged the issue and stated that the pharmacist should be consulted if the temperature was out of range. The DON emphasized that maintaining the appropriate temperature range was crucial to preserving medication potency.
Failure to Ensure Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that 56 sampled residents received food at a safe and appetizing temperature. On the day of the observation, the Dietary Cook (DC) did not check the temperature of the food on the steam table before serving it to the residents. The DC placed trays of lasagna and other food items on the steam table without verifying their temperatures, which is a critical step to ensure food safety and palatability. During interviews, the DC admitted to not checking the temperatures and acknowledged the absence of temperature logs for the steam table items. The Dietary Services Supervisor (DSS) confirmed that the DC should have checked the temperatures to ensure the food was warm and safe for consumption. The Registered Dietitian (RD) also emphasized the importance of checking food temperatures to prevent bacterial growth and ensure food safety. The facility's policy on meal preparation and service, dated 2011, specifies that food items like casseroles and vegetables should be held at a minimum temperature of 140 degrees Fahrenheit. The failure to adhere to this policy had the potential to result in residents being served cold food, which could lead to decreased food intake and weight loss, as well as an increased risk of foodborne illnesses.
Failure to Maintain Safe Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition, specifically the medication refrigerator in the B-wing. During an observation, the refrigerator's temperature was recorded at 32 degrees Fahrenheit, which is below the acceptable range for storing medications. The Minimum Data Set Nurse (MDSN) confirmed that such a low temperature could damage medications, making them unsafe for resident use. The Temperature Log indicated that temperatures below 36 degrees Fahrenheit are too cold, and the MDSN acknowledged the risk of medication damage if stored at such temperatures. The Assistant Director of Nursing (ADON) stated that the Infection Prevention Nurse was responsible for monitoring the refrigerator temperatures. If the temperature was out of range, the protocol was to notify maintenance and consult the pharmacist. The Maintenance Director (MAINTD) later observed the refrigerator temperature at 41 degrees Fahrenheit after adjusting the control knob, indicating that the door being open could have caused a temporary rise in temperature. However, the MAINTD admitted that the refrigerator was not regularly checked for maintenance, and there was no maintenance log for it. Interviews with staff revealed that the B-wing medication refrigerator had issues, such as leaking water, and required defrosting. Medications were moved to another refrigerator as a precaution. The MDSN consulted with a pharmacist, who advised checking medications for crystallization before use. The facility's job descriptions for maintenance staff emphasized the importance of regular inspections and preventative maintenance, but these were not implemented for the medication refrigerators, leading to the deficiency.
Failure to Implement Pain Management Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident experiencing chronic pain, particularly in relation to pre-medicating with an analgesic before physical therapy sessions. The resident, who was admitted with conditions including generalized abdominal pain, poly-osteoarthritis, muscle weakness, and muscle contractures, reported experiencing significant pain during transfers and physical therapy. Despite the care plan specifying the administration of pain medication 30 minutes prior to treatments, this intervention was not followed, resulting in unmanaged pain for the resident. Interviews with staff revealed a lack of adherence to the care plan. A Licensed Vocational Nurse (LVN) admitted to not administering the prescribed analgesic before physical therapy, stating she was unaware of this requirement in the care plan. The Certified Nursing Assistant (CNA) confirmed that the resident frequently complained of pain, which was reported to the nursing staff. The Minimum Data Set (MDS) Nurse Coordinator acknowledged that the care plan was not followed, which could hinder the resident's participation in physical therapy due to unmanaged pain. The Director of Nursing (DON) and other staff members emphasized the importance of following care plans to ensure proper resident care. The Physical Therapy assistant also noted the resident's complaints of pain during transfers and the necessity of premedication for effective therapy sessions. The facility's policy on care plans highlighted the need for comprehensive, person-centered plans with measurable objectives, which were not adhered to in this case, leading to inadequate pain management for the resident.
Failure to Administer Pain Medication Before Physical Therapy
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 3, who was not administered analgesia as per his care plan before undergoing physical therapy. This oversight resulted in Resident 3 experiencing significant pain during transfers using a Hoyer lift and during physical therapy sessions. Resident 3, who suffers from generalized abdominal pain, poly-osteoarthritis, muscle weakness, and contractures, reported daily pain, particularly during transfers and physical therapy, which was not adequately addressed by the facility staff. Observations and interviews revealed that Resident 3 frequently expressed pain, especially during transfers and physical therapy. Despite having a care plan that specified the administration of PRN analgesia 30 minutes before treatments, this was not followed. Licensed Vocational Nurse (LVN) 1, who was responsible for Resident 3's care three days a week, admitted to not administering the PRN analgesic prior to physical therapy, as she was unaware of this requirement in the care plan. The failure to administer pain medication as outlined in the care plan was acknowledged by multiple staff members, including the MDS Nurse Coordinator and the Director of Nursing, who confirmed that the care plan was not followed. The facility's policies and procedures for pain management and care plans emphasize the importance of assessing and addressing pain to ensure residents' well-being. However, in this case, the staff did not adhere to these protocols, resulting in Resident 3 experiencing unnecessary pain. The Director of Nursing and other staff members recognized that the failure to manage Resident 3's pain according to the care plan could negatively impact his participation in physical therapy and overall condition.
Failure to Follow Physician's Dietary Order for Resident
Penalty
Summary
The facility failed to adhere to a physician's dietary order for a resident, identified as Resident 14, who was supposed to receive a small portion diet. On a specific date, during a tray line observation in the kitchen, it was noted that the dietary staff used a number 8 scoop size instead of the required number 10 scoop size for small portions. This discrepancy was confirmed by the Dietary Services Supervisor, who acknowledged that the incorrect scoop size was used, potentially leading to Resident 14 receiving more calories than prescribed. Resident 14, who was cognitively intact with a BIMS score of 15, had multiple medical diagnoses including hypertension, type 2 diabetes, anxiety disorder, gastritis, gout, and irritable bowel syndrome. The facility's policy on food preparation emphasized the importance of portion control to meet nutritional specifications, yet the dietary staff failed to follow the physician's order for a small portion, as indicated in the resident's order listing report. The Registered Dietitian also confirmed that the correct scoop size was not used, which could have resulted in weight gain for the resident.
Failure to Follow Resident Meal Preferences
Penalty
Summary
The facility failed to adhere to a resident's meal preferences, which were crucial due to her medical conditions. The resident, who had diverticulitis and protein-calorie malnutrition, was served chicken with skin and beets, despite her documented dislikes and dietary restrictions. This oversight was observed during a meal service, where the resident expressed her dissatisfaction and concern that consuming such foods could exacerbate her condition. The Registered Dietitian confirmed that the resident's preferences should have been followed to prevent malnutrition. Interviews with facility staff, including a CNA, the Director of Staff Development, an LVN, and the Director of Nursing, revealed a lack of proper checks and communication regarding meal preferences. The CNA and DSD indicated that nurses were responsible for ensuring meal accuracy, but CNAs could also verify trays. The LVN and DON acknowledged the importance of following dietary orders, especially given the resident's medical history. A review of the facility's policy on therapeutic diets emphasized the need to align meals with residents' informed choices and treatment goals.
Incomplete Antipsychotic Consent Forms for a Resident
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards of practice for a resident, identified as Resident 8. Specifically, the antipsychotic consent forms for Resident 8 were incomplete, as the physician signatures on the forms dated March 5 and September 4 were not dated. This oversight put Resident 8 at risk of receiving antipsychotic medication without being informed of the risks and benefits. The Director of Nursing (DON) acknowledged that the consent forms should have been dated by the physician and that the consents were not valid without a dated signature. The DON also stated that the Medical Records Department was responsible for verifying the completion of consents, and nurses were expected to verify consents before administering medications. During the review, it was noted that Resident 8 had a severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of three, indicating a significant need for careful consent procedures. The Licensed Vocational Nurse (LVN) confirmed that the antipsychotic consents were incomplete without the physician's dated signature, emphasizing the importance of knowing when consent was obtained. The facility's job description for the Medical Records Technician and the policy on Informed Consent both highlighted the responsibility to ensure records are accurate and complete, and that informed consent must be verified before administering psychotropic medications.
Infection Control Breach in Kitchen
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a contractor technician (CT) who did not wash his hands upon entering the kitchen. This incident was observed on 10/25/24 at 8:55 a.m. when the CT proceeded to scoop ice from the ice machine without prior handwashing. During an interview, the CT acknowledged the importance of handwashing to prevent cross-contamination and admitted that he should have washed his hands before handling the ice. This lapse in protocol had the potential to cause cross-contamination and foodborne illnesses among the 56 residents, staff, and visitors who consumed ice from the machine. Interviews with the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) further confirmed the deficiency. Both the DSS and RD stated that the CT should have washed his hands upon entering the kitchen to prevent the spread of germs and bacteria. The facility's policy and procedure on sanitation and infection control, dated 2011, also indicated that handwashing should occur before starting work in the kitchen. Additionally, a professional reference on food contamination and foodborne illness prevention highlighted inadequate handwashing as a contributing factor to foodborne illnesses. This incident underscores a failure to adhere to established infection control protocols, potentially compromising the safety and health of residents and others in the facility.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required space of at least 80 square feet per resident in multiple resident rooms. During the survey conducted from October 22 to October 28, 2024, it was observed that 22 rooms, each housing two residents, measured only 154 square feet, which is below the required space per resident. This deficiency was identified during an environmental tour with the Maintenance Supervisor, who confirmed the room measurements. Despite the deficiency, interviews with staff and residents indicated that there were no complaints or issues regarding room size, privacy, or space for care. Certified Nursing Assistant 7, who has worked at the facility for seven years, stated that room sizes had not been an issue, and there was adequate space for care and storage. Similarly, a resident interviewed expressed no concerns about room size, privacy, or storage. Observations during the survey period noted that the rooms provided reasonable privacy, adequate storage, and sufficient space for nursing care and resident ambulation. The report suggests that the waiver for room size requirements should continue, as it does not adversely affect the health and safety of residents.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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