Blue Oak Post-acute

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with dementia, hemiplegia, and hemiparesis received resident-centered care in accordance with her care plan and goals of care when she experienced a change of condition in the morning and her responsible party was not notified until approximately 3 hours later. The resident’s care plan stated it was very important for her son to be involved in discussions about her care, and her physician orders identified her as lacking capacity with her son as the surrogate decision maker. Her POLST indicated DNR and comfort-focused treatment, and it was signed by her RP. According to the record, a CNA reported low blood pressure to the nurse around 8 a.m. The nurse rechecked vital signs and found the resident’s BP was 72/40. The resident was repositioned, encouraged to drink fluids, and encouraged to eat breakfast. After breakfast, her condition remained unstable, with BP 77/43, HR 103, and oxygen saturation 81% on room air. The nurse documented that the physician was notified for an order for supplemental oxygen, and the resident was placed on 2 liters of oxygen via nasal cannula. The nurse did not notify the RP at that time; instead, the RP arrived later during the decline and was informed after he was already at the facility. The change of condition assessment completed at 11 a.m. documented unstable vital signs, mental status change, and that the resident was unresponsive, sweaty, lethargic, and not responding to verbal commands. The ambulance record showed the resident was still critically ill on arrival to EMS, with fever, low BP, tachycardia, and low oxygen saturation. EMS documented that the RP and family stated the resident was never supposed to be comfort care and wanted treatment except CPR. The hospital record showed the resident arrived with altered mental status and septic shock due to a urinary tract infection, was admitted to the ICU, and later died from septic shock due to UTI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse, specifically resident-to-resident altercations, by not implementing effective, individualized nursing care plan interventions. Several residents with severe mental illness and known histories of aggression were involved. One resident, admitted in 2017 and readmitted with a diagnosis of severe mental illness, had a known history of aggression toward peers prior to his current admission. During a medication pass, this resident suddenly began punching another resident in the head and face with a closed fist. The assaulted resident’s care plan for skin integrity documented swelling and redness to the back right side of his head after being hit, with a goal for the redness and swelling to decrease. The assaulted resident later recalled the incident, indicated pain in the area where he was struck, and stated he wanted to be discharged when asked if he felt safe. In a separate incident, an unlicensed staff member reported hearing commotion on the patio and finding the same aggressive resident kicking another resident who was on the ground. Other staff reported that the aggressive resident attacked without provocation, initially striking the resident on the head and then kicking him in the torso until staff intervened. A progress note documented a head-to-toe assessment of the assaulted resident, noting an abrasion with bleeding on the right ear, which was cleaned, and the injury was reported to the physician and wound care nurse. These events occurred in the context of multiple residents with severe mental illness residing in the facility, and the facility’s abuse reporting and prevention policy stated that staff and physicians would help identify risk factors for abuse, such as significant numbers of residents with unmanaged problematic behaviors. Another incident involved two different residents, both with severe mental illness, where one resident with a known history of physical aggression struck another resident on the chin after becoming upset about not being able to shower first. A change-in-condition assessment documented that the aggressive resident hit the other resident, and a mandated abuse report (SOC-341) indicated that a nurse witnessed the incident. The assaulted resident’s MAR showed administration of acetaminophen for pain, and his care plan documented that he experienced abuse when struck on the chin, resulting in a skin injury with redness and placing him at risk for emotional distress and psychosocial decline. The care plan for the aggressive resident related to this altercation was created 19 days after the incident, and the ADON acknowledged that nursing care plans must be updated timely with appropriate resident-specific interventions during changes in condition, and that delayed or backdated documentation can place residents at risk for harm because staff may be unaware of current needs or events. The DON and Administrator also acknowledged the purpose of individualized care plans and the requirement for timely documentation of alleged abuse incidents, consistent with facility policies on abuse prevention and resident rights to be free from abuse and neglect.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.

Plan Of Correction

From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the implementation of a fall care plan for Resident 3. Resident 3 was admitted on 3/4/26 with diagnoses of difficulty walking and muscle weakness. Following an unwitnessed fall, a Fall Care Plan dated 3/31/26 specified that the resident’s bed was to be kept in the lowest position as an intervention. During an observation on 4/2/26 at 3:38 p.m., surveyors found the resident’s bed was not in the lowest position, despite the presence of sitter D and Licensed Nurse (LN) E in the room. LN E confirmed that the care plan required the bed to be in the lowest position, and sitter D acknowledged that the bed was not in the lowest position at that time. In interviews, sitter D stated it was important for the bed to be in the lowest position to prevent the resident from hurting himself if he fell and admitted she had forgotten to lower the bed earlier. LN E stated that the resident was at high risk for falls, had already experienced multiple falls, and that the care plan intervention to keep the bed in the lowest position was intended to decrease the risk of injury when the resident falls. During a concurrent interview and record review, the DON verified that the Fall Care Plan included the intervention to keep the bed in the lowest position and stated that fall care plan interventions are put in place for a reason and must be followed, adding that she expected the bed to be in the lowest position unless staff were performing care. The facility’s Falls and Fall Risk, Managing policy indicated that staff, in conjunction with the attending physician, will identify and implement relevant interventions to minimize serious consequences of falling.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain an effective call light system that allowed residents to directly communicate with staff when assistance was needed. One resident with Parkinson’s disease and malaise, who had a BIMS score of 15 indicating no memory issues, used a pendant call light to request help and waited approximately 21 minutes without staff response. Observation in the hallway outside this resident’s room revealed no audible alert, and only a faint beep could be heard at the nearby nursing station. The Director of Staff Development and the Maintenance Director confirmed that the call light’s volume was too low to be heard unless staff were at the nursing station, and a licensed nurse acknowledged that staff had been aware of this issue but she had not reported it to a supervisor or maintenance, despite recognizing that the faint alert meant there was a significant chance no one would respond. A second resident, admitted with difficulty walking and muscle weakness and having a BIMS score of 12 indicating moderate cognitive impairment, also experienced problems with the call light system. When this resident pressed the call light, the light above the door that should illuminate did not turn on, and the resident reported that staff had not answered the call light the previous night or that morning. The Director of Staff Development and the Maintenance Director verified that this resident’s call light was broken and that the door light failed to illuminate when activated. The facility’s undated policy on call lights stated that staff must report call light problems immediately to a supervisor or the maintenance director and provide immediate or alternative solutions, but staff did not follow this policy in relation to the identified call light issues.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the State Survey Agency (CDPH) with written five-day investigation reports for two separate, facility-reported allegations of suspected dependent adult/elder abuse involving resident-to-resident altercations. One allegation involved an altercation between Resident 1 and Resident 2, and another involved an altercation between Resident 3 and Resident 4. Facility documents showed that both allegations were reported to CDPH on the same dates they were made, but there was no evidence that the required follow-up investigation reports were completed and submitted within five calendar days as required by facility policy and regulatory expectations. During interviews, the Administrator, whose first day in the role was 1/01/2026, stated she could not locate the facility files that would normally contain the five-day investigation reports for either abuse allegation and confirmed she could not provide evidence that the reports were sent to CDPH. The DON stated she did not know if the investigation reports for both abuse allegations were completed and acknowledged that the purpose of these reports was to ensure the facility investigated what happened and what interventions were implemented to provide resident safety, and that it was a regulatory requirement to provide the five-day investigation report to CDPH. The facility’s written policy on abuse, neglect, exploitation, or misappropriation specified that all allegations are thoroughly investigated, that the administrator initiates investigations, and that a follow-up investigation report is to be provided within five business days of the incident, which did not occur in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that nursing services met professional standards for assessment and documentation following an abuse allegation involving Resident 1. Resident 1, who had COPD, left-sided hemiplegia, and major depressive disorder and was cognitively intact per a BIMS score of 13, reported alleged physical abuse on 12/18/25, stating that someone grabbed her right arm. An SBAR change-of-condition note documented skin discoloration on the right forearm with intact skin, no swelling, and no pain. However, no detailed skin integrity assessment was completed at that time to describe the bruising in terms of size, exact location, and characteristics, despite facility policy requiring detailed observations and the DON’s expectation that a skin integrity assessment be completed when the bruising was first reported. A skin/wound note was not entered until 12/21/25, and during a later observation on 1/05/26, two distinct bruises were noted on the lateral aspects of Resident 1’s right upper and lower arm, with specific measurements and color changes that had not been previously documented. The deficiency also involves the facility’s failure to complete ordered 72-hour monitoring every shift following a change in condition for Resident 2. Resident 2, who had DM, vascular dementia with behavioral disturbances, and major depressive disorder and was cognitively intact per a BIMS score of 13, was observed on 12/17/25 to have increased agitation, physical aggression, wandering, and entering other residents’ rooms. An SBAR change-of-condition note documented these behaviors and indicated that 72-hour monitoring was initiated, and the care plan reflected that the resident was exhibiting adverse behaviors affecting physical well-being, safety, and aggression toward staff and other residents, with 72-hour monitoring started. Facility documentation and the DON’s review showed that required 72-hour monitoring notes were not completed every shift as expected. Record review revealed that for Resident 2, there was no evidence that 72-hour monitoring was completed by nursing staff on any shift on 12/18/25, nor on AM, PM, and NOC shifts on 12/19/25, and NOC shift on 12/20/25. The DON stated that her expectation was that licensed nursing staff complete 72-hour monitoring every shift, resulting in nine progress notes over the monitoring period, but confirmed that only two notes were completed on 12/20/25. Facility policies required that all services provided to residents be documented in the medical record and that charge nurses ensure care is provided according to the care plan and that nurses’ notes reflect that the care plan is being followed. These omissions in assessment and monitoring documentation for both residents constituted failures to meet professional standards of quality and facility policy requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from physical abuse by other residents in two separate incidents. In the first incident, a resident with schizophrenia and no memory impairment struck another resident, also with schizophrenia and no memory impairment, several times on the back of the head while the latter was sitting on his bed. The assaulted resident reported the incident, denied pain, and had no visible injuries. The aggressor admitted to hitting the other resident, stating that the victim was making weird noises. Facility staff, including the case manager and program director, confirmed the occurrence of physical abuse. In the second incident, a resident diagnosed with schizoaffective disorder hit another resident, who also had schizophrenia and no memory impairment, several times in the head while she was lying in bed. The victim experienced mild pain to the right temple and expressed fear of the aggressor. The program director documented the incident and acknowledged it as physical abuse. Both incidents were confirmed through interviews and record reviews, and the facility's policy states that residents have the right to be free from abuse, including physical abuse.

Penalty

Inspection fine: $28,106

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A Certified Nursing Assistant (CNA) and an unlicensed staff member required a resident diagnosed with Paranoid Schizophrenia to unclog her own toilet, which contained urine and feces, using her gloved hands. The CNA instructed the resident to perform this task while the door to her room was intentionally left open, despite the resident's request for privacy. The CNA justified her actions by stating she was trying to teach the resident a lesson, and the unlicensed staff member confirmed the incident occurred as described. The resident reported feeling embarrassed, humiliated, and victimized by the incident, which negatively impacted her psychological well-being. At the time, the resident had no memory impairment, depression, hallucinations, or behavioral symptoms according to her Minimum Data Set assessment. The facility's policy prohibits all forms of abuse, including mental abuse, and commits to preventing such incidents. The actions of the CNA and unlicensed staff directly violated the resident's right to be free from psychological abuse.

Penalty

Inspection fine: $28,106

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly investigate an abuse allegation by not interviewing other residents who may have been affected. According to a review of the 5-day summary report, only one resident was interviewed in relation to the abuse allegation. During interviews, both the Director of Behavioral Health and the Administrator confirmed that no other residents were interviewed as part of the investigation, despite facility policy requiring interviews with the resident's roommate and other residents who received care from the accused employee. This omission prevented the identification of any additional residents who could have been impacted by the alleged abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents’ rights to confidentiality when resident meal tickets containing personal and medical information were found in a kitchen trash can during observation in the kitchen. A dietary aide was seen scraping food off breakfast plates into a large trash can, and numerous resident meal tickets were observed in the trash can with discarded food. Trash bags were then thrown into an unsecured dumpster behind the building. During interview, the Dietary Services Supervisor stated the kitchen team had been discarding meal tickets in the trash with uneaten food for over a year and was not aware that the information on the meal tickets needed to be protected or that shredding was the proper method. The supervisor stated this was a privacy issue and a HIPAA violation. The Registered Dietician later stated that throwing away resident meal tickets in the trash was a HIPAA violation on multiple counts and that the meal tickets should have been shredded to protect residents’ private information. Facility policies on Resident Rights and Confidentiality of Information and Personal Privacy stated that resident privacy and confidentiality must be safeguarded.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its medication storage policy and procedure for a census of 142 residents when multiple medications were found not labeled and not stored in a safe manner. During a concurrent observation and interview with LN 1 at 10 a.m., medication cart 2A contained a budesonide inhaler that was open with no open date, a fluticasone/salmeterol Diskus and a decongestant nasal spray that had resident information only on the outer packaging and not on the actual product, a beclomethasone inhaler with an expiration date of 8/25 and only a room number written on it, and an unidentified peach oval-shaped tablet loose in a drawer. LN 1 confirmed these findings during the observation. During an interview with the DON at 9 a.m., the DON stated she was aware of the labeling problems and the expired inhaler and that this was not her expectation. She also stated expired non-controlled medications should have been placed in the white bins in the medication room, logged, and destroyed. The facility's policy on medication ordering and receiving from pharmacy stated the resident's name must be maintained directly on the actual product container and resident-specific non-prescription medications must be kept in the original container and identified with the resident's name. The facility's disposal policy stated unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow the standardized recipe for a pureed lunch meal for nine residents when the cook did not use the correct amounts of ingredients for the pureed bread or roll and the pureed smothered pork chop. The lunch menu for the day included smothered pork chop, whipped potatoes, mixed vegetables, bread or roll with margarine, and lemon chiffon dessert, and the facility's recipes specified that seven and a half slices of white bread were to be used for 15 servings and one and a half cups of broth were to be used for 15 servings of pureed smothered pork chop. During observation, the cook stated she was making 14 servings of the pureed food items, but she placed 14 slices of white bread in a blender with warm milk and pureed it, then placed 15 boneless pork chops into a food processor and added four cups of beef broth before pureeing the mixture. The mixture was observed to be watery and sloshed around in its container. The cook stated she had finished making the pureed pork chop mixture and confirmed she did not follow the recipe. The Dietary Services Supervisor confirmed the recipe was not followed and stated that because of this, residents might not receive the recommended daily allowance of nutrients they need, and watered down foods could lead to weight loss in vulnerable residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate residents' food allergies, intolerances, and meal preferences for five residents. Resident 119 was admitted with a documented lactose allergy and was cognitively intact on the most recent MDS. During observation, dietary staff prepared mashed potatoes using a recipe that included sour cream, and at lunch Resident 119 was served mashed potatoes with sour cream even though the tray ticket indicated a lactose allergy. The Dietary Services Supervisor confirmed the resident was plated mashed potatoes with sour cream and stated the recipe was not recommended for residents with lactose allergy. Resident 119 stated that eating foods containing lactose causes her lips to double in size, blisters in her mouth, and her throat to close up. The facility also did not serve the food preferences listed on tray tickets for four residents. During lunch tray line observation, Resident 14's tray had no fruit despite a request for fruit with the meal, Resident 43's tray had no soup despite a request for soup, Resident 44's tray had one portion of protein despite a request for double portions of protein, and Resident 129's tray had no fruit despite a request for fruit with every meal. The DSS confirmed the discrepancies and stated the cooks were expected to follow the written tray ticket requests. The facility policy stated residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value, with steps taken to prevent exposure to allergens.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food items were found improperly stored and maintained in the dietary areas during observation with the Dietary Services Supervisor (DSS). In the reach-in refrigerator, there was a container of fresh minced garlic with an expiration date of 9/21/25, an open jar of pickle relish with an expiration date of 9/18/25, and an unsealed bag of parsley with yellowing sprigs that had been opened on 9/8/25 and had no expiration date. In the dry goods storage room, multiple packages of bread were found open or unopened but unlabeled and undated. In the walk-in refrigerator, sliced ham was found with a use-by date of 9/20/25, and DSS confirmed it was past its expiration date. The same parsley was later observed being prepared for lunch the next day, and DSS acknowledged it had remained in the refrigerator since the prior day. The facility also had food storage and preparation equipment that was not maintained in sanitary condition. A metal storage shelf holding plastic food bins had a reddish-brown substance on the bottom rack, which DSS identified as rust and stated was not appropriate for storing food bins. A green cutting board had several brown stains, and a blue cutting board had a sticky substance measuring approximately 3 x 8 inches. A frying pan was observed with an oily substance near the rim and a hard brown residue inside, and a steamer food tray had two small areas of brown residue. DSS confirmed these items were not safe for food preparation and stated the residue could be dried-on food. Additional observations showed two electric insect control machines mounted on walls, including one above a food preparation area and one above a toaster. A ceiling ventilation fan over a food preparation area had a thick layer of black substance on the inner casing and fan blades. Record review also showed the cool down logs for cooked potentially hazardous food were incomplete from June through September 2025, with the second step of the two-stage cooling process not documented. DSS and the Kitchen Supervisor stated staff were not completing the required temperature checks, and the Registered Dietician stated the unlabeled, undated, and expired food, dirty equipment, wall-mounted insect control devices above food areas, and incomplete cooling documentation were unsafe.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper infection control measures were implemented when two washing machines in the behavioral unit laundry rooms were observed closed while not in use with visible moisture inside, and one machine in station B had black spots around the door seal. The Director of Environmental Services confirmed the washers should have been left open after use for infection prevention and to prevent odor, and stated the black spots were mold. The Infection Preventionist stated closing the machines with moisture inside could cause bacteria build-up and contaminate residents' clothes. The facility policy for Environmental Services laundry and linen indicated washing machine doors should be left open when not in use. The facility also failed to ensure hand hygiene was performed before medication preparation. An LPN was observed blowing his nose with a tissue and then preparing medications without performing hand hygiene. The LPN confirmed he forgot to perform hand hygiene after blowing his nose and before preparing medications. The DON stated nurses should perform proper hand hygiene to prevent the spread of infections and protect residents. The facility's hand hygiene policy stated hand hygiene is the primary means to prevent spread of healthcare-associated infection and that all personnel are expected to adhere to hand hygiene practices. Enhanced Barrier Precautions were not followed for three residents. One resident admitted in July 2025 had EBP for a left foot wound and urinary catheter, with staff directed to wear PPE during care; two staff entered the room wearing gloves but no gown while assessing the wound. Another resident admitted in August 2025 had EBP for a left heel blister; a PA entered wearing gloves, removed the dressing, and performed wound debridement while the wound nurse assisted, and neither wore a gown. A third resident admitted in April 2025 with a G-tube was on EBP, and a CNA changed linens while wearing gloves but no gown despite an EBP sign on the door. The DON and Infection Preventionist stated gowns and gloves should have been worn for the care provided, and the resident care plan and facility EBP policy required gown and glove use for high-contact care activities such as changing linens and for residents with indwelling medical devices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that working call systems were available in residents’ bathrooms and bathing areas in the behavioral unit. Surveyors found that the rooms and bathrooms in that unit did not have a functioning call system for 46 residents out of a census of 142, and the facility’s policy stated that each resident is to have a means to call staff directly from the bed, toileting/bathing facilities, and the floor, with the call system remaining functional at all times. During observation and interview, Resident 102, who was admitted with schizophrenia and had a BIMS score of 14 out of 15, had no call button in the room and stated he would go to the nurses’ station if he needed help. Resident 105, who was admitted with bipolar type schizoaffective disorder and had a BIMS score of 15 out of 15, also had no call button in the room and stated he would make noise, bang the wall, and yell for help if he needed assistance. PT 1 confirmed that residents’ rooms and bathrooms in the behavioral unit did not have a call system and stated it had not worked for years, and the PD confirmed the behavioral unit did not have a call system.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure two sampled residents were free from abuse when both were subjected to offensive language and profanity during a verbal altercation witnessed by staff. Resident 28 was admitted in December 2024 with recurrent depressive disorder and had a BIMS score of 15 out of 15 with intact cognition on the 8/16/25 MDS. Resident 140 was admitted in February 2024 with adjustment disorder with depressed mood and had a BIMS score of 14 out of 15 with no memory impairment on the MDS. During an observation on 9/22/25, Resident 140 was seen speaking with staff about a disagreement with her roommate over a television remote, and Resident 28's visiting son was also present and requesting staff address Resident 140's accusation that Resident 28 was a thief. Licensed Nurse 5 stated she observed Resident 140 upset outside her room and attempted to calm her, but once inside the room Resident 140 directed profanity at Resident 28 and Resident 28's visiting son. The Director of Staff Development stated that Resident 28's son became angry after Resident 140 called Resident 28 a thief and told Resident 140, "I'm going to kick your ass" and "Fuck you." The Administrator confirmed the verbal altercation between the two residents and Resident 28's son and stated abusive behaviors of residents and visitors were not tolerated. The facility policy titled Abuse Prevention Program stated residents had the right to be free from abuse and to be protected from abuse by anyone including staff and other residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately assess the nutritional status of one resident when the MDS quarterly review indicated no weight loss despite the resident having significant documented weight loss. The resident was admitted with a diagnosis of type 2 DM, and during an observation the resident was lying in bed facing away from an untouched meal tray. The medical record showed a weight of 193.8 pounds on 1/1/25, with a severe weight loss of 16.82% in six months, and later weights of 171.2 pounds on 6/15/25 and 161.2 pounds on 7/15/25, reflecting a severe weight loss of 5.84% in one month. The MDS dated [DATE] was marked "No" for weight loss, stating the resident had no loss of 5% or more in the last month or 10% or more in the last 6 months. During interview and record review, the DSS stated she did not complete the assessment accurately and should have answered "Yes" to weight loss. The DSS also stated that without an accurate assessment, the resident's care plan was not updated accordingly and the resident could continue to lose weight without it being caught. The DON and MDSC both stated that accurate completion of the MDS was important because it was used for care planning, and the MDSC confirmed that the inaccurate weight loss entry might not trigger a CAA to update the care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Professional standards of care were not followed for enteral feeding and medication administration for one resident who had been admitted with diagnoses including enterocolitis due to C. difficile, acute gastric ulcer with hemorrhage, and aphasia following a stroke. The resident’s physician order for enteral feeding listed a rate of 60 ml per hour for 20 hours per day and stated that tube feeding could be stopped for activities of daily life and other resident activities, but it did not include start or stop times or instructions for medication administration or flushing. During observation, an LN administered crushed medications through the resident’s G-tube using 30 ml of cool tap water to dilute each medication, between medications, and after the last medication was delivered. During interview and record review, the LN confirmed this did not follow the facility policy for administering medications through an enteral tube. The DON stated enteral orders were expected to include type, rate, start and stop times, and flushing instructions, and that if flushing was not specified, staff should follow facility policy. The facility policy required warm purified water, a specific order for crushed tablets, and 15 ml between medications and 15 ml again when the last medication began to drain from the tubing.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an enteral feeding was administered according to physician's orders for one resident with dysphagia and a gastrostomy tube. The resident was admitted with diagnoses including dysphagia and had an enteral feed order dated 10/7/24 for a strict NPO diet with tube feeding to run 18 hours a day and be off for 6 hours, totaling 1530 cc, scheduled from 4 p.m. to 10 a.m. During an observation on 9/23/25 at 9:24 a.m., the resident's tube feeding pump was observed turned off, and the feeding tube was detached from the resident's g-tube and wrapped around the pump. During interview, LN2 stated the pump had been turned off after medication administration around 8:20 a.m. and was not turned back on, resulting in the resident missing 1 hour and 40 minutes of feeding. The DON stated this was not good and that missing the enteral feeding could have a negative effect on the resident's health and nutrition. The facility policy for administering medications through an enteral tube stated that when medication administration is complete, the feeding formula should be reconnected.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide respiratory care services according to professional standards of quality for one resident with COPD. Resident 28 was admitted in December 2024 with a diagnosis of chronic obstructive pulmonary disease and had an MDS assessment dated 8/16/25 showing a BIMS score of 15 out of 15, indicating intact cognition. During observation on 9/22/25, the resident was seen in bed receiving oxygen at 2.5 L/min via nasal cannula and stated she needed more oxygen than was being delivered and typically required 3 L/min. During interview and record review, the nurse could not locate the resident’s oxygen order and stated the resident had been using oxygen continuously at 2 L/min since admission. The resident’s hospital transfer orders dated 12/18/24 showed an order for oxygen at 3 L/min continuous for COPD. The DON stated nurses should follow the doctor’s order to safely provide care and prevent health complications. The facility’s Oxygen Administration policy required verification and review of the physician’s order and administration of the proper flow of oxygen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate documentation, disposition, and storage of controlled medications for one resident with diagnoses including a closed fracture and an anxiety disorder. The resident had an order for clonazepam 0.5 mg, two tablets daily and one tablet at bedtime. During a concurrent observation and interview, a sealed plastic bag containing the resident’s medications was found in the general medication compartment of Medication Cart-2A, and a bottle of clonazepam 0.5 mg was inside the bag. The LN stated the medications had been brought in by the resident on admission and should have been locked with the other controlled medications. During the same observation, the controlled medication compartment and the resident’s Controlled Drug Record were reviewed. The resident’s clonazepam bubble pack was counted at eight tablets, while the CDR showed a count of 10 tablets. The LN confirmed the actual count and stated the CDR did not match the bubble pack. The DON stated nurses should have created a CDR when the controlled medication was received, reconciled and signed it out when passing it and at shift change, and expected the CDR to match the actual medication count with controlled medications stored in a locked drawer accessible only to nurses. The facility policy stated controlled substances are to be stored in a locked container separate from non-controlled medications and reconciled upon receipt, administration, disposition, and at the end of shift.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly dispose of garbage when, during a concurrent observation and interview with the Maintenance Director at the kitchen dumpsters, one garbage dumpster was found with warped lids separated at the midline, leaving a one-inch gap between the lids. Three flies were observed hovering at the gap, and the Maintenance Director stated it was a pest problem because insects and rodents could access the dumpster. A review of the facility document titled "Garbage and Trash," dated 2023, indicated that adequate, clean, vermin-proof areas must be provided for storage of garbage and that the lids are closed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a record of COVID-19 vaccination status for one of two sampled staff members, CNA 2, because CNA 2 was not provided education regarding the COVID-19 vaccine and the refusal of the vaccine was not documented. During a concurrent interview and record review with the Director of Staff Development, CNA 2’s employee record was found to have no COVID-19 vaccination record on file. The DSD stated that the vaccine had been offered and CNA 2 declined, but also confirmed that education about COVID-19 vaccination was not provided and the declination was not documented. The facility policy titled, Employee Infection and Vaccination Status, revised January 2024, states that employees are provided educational materials to make informed decisions about vaccinations and that if declined, a declination form is completed and placed in the employee’s health record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent abuse when one resident threw a pitcher of water at another resident. Resident 1, who had a history of respiratory failure, hemiplegia, hemiparesis following a stroke, and major depressive disorder, was assessed as having moderately intact cognition. Resident 2, who had a history of stroke, anxiety disorder, and aphasia, was assessed as having intact cognition. According to documentation, Resident 2 became agitated by what he perceived as excessive noise from Resident 1 and responded by throwing water at him. Resident 1 was surprised by the incident and did not realize his behavior was agitating his neighbor. Interviews confirmed that Resident 2 admitted to throwing water on Resident 1 due to ongoing frustration with the noise and a perceived lack of intervention by staff. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including abuse by other residents. The incident demonstrates a failure to protect Resident 1 from abuse as required by facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a licensed nurse (LN B) physically assisted a resident who was lying on a blanket in the hallway by lifting her from the floor and placing her in bed, despite the resident's repeated verbal refusals and explicit statements that she did not consent to being touched. The resident, who was self-responsible and experiencing significant pain at the time, repeatedly told LN B not to touch her and requested that the police be called, but LN B did not comply with these requests. LN B later acknowledged that he should not have touched the resident without her consent. Interviews with other staff, including the Director of Nursing and additional licensed and unlicensed staff, confirmed that facility policy and standard practice require staff to respect residents' rights to refuse physical contact and to be treated with dignity. The facility's policy on resident rights, as well as staff statements, indicated that touching a resident without consent is a violation of those rights. The incident resulted in the resident feeling disrespected and that her rights had been violated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an allegation of physical abuse made by a resident against a licensed nurse was reported to the appropriate authorities within the required two-hour timeframe. According to documentation, the resident reported the abuse on 7/7/25 at 3:10 p.m., but the allegation was not reported to the local police department until the following day, 7/8/25. Interviews with facility staff, including the Director of Nursing, Licensed Nurse, and Director of Staff Development, confirmed that all abuse allegations should be reported to the police, ombudsman, and state licensing agency within two hours to ensure resident safety. Record reviews further verified that the reporting to law enforcement was delayed beyond the required period. A review of the facility's policy and relevant regulatory guidance indicated that abuse allegations must be reported immediately, defined as within two hours, to state licensing, the ombudsman, and law enforcement. The facility's own documentation and fax confirmation sheet confirmed the delay in reporting. This deficiency was identified for one of three sampled residents and was substantiated through interviews, record reviews, and examination of facility policies and state requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A medication cart was observed left unlocked and unattended in the facility, with no nurse present in the area at the time. Shortly after, a nurse returned and locked the cart, confirming that she had left it unlocked while accompanying the DON into the medication room. The nurse acknowledged that the cart should remain locked when unattended to prevent unauthorized access to medications. The DON and another nurse both confirmed the expectation that medication carts be locked at all times when not in use, in accordance with the facility's policy and procedure, which requires all compartments containing drugs and biologicals to be locked when not in use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident admitted for surgery aftercare following a right lower leg fracture, with a history of falls and difficulty walking, was left on a soiled bedpan for hours during the night without any response to multiple call light activations. The resident reported feeling helpless and embarrassed by the experience and notified a nurse the following morning. Staff interviews confirmed that the resident was left unattended due to a communication breakdown between two CNAs who changed assignments mid-shift, resulting in the resident's needs being overlooked. Facility staff, including a CNA, a licensed nurse, and the DON, acknowledged that the standard procedure is to respond promptly to call lights and not to leave residents on bedpans for extended periods, as this can cause discomfort and potential skin breakdown. Review of facility policies confirmed that residents should be treated with dignity and respect, with prompt toileting assistance and removal from bedpans as soon as they indicate they are finished. The failure to follow these procedures led to the resident enduring an undignified and uncomfortable situation.

Plan Of Correction

F550 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: DSD/ADSD/Nursing Supervisor In serviced 6/5/25. CNAs on 5/28/25 and 6/5/25 offering and removal of bedpans that emphasize dignity and respect for the residents during this process. One resident was affected by deficient practice. Follow-up interviews with the affected resident confirm that there have been no recurrences of deficient practice and deny any residual emotional effects. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: DON/MDS/Nursing Supervisor identified residents who utilize bedpans. Three (3) residents have the potential to be affected by deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Therapy will track new admissions who utilize bedpans, communicate identified residents to Nursing. Identified residents who utilize bedpans will be updated in their toileting care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system and includes dates when corrective action will be completed. The corrective action dates must be acceptable to the State Agency. Department heads/Interdisciplinary Team will identify resident concerns through daily Angel rounds, via review of monthly Resident Council minutes, and during quarterly care conferences. Findings will be reviewed in QAPI for three months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete and provide a timely investigation report to the Department following an allegation of abuse involving a resident and a staff member. Specifically, after a resident reported not being treated with dignity and respect by a housekeeper, the administrator conducted an internal investigation but did not submit the required five-day follow-up investigation report to the Department. During an interview, the administrator stated that he was unaware of the requirement to send a follow-up report within five days after an abuse allegation, referencing guidance documents that did not indicate this obligation. A review of the facility's policy on abuse, neglect, exploitation, and misappropriation prevention confirmed that the facility is committed to investigating and reporting all allegations within federally required timeframes. However, the lack of a timely report in this instance meant that the Department did not receive necessary information to intervene or ensure protective actions for the resident involved and the other residents in the facility.

Plan Of Correction

Immediate Action Taken The Administrator reviewed the abuse investigation file involved. The alleged abuse was non-physical and was reported under California Welfare & Institutions Code 15630(a)(b)(1)(C). The code section calls for reporting to the local ombudsman or local enforcement agency. The initial report was made to the State Survey Agency, local ombudsman, and local law enforcement agency. Moving forward, results of investigation that fall under this State Law code section will be reported to the State Survey Agency under CFR Section 483.12(c)(4) within 5 working days. Action taken for other potentially affected residents The Administrator reviewed previously reported allegations, and all involved physical abuse in which both federal and state law requires reporting to the State Survey Agency, the local ombudsman, and local law enforcement agency. All initial reports were followed by a 5-day report to the State Survey Agency. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with a diagnosed mental illness received a required Level II PASRR (Preadmission Screening and Resident Review) evaluation. The resident, who had a history of Alzheimer's disease, non-Alzheimer's dementia, anxiety, depression, and bipolar disorder, was admitted with a positive Level I PASRR screening indicating the need for a Level II evaluation. Despite this, documentation showed that the Level II PASRR was not completed, with correspondence from the Department of Health Care Services at one point stating the evaluation could not be conducted due to the resident being isolated for health or safety reasons, and later stating the resident did not require the screening due to not having a severe mental illness. The resident's cognitive status declined over time, as evidenced by a drop in BIMS score from 11 to 3, indicating severe cognitive impairment. Interviews with facility staff revealed a lack of clarity and policy regarding the PASRR process. The Business Manager was unaware of the steps to take if the acute care hospital did not complete the PASRR accurately or if a resident developed a mental illness while in the facility. The Administrator acknowledged that a Level II PASRR should have been conducted and identified a gap in the facility's PASRR process. The facility's policy required referral for Level II evaluation when indicated, but this was not followed, resulting in the resident not receiving a complete mental health evaluation or access to appropriate mental health resources.

Plan Of Correction

On 4/25/25, the Administrator completed a revision of the facility's policy and procedure (P&P) for PASSR to 1) include the definition of a significant change and 2) address what to do when a resident is noted to have a significant change of condition. On 4/28/25, the Administrator revised the P&P with the facility's current PASSR system, authorized users, and the Interdisciplinary Team (IDT), the requirement that a Resident Review (RR) must be initiated by submitting a Level I Screening upon a resident's significant change in condition. On 4/28/25, the Administrator reviewed with the Interdisciplinary Team (IDT) the definition of a "significant change of condition." The facility's current PASSR System authorized users include the Business Office Manager, Business Office Assistant, and Admission's Director. The IDT includes the Director of Nurses, Director of Staff Development, Minimum Data Set Nurse, Social Services Director, Activities Director, Rehabilitation Director, Medical Records Designee, and Administrator. The IDT will review changes of condition as defined in the P&P during morning stand-up meetings and communicate the need to submit Level I Screening to PASSR systems users as needed. The Medical Records Designee will audit changes of conditions and for completion of the process and report findings to the IDT. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to consistently offer or perform hand hygiene (HH) for residents after meals, as observed with multiple residents who were not provided HH following lunch. Interviews with staff confirmed that facility policy requires offering HH before and after meals for infection control, and staff acknowledged not following this policy during the observed incidents. The nurse manager also confirmed that HH should be offered to residents before and after meals to prevent infection. Additionally, staff did not perform HH prior to preparing medications or before and after donning gloves, as observed with a licensed psych technician during medication pass and glove use. Staff interviews confirmed awareness of the facility's policy to perform HH in these situations, and the facility's written policy also requires HH before and after eating, before preparing medications, and after removing gloves. These lapses were directly observed and verified by staff and the nurse manager during interviews.

Plan Of Correction

On 4/7/25-4/10/25, all staff were in-serviced on Hand Washing/Hand Hygiene Policy and Procedure (P&P) by the Director of Nursing (DON), Director of Staff Development (DSD), Assistant Director of Staff Development (ADSD), and Infection Preventionist (IP). The training included: 1) Offering Hand Hygiene (HH) to residents after meals 2) Utilizing HH prior to preparation of medications 3) Utilizing HH prior to donning and doffing of gloves The IP, DSD, and ADSD will observe and monitor: (1) Staff offering HH to residents after meals (2) Utilizing HH prior to preparation of medications (3) Utilizing HH prior to donning and doffing of gloves Audits will be conducted three times a week for 3 weeks, twice weekly for 2 weeks, and then once weekly for 1 week. Additionally, random audits will be performed for one month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee for three months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple failures in the facility's handling of discontinued and unused medications. During observations, medications belonging to two discharged residents were found left inside a medication room refrigerator, despite both residents having been discharged weeks prior. Additionally, discontinued medications for two other residents were found disposed of in their original containers inside resealable plastic bags within a disposal bin, rather than being properly destroyed according to facility policy. Further, various discontinued medications, including birth control pills, were left intact and undisposed in a disposal bin, and a discontinued medication for another resident was found stored among active medications in a medication cart. Interviews with licensed nurses confirmed that the medications found belonged to residents who were no longer in the facility or whose medication orders had been discontinued. Record reviews corroborated the discharge dates and medication discontinuation orders for the affected residents. The facility's policy requires that discontinued and unused medications be destroyed in compliance with federal and state regulations, and that such medications be removed from storage areas and secured until destruction. Despite these requirements, the facility failed to properly identify, segregate, and dispose of discontinued and unused medications. The observed practices included leaving medications accessible in medication rooms and carts, and placing them in disposal bins without proper destruction. These actions were not in accordance with the facility's own policies or regulatory requirements for pharmaceutical service, labeling, and storage.

Plan Of Correction

From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 Inservices with licensed staff regarding the facility policy and procedure titled Discarding and Destroying Medications. Licensed staff will follow the facility protocol for proper disposal and destruction of unused and discontinued medications. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medications 3 times a week for 3 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused medications 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication randomly for 1 month. System Effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify and provide evidence that the LTC Ombudsman was given a copy of the transfer notice for 42 out of 42 residents who were subjected to a facility-initiated discharge or transfer to the hospital between December 2024 and March 2025. Multiple staff interviews, including those with the program director, nurse manager, licensed nurses, and the social services director, confirmed that the behavioral unit had never notified the ombudsman of any discharges or transfers to the hospital. Staff members indicated that they were either unaware of the requirement or believed it was not necessary to notify the ombudsman. A review of facility policy and the All Facilities Letter (AFL 17-27) indicated that the facility is required to send notice to the local LTC Ombudsman for any transfer or discharge initiated by the facility. The administrator acknowledged that the behavioral unit is licensed under the skilled nursing facility and is therefore required to follow state regulations, including ombudsman notification for all discharges and transfers. No evidence was found in the health records that the ombudsman had been notified for any of the affected residents.

Plan Of Correction

On 4/26/25, the Administrator reviewed the content of AFL 17-27 with the Social Services Director (SSD) and Behavioral Unit's Program Director (PD) and Nurse Manager (NM) for compliance. The Administrator stressed AB 940's requirement that the facility 1) must notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representative when a facility-initiated transfer or discharge occurs, and 2) is required to provide a copy of the notice to the LTC Ombudsman as soon as practicable if the resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis. The SSD will maintain a binder organized by year containing 1) a list of all discharged residents to date, 2) copies of the facility-initiated transfer notices, and 3) proof of transmission of the notices to the LTC Ombudsman's office. The PD and NM will maintain the same for the Behavioral Health Unit. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.

Penalty

Inspection fine: $8,278

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision for a resident who eloped and sustained injuries. The resident, who had been admitted with a diagnosis of cerebral infarction and had severe memory impairment, was assessed as being at moderate risk for falls and low risk for wandering. Despite this, an elopement care plan and a wandering device (WMD) were initiated after the resident exhibited wandering behavior and attempted to leave the facility. However, the WMD was improperly placed on the resident's wheelchair instead of on the resident, and the elopement care plan did not document the reason for this placement. On the night of the incident, the resident was found missing from the facility, and staff discovered the resident outside on the sidewalk with injuries, including a fracture to the left thumb and abrasions to the face and knees. Interviews with facility staff revealed that the resident was not adequately supervised, and there was a breakdown in the system that allowed the resident to elope without staff knowledge. The Director of Nursing acknowledged the inaccuracies in the resident's wandering risk assessment and the improper use of the WMD, confirming the facility's responsibility for ensuring resident safety.