Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Broadway By The Sea during CMS and state inspections, most recent first.
A resident with impaired cognition and multiple medical conditions developed a documented fever that met criteria for a PRN acetaminophen order, but nursing staff did not administer the medication or document ongoing temperature monitoring and reassessment. An LVN acknowledged taking the resident’s temperature but did not document it, and the DON confirmed that staff failed to give the ordered acetaminophen and to continue monitoring the fever, contrary to the facility’s change-of-condition policy requiring assessment, documentation, and ongoing observation.
Two residents with cognitive impairment and multiple medical conditions did not receive their scheduled 9 a.m. medications within the facility’s required one-hour administration window. One resident’s ordered morning medications, including cardiovascular, diuretic, antiviral, and supplement therapies, were all given more than an hour and a half late. Another resident’s ordered Tamiflu dose was also administered more than an hour and a half after the scheduled time. An LVN reported being behind on the med pass due to multiple tasks, and another LVN cited delayed pharmacy delivery and acknowledged the duty to follow up. The DON and facility policy both specified that medications must be administered within 60 minutes of the scheduled time to ensure effectiveness and minimize side effects.
A resident with diabetes, rheumatoid arthritis, moderate cognitive impairment, and documented bilateral foot infection had a physician’s order for daily Ciclopirox cream to both feet for tinea pedis. Over multiple days, nursing staff documented repeated refusals of the ordered foot treatment in progress notes and on the TAR, but the physician and the resident’s POA were not notified after these ongoing refusals. The treatment nurse later acknowledged that notification should have occurred after the third refusal, and the DON confirmed that a change of condition process and notifications were required under facility policy. This failure resulted in the resident not receiving the ordered antifungal treatment for several days and, per the report, had the potential to cause infection, inflammation, and hospitalization.
Improper Food Storage and Labeling in Kitchen: Surveyors found a bag of mixed vegetables in the refrigerator without proper storage or an open date, along with a bag of sweet potato fries and a box of waffles in the freezer that were not stored properly; the fries also lacked an open date. The DS stated the mixed vegetables had been used for an omelet and the leftovers were forgotten without being labeled and dated. The RD stated kitchen foods needed delivery, open, and/or use-by dates and had to be covered and sealed, and the facility policy required refrigerated and frozen foods to be covered, labeled, and dated.
Advance directive documentation was incomplete for four residents. Two residents had capacity and their POLST forms lacked documentation showing the AD discussion or written information was provided, while two other residents had cognitive impairment and their Social Services assessments did not clearly show that representatives were informed of the right to formulate an AD. The SSD and DON acknowledged the missing documentation and the need for written AD information and completed POLST/assessment documentation.
Inaccurate MDS coding affected three residents. One resident with dysphagia, dementia, and enteral feed orders had an MDS that did not identify a feeding tube. Two other residents with orders for RNA programs had MDS assessments that did not show RNA participation, even though the MDSC stated they were receiving those services. The DON stated the MDS should accurately reflect the resident’s condition and the care being provided.
Failure to monitor and document intake and output for two residents with urinary catheters. One resident had a suprapubic catheter ordered for obstructive uropathy, with multiple missing I&O entries and some output recorded as frequency instead of measured volume; the resident was later transferred to a GACH for catheter leakage. Another resident with a Foley catheter had repeated missing I&O documentation across day, PM, and night shifts, despite orders to calculate 24-hour totals and monitor every shift.
Care plans were not updated for two residents to match current care needs. One resident with dementia and encephalopathy had a tube-feeding care plan that remained active even though he was eating by mouth and no longer had a tube-feeding order. Another resident with metabolic encephalopathy and BPH had a urinary retention care plan that still addressed catheter care even though his catheter had been discontinued and he was using a urinal. The DON and RNS both acknowledged the plans were incorrect and should have been revised when the residents’ conditions changed.
A resident with ESRD missed an ordered HD session because transportation did not occur, and the record lacked documentation of the missed treatment or a makeup session. Staff interviews showed the CM, SSD, and DON were not notified or involved in arranging follow-up. In a separate finding, another resident receiving HD did not have an emergency dialysis kit at the bedside, and staff could not locate it during observation.
Failure to Educate and Offer COVID-19 Vaccination: The facility did not document that a resident with COPD, RA, and severe cognitive impairment was educated about or offered the COVID-19 vaccine for the respiratory season, and there was also no documentation that staff were educated about or offered the vaccine. The IPN stated the facility was responsible for offering the vaccine to all residents and staff, and the DON stated consent forms serve as proof of education and offer.
A resident with DM, osteomyelitis, and a non-pressure ulcer did not receive the lunch tray at the same time as roommates, while the roommates had already received and finished lunch. The resident stated this had happened repeatedly. CNA forgot to serve the tray, and the RNS, DS, and DON acknowledged that meal trays are expected to be served at set times and that delayed tray delivery can affect resident dignity.
Call Light Not Within Reach for Resident With Left-Sided Weakness: A resident with cataracts, CVA, left-sided hemiplegia, and left-sided hemiparesis was observed with the call light under the pillow and out of reach. The resident stated he could not find it or reach it because he could not move his left side and needed it on his right side. The ADON confirmed the call light was not within reach, and the DON stated call lights should always be accessible.
A resident with anemia, dementia, and severe cognitive impairment refused a scheduled epoetin alpha injection, and the missed dose was not documented as reported to the physician. The MAR showed the dose was not given, and later the resident's hemoglobin was critically low. The DON stated the physician needed to be notified when the epoetin alpha injection was missed so the resident's meds or plan of care could be reviewed.
Failure to Report Injury of Unknown Origin: A resident with severe cognitive impairment and multiple medical diagnoses developed swelling in the lower thigh, and an x-ray later showed a distal femur fracture with no known fall or observed cause. The RNS stated the fracture should have been reported and investigated, and the DON acknowledged no report was made despite facility policy requiring injuries of unknown origin to be reported within 24 hours to CDPH and other required agencies.
Failure to Investigate Alleged Fall Incident: The facility did not follow its Fall Management System policy for a resident with right-sided hemiplegia and gait abnormalities by failing to investigate an alleged fall. Hospital ED paperwork received by the facility documented right arm and hand pain after a fall 7 days earlier, and the resident later stated she fell at the facility and injured her right hand. The DON stated the RN supervisor should have reviewed the hospital records and reported the fall so it could be investigated as an actual fall and probable causal factors identified.
Delayed RD Follow-Up for Poor PO Intake: A resident with encephalopathy and infective endocarditis had ongoing poor PO intake, with repeated meals eaten at 0-50% and several refusals. An RD consult was ordered after a change in condition for decreased appetite and fluid intake, but the RD was not notified and did not see the resident again after the prior nutrition visit. The DON confirmed the consult order was present and that the RD had not followed up.
Pain Assessment and Reassessment Not Documented: A resident with osteomyelitis, wounds, and amputations reported constant pain rated 6-7/10, poor sleep, and reduced participation in activities and therapy because pain was not relieved. Although the resident had orders for scheduled pain monitoring and PRN Tylenol and Norco, staff did not consistently document pain levels before and after Norco administration on the MAR or in PN. The RN supervisor and DON stated pain should be assessed and documented before and after medication to evaluate effectiveness, and the MDS reflected severe pain affecting sleep and daily activities.
Failure to Document Acetaminophen Administration: An LVN administered acetaminophen to a resident with intact cognition, metabolic encephalopathy, and kidney disease, but the dose was not documented on the MAR. The RNS confirmed there was no record of the administration, and the DON stated timely documentation is important to avoid duplicate dosing. The facility policy required the administering staff member to record the medication on the MAR after the med pass.
Diagnosis List Not Updated for Dementia: A resident’s chart did not reflect dementia on the current diagnosis list even though the MDS showed cognitive impairment and dementia, and the resident was receiving Memantine 5 mg BID for dementia. The DON confirmed the diagnosis was missing from the active list, and the ADM confirmed the facility had no P&P for documentation accuracy.
Failure to use required PPE during high-contact care: An RNA provided AAROM to a resident on EBP while wearing a mask and gloves but no gown. The resident had a suprapubic catheter and records identified EBP and PPE requirements for high-contact care; the RNA stated he did not know the resident was on EBP, while the IPN and DON stated gowns, gloves, and masks were required for high-contact resident care.
Resident Rooms Did Not Meet Required Square Footage: A record review showed multiple rooms housing two or three residents did not meet the required sq ft per resident, with several 3-resident rooms measuring 223 sq ft and several 2-resident rooms measuring 144 sq ft. The ADM stated room size was important for comfort, movement, daily activities, and safe transfers, and that inadequate space could make it unsafe for staff to maneuver residents. Observation found no issues with resident needs, and health and safety were not affected by room size.
A resident with diabetes and cognitive impairment did not receive prescribed Ciclopirox 8% for toenail fungus for two months due to the facility's failure to follow a podiatrist's orders. The medication was not administered because the orders were not transcribed or implemented, and delays in obtaining office visit notes contributed to the oversight. Staff confirmed the resident had not received the treatment as directed.
A resident with diabetes and cognitive impairment did not receive prescribed antifungal treatment for toenail fungus due to the facility's failure to obtain and act on physician visit summaries, resulting in a two-month lapse in care. Staff interviews revealed confusion about the process for securing and implementing physician orders, and the resident's condition persisted without appropriate treatment.
A resident with a history of mental and behavioral disorders exhibited ongoing depressive symptoms and had multiple physician orders for psychiatric evaluation, but was not seen by a psychiatrist for several months. Despite care plan interventions and repeated requests from the resident, staff failed to arrange timely psychiatric consults or monitor and document behavioral health status as required, resulting in worsening symptoms.
A resident with severe cognitive impairment and a history of falls was unable to access her call light, which was found out of reach during an observation. Facility staff, including the ADON and DON, confirmed that the call light should have been accessible as per the resident's care plan and facility policy.
A Licensed Vocational Nurse worked 61 shifts with an inactive license after mistakenly selecting the wrong renewal option and failing to verify her license status. The facility's HR department did not detect the lapse during required monthly verifications, allowing the nurse to continue working without a valid license until the issue was reported by the state licensing board.
Two residents with severe cognitive impairment and skin integrity issues did not receive timely or properly documented wound care. For one, daily wound treatments ordered by a physician were not recorded on the TAR for specific days. For the other, MASD was identified on admission but wound measurements were not documented and a barrier cream order was delayed by three days. Nursing staff and the DON confirmed these lapses, which were not in accordance with facility policy.
A resident at high risk for falls, with a history of atrial fibrillation and dementia, experienced significant injuries due to inadequate fall prevention measures. The care plan lacked specific interventions and was not updated after previous falls. Despite being on anticoagulant therapy, the resident was not provided with necessary supervision or monitoring, leading to a fall that resulted in a subdural hematoma and spinal fracture.
A resident with a history of cerebral infarction, dementia, and atrial fibrillation experienced three unwitnessed falls due to inadequate supervision in an LTC facility. Despite being identified as a high fall risk and requiring assistance for daily activities, the resident was not consistently monitored, particularly in the restroom. The care plan's interventions, such as frequent visual checks and assistance with transfers, were not effectively implemented, leading to repeated falls.
A facility failed to document and monitor the effectiveness of a 1:1 sitter intervention for a resident at high risk for falls, who had multiple diagnoses including dementia and atrial fibrillation. Despite requiring supervision for daily activities, there was no care plan or physician's order for the sitter, and staff did not document the resident's behaviors or the intervention's effectiveness. Interviews with staff revealed the resident frequently attempted to get up unassisted, highlighting the need for proper documentation and monitoring.
The facility failed to implement its Infection Prevention and Control Program by not ensuring all staff, including registry staff, were tested for COVID-19 according to local health department guidance. Registry staff did not perform COVID-19 tests before shifts, and only day shift staff received COVID-19 protocol in-services. The Infection Prevention Nurse was unaware of registry staff testing, and the Director of Nursing acknowledged the need for all staff to receive infection control training.
A resident with intact cognition and moderate assistance needs filed repeated grievances about lengthy call light response times, particularly during night shifts. Despite in-service training for staff, the issue persisted due to reliance on registry CNAs. The facility's grievance policy was not effectively implemented, and the recurring issue was not included in the QAPI plan for monitoring and prevention.
A resident with severe cognitive impairment and diagnoses of hydronephrosis and obstructive uropathy did not receive proper monitoring and treatment for their nephrostomy tube and suprapubic catheter. Physician orders required daily cleansing and monitoring for signs of infection, but these were not completed over a three-day period. Interviews with staff confirmed the oversight, and the facility's policy for placing treatment orders was not followed.
A resident at moderate risk for skin injury developed a Stage III pressure ulcer due to the facility's failure to implement a care plan intervention for repositioning every two hours. Despite the resident's medical history and risk factors, the facility did not adhere to its skin and wound management policy, leading to the development of the ulcer. Interviews and documentation revealed that the resident was not repositioned as required, and the care plan was not updated with necessary interventions.
Two residents' RNA programs were improperly modified by unqualified staff. One resident received unauthorized motorized exercises, while another had a splint applied without a physician's order. The facility's policies require licensed therapists to establish and modify RNA programs, but the RNAs acted independently, risking resident safety.
The facility failed to update informed consent for a resident receiving Seroquel and did not ensure a medical diagnosis for another resident prescribed Haloperidol. The first resident's informed consent did not match the current medication order, potentially leading to unnecessary medication. The second resident was prescribed Haloperidol without a documented diagnosis of schizophrenia, as required by facility policy.
A medication pass in an LTC facility resulted in a 22.58% error rate. Two residents were given chewable aspirin to swallow instead of chewing, and a resident with a G-tube received five medications mixed together, contrary to policy. The errors were acknowledged by an LPN and the DON, highlighting a failure to follow medication administration protocols.
A resident with a G-tube was administered five medications crushed and mixed together by an LVN, contrary to the facility's policy requiring separate administration. The medications were for hypertension, psychotic features, depression, and mood disorders. The DON confirmed the need for individual administration to ensure safety.
The facility failed to ensure safe medication handling and storage for two residents. A resident with severe cognitive impairment had an unidentified medication left at their bedside, which was deemed unsafe by staff. Additionally, an opened Budesonide Inhalation envelope lacked an open date, risking ineffective dosing for a resident with COPD. The facility's policy requires secure storage and adherence to manufacturer guidelines.
The facility failed to label open dates on seven seasoning containers and did not ensure proper hair net usage by a Dietary Aid, potentially risking food contamination.
An OTA, also serving as the DOR, independently conducted Joint Mobility Assessments for three residents, despite lacking the qualifications to do so without supervision from a licensed OT or PT. This practice was against the facility's policy and state regulations, which require such assessments to be performed by licensed therapists.
The facility failed to accurately document Restorative Nursing Aide services for two residents, leading to a deficiency in care. One resident did not receive documented passive range of motion exercises as ordered, while another had no documentation for splint application despite wearing it. The Director of Nursing acknowledged the importance of accurate documentation, but grouped orders led to confusion and inaccuracies.
The facility failed to document the annual review of their Infection Prevention and Control Program policies and procedures. Additionally, staff did not wear required PPE, such as isolation gowns, while providing care to residents on Enhanced Barrier Precautions. This included a resident with an indwelling medical device and another with a stage 3 pressure injury. Interviews confirmed the oversight, and the importance of following infection control protocols was acknowledged by staff.
A facility failed to conduct a quarterly IDT care conference for a resident with severe cognitive impairment, involving the resident's family member. The last documented conference was overdue, violating the resident and family's rights to be informed and participate in the care plan. The facility's policy required family involvement in care plan development, but this was not adhered to.
A resident with asthma and allergic rhinitis was observed self-administering medications without an assessment by the facility's interdisciplinary team. The facility's policy requires such an assessment to ensure safe medication practices, but no documentation was found to support the resident's capability to self-administer. Interviews with staff confirmed the lack of assessment and documentation.
A facility failed to assess and obtain informed consent and a physician's order for the use of bolsters as restraints for a resident with severe cognitive impairment. The oversight was identified during an observation, revealing that while side rails had the necessary documentation, the bolsters did not, violating the resident's rights.
A resident with severe cognitive impairment and multiple medical conditions was observed with a possible fracture in their left lower leg, but the facility failed to report this unknown injury to the CDPH. The administrator did not consider the incident reportable, despite the facility's policy requiring such injuries to be reported. The resident was taken to a hospital where the injury was noted, and a social work consult was conducted due to its unexplained nature.
A resident with advanced dementia was found with a potentially fractured leg, but the facility failed to investigate or report the injury to CDPH within the required timeframe. The administrator did not consider the incident reportable, and no investigation was documented by the previous DON. The interim DON acknowledged the reporting requirement, but the lack of timely action prevented CDPH from investigating the incident promptly.
A resident with schizoaffective disorder and bipolar disorder was readmitted to the facility without the required PASARR screening. The resident's MDS indicated moderate cognitive impairment, necessitating a Level II PASARR. Interviews with the ADON and DON confirmed the oversight, and the facility's policy mandates PASARR completion upon admission.
A resident with hemiplegia and contracture was observed wearing a splint without a documented care plan or order for its application. The RNA applied the splint daily, but both the RNA and OT confirmed the absence of necessary documentation. The interim DON highlighted the importance of care plans to prevent risks like skin breakdown, as per the facility's policy.
Failure to Administer PRN Antipyretic and Monitor Fever
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered care and monitoring for a resident who developed a fever. The resident was admitted with diagnoses including lack of coordination, dysphagia in the oropharyngeal phase, and urinary retention, and had moderately impaired cognitive skills for daily decision-making, requiring setup or cleanup assistance with eating, oral hygiene, and personal hygiene. The resident’s vital sign record showed a documented temperature of 100.1°F late in the evening, which met the threshold for a PRN order for acetaminophen 325 mg, two tablets by mouth every six hours as needed for fever greater than 100°F. However, there was no documentation that the resident’s temperature was monitored or reassessed after this elevated reading. Interview and record review revealed that the nurse on duty acknowledged the resident’s temperature was elevated from the previous shift and stated it was the licensed nurse’s responsibility to monitor any change of condition and elevated temperatures, to see if the temperature decreased, and to administer medication as ordered. The nurse reported taking the resident’s temperature but not having time to document it. The DON confirmed that licensed staff failed to administer the ordered acetaminophen for the fever and stated that licensed staff should assess, give medication as ordered, and continue monitoring for fever. Review of the facility’s change of condition/quality of care policy indicated that nurses are required to perform and document an assessment, implement existing orders or obtain new orders, and provide at least three days of observation and documentation for residents with a change in condition, which was not carried out in this case.
Late Administration of Scheduled Medications Outside One-Hour Window
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services by not administering scheduled 9 a.m. medications within the facility’s required one-hour before or after window for two residents. For the first resident, who had severe cognitive impairment and required substantial to maximal assistance with eating, oral hygiene, and personal hygiene, the admission and assessment records showed multiple diagnoses including type 2 diabetes with circulatory complications, hypertension, and dysphagia. The resident’s February medication orders included aspirin, ferrous gluconate, furosemide, metoprolol, a multivitamin, Tamiflu, spironolactone, and sacubitril-valsartan. Review of this resident’s Medication Audit Report for early February showed that on a specific date all eight of the resident’s 9 a.m. medications were administered at 11:27 a.m., which was 1 hour and 27 minutes after the scheduled time and outside the facility’s stated one-hour window. For the second resident, who had moderate cognitive impairment and required setup or clean-up assistance with eating, oral hygiene, and personal hygiene, the admission and assessment records documented diagnoses including lack of coordination, dysphagia in the oropharyngeal phase, and urinary retention. This resident had an order for Tamiflu 30 mg to be given twice daily for influenza. The Medication Audit Report for the second resident showed that on the same date the 9 a.m. Tamiflu dose was administered at 11:37 a.m., 1 hour and 37 minutes after the scheduled time, also outside the one-hour window. In interviews, one LVN stated that medications should be given one hour before or after the scheduled time and reported being behind on the medication pass due to having multiple tasks. Another LVN stated that the late administration for the second resident was due to a pharmacy delivery delay and acknowledged responsibility to follow up with the pharmacy if medications were not delivered on time. The DON confirmed that scheduled medications were to be administered within one hour before or after the scheduled time to ensure effectiveness and minimize side effects, and facility policy dated January 2017 specified that medications are to be administered within 60 minutes of the scheduled time unless otherwise specified by the prescriber.
Failure to Notify Physician and POA of Repeated Refusals of Antifungal Foot Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and power of attorney (POA) of repeated refusals of prescribed antifungal treatment for tinea pedis. The resident had diagnoses including diabetes mellitus and rheumatoid arthritis, was documented as alert and oriented in a history and physical, and had moderate cognitive impairment and an infection on both feet per the MDS. A physician’s order dated 11/6/2025 directed that Ciclopirox cream be applied to both feet once daily for tinea pedis. Progress notes documented that the resident refused treatment to both feet on 1/8/2026, 1/10/2026, 1/11/2026, and 1/12/2026, and the Treatment Administration Record showed refusals of the fungal treatment on 1/10/2026, 1/11/2026, and 1/12/2026. Despite these repeated refusals, the physician and the resident’s POA were not notified. During an interview, the treatment nurse stated he should have notified the physician and POA after the resident’s third refusal of the fungal treatment. In a concurrent interview and record review, the DON stated the treatment nurse should have completed a change of condition (COC) when the resident refused the foot fungal treatment for the third time so that the physician could be informed and a new plan of care considered, and that the POA should have been notified so they could talk to the resident about refusing care. The facility’s Change of Condition policy indicated that when a resident’s condition or care needs change, the nurse should use clinical judgment to contact the physician and notify the resident or resident representative of the change in condition and any changes in medical or nursing care. The failure to follow this process resulted in the resident not receiving the ordered treatment for four days and, as stated in the report, had the potential to cause infection, inflammation, and hospitalization.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store food in a sanitary manner to prevent growth of microorganisms for 74 of 84 residents. During a kitchen observation with the Dietary Supervisor, surveyors found a bag of mixed vegetables in the refrigerator that was not properly stored and did not have an open date label. In the freezer, a bag of sweet potato fries and a box of waffles were observed not to be stored properly, and the sweet potato fries also did not have an open date label. The Dietary Supervisor stated the mixed vegetables had been used for an omelet and that the leftovers had been forgotten without being labeled and dated. During an interview, the Registered Dietician stated that all food stored in the kitchen needed a delivery date, date opened, and/or use-by date so spoiled or poor-quality food would not be served to residents. The RD also stated that food items needed to be properly sealed and covered so they were not exposed to air, and that dietary staff were responsible for ensuring food was labeled, dated, and stored properly. The facility policy titled Food Receiving, labeling, and Storage stated that foods stored in the refrigerator or freezer were to be covered, labeled, and dated.
Advance directive documentation incomplete for four residents
Penalty
Summary
The facility failed to ensure that residents' medical records were up to date regarding advance directives for four sampled residents. The deficiency involved Resident 2, Resident 8, Resident 11, and Resident 86, and centered on whether written information about the right to formulate an advance directive was provided and whether the discussion was documented in the resident record or POLST form as required by facility policy. For Resident 2, the record showed the resident was admitted with sepsis, ESRD, and dialysis dependence, and the H&P indicated the resident had capacity to understand and make decisions. The POLST dated 11/4/2025 had section D left blank for advance directive availability and discussion. The SSD later stated she verbally educated the resident about the right to formulate an AD, but had no written evidence that written information was provided, and acknowledged she should have provided written information and documented the discussion on the POLST. For Resident 8, the record showed admission for osteomyelitis of the right ankle and foot, an unstageable sacral pressure ulcer, and surgical removal of fingers and left toes. The H&P indicated the resident had capacity to understand and make decisions. The POLST dated 8/1/2025 indicated no AD and contained no documentation of discussion with the resident or decision maker. The SSD stated she verbally educated the resident, but could not provide evidence that written education was given and stated the POLST section regarding discussion with the resident or decision maker should have been documented. For Resident 11, the H&P indicated the resident was not alert and oriented, was forgetful, an inaccurate historian, and unable to make medical decisions; the Social Services assessment stated the resident and/or representatives had been informed of the right to formulate advance directives, but did not indicate whether the representative had been informed. For Resident 86, the MDS showed severe cognitive impairment for daily decision making, and the Social Services assessment stated the resident and/or representatives had been informed, but did not indicate whether the representative had been informed. The SSD stated the assessments were not clear whether the representatives for Residents 11 and 86 had been informed of the right to formulate an AD.
Inaccurate MDS Coding for Feeding Tube and RNA Services
Penalty
Summary
The facility failed to provide accurate information in the MDS for three sampled residents. For Resident 11, the admission record showed diagnoses of dysphagia, HTN, and dementia, and the order summary showed enteral feedings of Glucerna 1.5 twice daily through a feeding regimen. However, the MDS dated [DATE] indicated the resident was rarely or never understood, the brief interview for mental status was not done for daily decision making, and the resident required supervision or maximal assistance with several areas of care, but it did not identify that the resident had a feeding tube such as a nasogastric or abdominal tube for nutritional approaches while in the facility. For Resident 33, the admission record showed diagnoses of spinal stenosis, COPD, hemiplegia, and hemiparesis. The order summary dated 10/10/2025 indicated an RNA program for both lower extremities with AAROM using a cycle every day two times a week or as tolerated. The MDS dated [DATE] described the resident as having intact cognitive skills for daily decision making and needing maximal assistance with self-care and moderate assistance with mobility, but it did not indicate participation in the RNA program. For Resident 86, the admission record showed diagnoses of anemia, benign neoplasm of the parotid gland, and DM. The order summary dated 10/18/2025 indicated an RNA program for AAROM of both upper and lower extremities with a cycle three times a week or as tolerated. The MDS dated [DATE] described severe cognitive impairment for daily decision making and need for maximal assistance with self-care and moderate assistance with mobility, but it did not indicate participation in the RNA program. During interview, the MDSC stated that Resident 33 and Resident 86 were getting RNA services and that if it was not documented that residents received the 15-minute session, then the RNA services were not done. The MDSC also stated Resident 11's MDS was miscoded, and the DON stated accurate MDS coding was important because it reflected what the resident had and the care being provided.
Failure to Monitor and Document Intake and Output for Two Residents with Urinary Catheters
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two sampled residents related to monitoring and documenting intake and output for urinary drainage devices. For Resident 71, the record showed admission and re-admission for sepsis, acute pyelonephritis, and chronic kidney disease, with fluctuating capacity to understand and make decisions. Resident 71 had a suprapubic catheter to a closed drainage system ordered for obstructive uropathy, and the order summary required calculation of total 24-hour intake and output on every night shift. During record review with the RNS, the MAR for Resident 71 showed missing intake and output documentation on multiple dates, and on several dates the output was documented as a frequency count instead of a measured amount in milliliters. The RNS stated the resident had been transferred to a GACH due to leakage of the suprapubic catheter, and the PCP had emphasized the importance of accurate intake and output monitoring to prevent complications such as blockage and leakage. The care plan also included a focus on risk for UTI with interventions to monitor intake and output. For Resident 49, the MAR showed orders to calculate total 24-hour intake and output on the PM shift every night and to monitor intake and output every shift for use of a Foley catheter, but documentation was missing on multiple day, evening, and night shifts across the reviewed dates. During interview, Resident 49 stated he had a urinary catheter because he could not urinate like before and had trouble urinating with recurrent UTIs. The MDSC stated accurate intake and output documentation was important to ensure kidney function was functioning properly and that missing output documentation meant the monitoring was not done. The DON stated care plans are person centered and interventions must be followed, and that inaccurate intake and output documentation could leave staff unaware of urine retention and compromise kidney function.
Care plans not revised to match current nutrition and urinary status
Penalty
Summary
The facility failed to ensure the comprehensive care plans for two sampled residents were revised to reflect their current plan of care. Resident 5 had diagnoses including dementia and encephalopathy and had an active care plan for tube feeding initiated for dysphagia and weight loss, with interventions for Glucerna 1.5 via gastrostomy tube at 75 ml per hour for 20 hours a day. However, the resident’s current physician orders showed he had been eating by mouth since 11/20/2025 and no longer had an order for tube feeding, while the care plan still reflected ongoing tube feeding. The DON acknowledged the care plan was not correct and stated it should have been revised when the resident’s status changed. Resident 6 had diagnoses including metabolic encephalopathy, chronic kidney disease, and BPH. The resident’s MDS showed intact cognition and varying levels of assistance with ADLs. During observation and interview, the resident stated he previously had a urinary catheter but now used a urinal, and no catheter bag was observed. Record review and interview with the RNS confirmed the urinary catheter had been discontinued on 11/20/2025, yet the care plan titled for risk for urinary retention related to BPH still included interventions for catheter care and catheterization. The RNS stated the care plan was incorrect and should have been revised when the catheter was removed.
Missed HD Treatment and Missing Emergency Dialysis Kit
Penalty
Summary
The facility failed to ensure a resident with ESRD and dependence on dialysis received hemodialysis twice a week as ordered. Resident 2 was admitted and re-admitted with sepsis, ESRD, and dependence on dialysis, and the H&P indicated the resident had capacity to understand and make decisions. The MDS showed the resident required assistance with multiple activities of daily living. During interview, Resident 2 stated he was scheduled for HD on Monday and Friday, missed the Friday appointment because no one came to pick him up, and no makeup session had been arranged. Record review and staff interviews confirmed the missed HD session and lack of follow-up documentation. The OSR showed HD was ordered for Monday and Friday with a pickup time of 1:15 p.m. The DCDC log had no documentation for the missed treatment date, and the RNS stated there was no documentation explaining why the resident missed HD and no makeup session was scheduled. The CM stated she thought the resident may have refused HD, but there was no documentation, and she did not arrange a makeup session. The SSD stated she was not notified of the missed HD session and that staff should have followed up and notified her so a makeup session could be arranged. The DON stated staff should have followed through with HD appointments and notified the doctor when the resident missed treatment. The facility also failed to ensure a resident receiving HD had an emergency kit at the bedside. Resident 3 had ESRD, dependence on HD, and type 2 diabetes mellitus, and the physician's orders required HD three times weekly. During interview and observation, Resident 3 stated he had not seen an emergency dialysis kit in his bedside drawer. The LVN searched the bedside table, drawers, and closet and could not find an emergency kit, and the ADON stated they did not know where it was. The DON stated Resident 3 should have had an emergency kit at the bedside, and the facility policy stated problems with the access site such as excessive bleeding should be addressed immediately.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to educate and offer the COVID-19 vaccination for the 2025-2026 respiratory infection season to one sampled resident and to staff, and failed to properly document vaccination status. Resident 7 was admitted with COPD with acute exacerbation and rheumatoid arthritis, and the MDS dated 11/28/2025 indicated severe cognitive impairment and dependence on staff for several activities of daily living. During a concurrent interview and record review with the Infection Prevention nurse, the resident’s record showed no documentation that Resident 7 was offered the COVID-19 vaccination for the season or educated on the risks and benefits of receiving it. During the same review, the facility’s COVID vaccination log for staff also showed no documentation that staff were offered the COVID-19 vaccination for the 2025-2026 respiratory infection season or educated on the risks and benefits of receiving it. The Infection Prevention nurse stated the respiratory season runs from October 1 through March 31 and that it was the facility’s responsibility to offer the vaccinations to all residents and staff. The DON stated the vaccination consent form is proof that residents and staff were educated and offered the vaccination. The facility policy on Immunizations, COVID-19 stated residents are to be informed about the benefits and risks of immunizations, given the opportunity to receive the COVID-19 vaccine unless contraindicated, refused, or already immunized, and that refusals are to be documented in the electronic medical record.
Delayed Meal Tray Delivery
Penalty
Summary
The facility failed to ensure that Resident 31 received the meal tray at the same time as the resident's roommates, affecting the resident's dignity. Resident 31 was admitted with diagnoses including DM, osteomyelitis of the left ankle and foot, and a non-pressure ulcer of the left heel and midfoot. The MDS dated 12/20/2025 indicated the resident could make self understood and understand others, was independent with eating and oral hygiene, and required extensive assistance with transfers, dressing, toilet use, personal hygiene, and bathing. A physician order dated 12/27/2025 specified a consistent carbohydrate, no added salt, 80-gram regular protein diet. During lunch observation on 1/7/2026 at 12:58 p.m., Resident 31 had not received the lunch tray at the scheduled meal service time while roommates Resident 3 and Resident 23 had received and completed lunch. In an interview shortly afterward, Resident 31 stated the meal tray was frequently delivered later than the roommate's and that this had been an ongoing issue affecting timely receipt of meals. During a concurrent observation and interview, CNA 2 stated she forgot to serve the lunch tray to Resident 3. RNS 1 stated meal tray service occurred at set times and that failure to deliver trays as scheduled may negatively impact nutrition and dignity. The DS also stated the warm food cart is delivered to each nurses' station 10 minutes before tray pass and that failure to deliver trays as scheduled can affect resident dignity. The DON reviewed the facility's Resident Rights policy and stated CNAs should uphold dignity by ensuring food trays are served warm to all residents at the same time as their roommates.
Call Light Not Within Reach for Resident With Left-Sided Weakness
Penalty
Summary
The facility failed to ensure the call light device was within reach for one resident who had been admitted with cataracts, CVA with left-sided hemiplegia, and left-sided hemiparesis. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the MDS showed the resident required extensive assistance for multiple activities of daily living, including dependent assistance for bathing and transfers, maximal assistance for bed mobility, dressing, and toilet hygiene, and setup assistance for eating and oral hygiene. During a concurrent observation and interview, the resident’s call light was found under the pillow, and the resident stated he could not find it and could not reach it because he could not move his left side and needed it placed on his right side. The ADON observed that the call light was not within reach and stated it should be placed within reach on the resident’s right side due to left-sided weakness. The DON stated call lights should always be accessible and within the resident’s reach. The resident’s care plan identified fall risk related to CVA with left-sided weakness, cataracts, and balance problems, and included an intervention to keep the call light within reach and encourage use for assistance.
Failure to Notify Physician of Missed Anemia Medication
Penalty
Summary
The facility failed to notify the physician when Resident 9 refused a scheduled epoetin alpha injection. Resident 9 was admitted and readmitted with diagnoses including cerebral infarction, osteoarthritis, anemia, and dementia, and the MDS dated 11/22/2025 indicated severe cognitive impairment with assistance needed for eating, oral hygiene, toileting hygiene, and bathing. During review of the medical record, Registered Nurse Supervisor 1 confirmed that Resident 9 had an order for epoetin alpha injection 10,000 units/mL every Tuesday for anemia, but the January 2026 MAR showed the dose scheduled for 12/23/2025 was not given. RNS 1 stated there was no documentation that the physician was notified of the missed dose. RNS 1 also reviewed Resident 9's change of condition documentation and noted that on 12/29/2025 the resident's hemoglobin was critically low at 6.1 g/dL, and later that day it was critically low at 5.8 g/dL. RNS 1 stated the facility should have notified the physician of the missed epoetin alpha dose because it could have caused the hemoglobin to drop. The DON stated it was important to notify the physician when Resident 9 refused the epoetin alpha injection so the physician could decide whether medications or the plan of care needed to be updated, and that missed epoetin alpha in a resident with anemia could lead to low hemoglobin and additional care such as a blood transfusion.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse reporting and prevention policy by not reporting a resident’s injury of unknown origin to CDPH and other required officials, including the Long-Term Care Ombudsman, Law Enforcement, and the Licensing Agency. The deficiency involved one sampled resident who had been admitted and later readmitted with diagnoses including cerebral infarction, osteoarthritis, anemia, and dementia. The resident’s MDS dated 11/22/2025 indicated severe cognitive impairment, setup assistance for eating and oral hygiene, moderate assistance for toileting hygiene, and maximal assistance for bathing. On 12/29/2025, the resident developed swelling to the right lower thigh, and an x-ray was ordered. Later that day, the x-ray showed a fracture of the distal femur, and the physician ordered transfer to a general acute care hospital due to the right leg fracture. During interview and record review, the RNS stated there was no indication the resident had fallen and that the cause of the fracture should have been reported and investigated because it was not normal to have a bone fracture. The DON stated the facility’s policy required reporting injuries of unknown origin within 24 hours and acknowledged no report had been made. The Administrator reviewed the abuse policy and the unusual occurrence reporting policy, both of which required reporting unusual occurrences and injuries of unknown source within 24 hours to the appropriate agencies.
Failure to Investigate Alleged Fall Incident
Penalty
Summary
The facility failed to follow its Fall Management System policy for Resident 27 by not investigating an allegation of a fall incident. Resident 27 was admitted and later readmitted with diagnoses including right-sided hemiplegia and abnormalities of gait and mobility. A Transfer Out Progress Note documented that the resident was alert, oriented, able to make needs known, and complained of right-hand pain radiating to the right shoulder, leading to transfer to a general acute care hospital for evaluation. The hospital emergency department paperwork received by the facility stated that Resident 27 presented with right arm and hand pain status post a fall 7 days prior, and that the resident fell backwards onto the right hand with the palm up. During an interview, Resident 27 stated she fell around the end of October at the facility and hurt her right hand. The DON reviewed the hospital record and stated she had not been aware of the incident, that the RN supervisor who readmitted the resident should have reviewed the hospital records and reported the fall, and that the facility should have investigated the allegation as an actual fall. The facility policy stated that review of all fall incidents would include an investigation to determine probable causal factors.
Delayed RD Follow-Up for Poor PO Intake
Penalty
Summary
The facility failed to ensure a timely RD evaluation for a resident with poor PO intake after an RD consult order was placed. Resident 16 was admitted with diagnoses of encephalopathy and infective endocarditis, and the admission record did not list dementia. The MDS dated 12/8/2025 indicated moderate cognitive impairment, no weight loss, and a mechanically altered therapeutic diet. The nutrition evaluation from 12/4/2025 documented poor PO intake, that intake would continue to be monitored, and that nursing staff was to notify the RD of significant changes. The resident’s records showed ongoing poor intake throughout December and early January, including multiple meals eaten at 0-25%, 26-50%, refusals, and several undocumented meal percentages. An SBAR summary dated 12/8/2025 documented a change in condition due to poor PO intake with decreased appetite and fluid intake, and the physician placed an RD consult order that same day. During interview, the RD stated the resident had not been seen again after the 12/4/2025 encounter and was not aware of the consult order because nursing staff did not inform the RD team. The DON confirmed the consult order was in the chart and that the resident had not been seen by the RD after the order was placed.
Pain Assessment and Reassessment Not Documented
Penalty
Summary
The facility failed to ensure effective pain management for one resident who had osteomyelitis of the right ankle and foot, an unstageable sacral pressure ulcer, and surgical removal of fingers and left toes. The resident was admitted with capacity to understand and make decisions, required extensive assistance with activities of daily living, and reported constant pain related to infected foot wounds and amputations. During observation and interview, the resident stated his pain was 6 or 7 out of 10, that it had never been zero even after pain medication, and that he could not sleep well and did not want to participate in activities or therapy because the pain was not relieved. The resident had physician orders to monitor pain every shift and to administer Tylenol for mild pain and Norco for moderate to severe pain. The RN supervisor stated staff should assess and document pain before and after giving pain medication to evaluate effectiveness. Review of the MAR showed pain was documented as 0 every shift except one shift with no pain level recorded, and Norco was administered on multiple days, but there was no documentation of pain level before and after administration on the MAR. The RN supervisor stated the actual pain level should have been documented before and after Norco was given. The MDS indicated the resident received PRN pain medication, had occasionally experienced pain, and that pain occasionally made it hard to sleep, limited participation, and limited day-to-day activities, with a numeric pain rating of 8 out of 10. The MDS coordinator stated the resident had severe pain affecting sleep and daily activities. The DON reviewed progress notes and stated there were no documented pain levels after Norco on multiple dates, that pain should be assessed and documented before and after administration to evaluate effectiveness, and that re-assessment after administration was not documented consistently. The resident’s care plan addressed pain related to the surgical incision, wound, and infection and included monitoring and documenting pain characteristics and assessing pain every shift.
Failure to Document Acetaminophen Administration
Penalty
Summary
The facility failed to document medication administration for one of three sampled residents, Resident 6. Resident 6 was admitted with diagnoses including metabolic encephalopathy and kidney disease. The MDS dated 11/4/2025 indicated Resident 6's cognition was intact and that the resident required supervision for eating and oral hygiene, moderate assistance for upper body dressing, maximal assistance for toileting hygiene and bathing, and was dependent for lower body dressing. Resident 6 had a physician order for acetaminophen 325 mg, two tablets by mouth every four hours as needed for generalized pain, not to exceed 3 grams in 24 hours from any acetaminophen sources. During observation on 1/7/2026 at 9:08 a.m., an LVN administered two tablets of acetaminophen to Resident 6 for a complaint of pain. During later record review, the RNS stated there was no documentation on the MAR showing Resident 6 received acetaminophen, and the DON stated it was important to document medication administration when the medication is administered. The facility policy stated the person administering the medication records the administration on the MAR after the medication pass is completed.
Diagnosis List Not Updated for Dementia
Penalty
Summary
The facility failed to ensure that Resident 16’s diagnosis list was updated to include dementia. Resident 16 was admitted with diagnoses of encephalopathy and infective endocarditis, but dementia was not listed as one of the resident’s current diagnoses in the admission record. A review of the resident’s MDS dated 12/8/2025 showed moderate cognitive impairment and indicated dementia, even though dementia still was not reflected on the current diagnosis list. During an interview and concurrent record review on 1/8/2026, the DON reviewed the resident’s active physician orders and confirmed that Resident 16 was receiving Memantine 5 mg twice daily for dementia. The DON also confirmed that dementia was not listed on the current diagnoses list and stated that it was important for the diagnosis list to be updated to reflect all current diagnoses so residents receive proper treatments and medications. The administrator confirmed by email on 1/13/2025 that the facility did not have a policy and procedure for accuracy of documentation.
Failure to Use Required PPE During High-Contact Care
Penalty
Summary
The facility failed to implement infection control measures when RNA 1 did not wear a gown while providing high-contact care to Resident 71, who was on Enhanced Barrier Precaution (EBP). During a concurrent observation and interview, RNA 1 was performing active assisted range of motion to the resident’s right leg while wearing a face mask and gloves, but no gown. RNA 1 stated he did not know the resident was on EBP because of a suprapubic catheter, and acknowledged that he should have worn a gown because the activity involved high contact with the resident and could spread infection. Resident 71’s record showed admission and re-admission for sepsis, acute pyelonephritis, and chronic kidney disease, with fluctuating capacity to understand and make decisions. The resident’s MDS indicated dependence or assistance with multiple activities of daily living, and the OSR and care plan identified EBP and PPE requirements due to an indwelling suprapubic catheter. The IPN stated staff should wear a mask, gown, and gloves before high-contact activities such as bathing, hygiene care, transferring, and providing AAROM for residents on EBP, and the DON stated EBP required a mask, gown, and gloves before high-contact resident care.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that multiple resident rooms met the required square footage per resident. A record review of the facility's client accommodation analysis form showed that rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 19, 21, 24, 25, 27, 29, 37, and 39 each accommodated three residents but measured 223 sq ft, and rooms 18, 20, 22, 28, 30, 31, 32, 33, 34, 35, and 36 each accommodated two residents but measured 144 sq ft. During interview, the Administrator stated that room size was important for resident comfort, movement, daily activities, and safe transfers, and noted that inadequate room size could make it unsafe for staff to maneuver residents. During observation from 1/5/2026 to 1/8/2026, no issues were observed with resident needs, and health and safety were not affected by the room size.
Failure to Administer Prescribed Antifungal Medication for Toenail Fungus
Penalty
Summary
The facility failed to follow a physician's order for a resident who was under the care of a podiatrist for onychomycosis (nail fungus) of the great toes. The resident, who had a history of type 2 diabetes and moderate cognitive impairment, was prescribed Ciclopirox 8% nail lacquer to be applied daily to the affected toenails. Despite ongoing orders from the podiatrist to continue this treatment for six months to one year, the medication was not administered to the resident for a period of two months. Observations revealed that the resident's right and left great toes appeared thick and discolored, and the resident reported pain and emotional distress related to the condition of her toenails. Multiple office visit notes from the podiatrist documented the need for continued application of Ciclopirox 8% and highlighted the lack of improvement in the resident's condition. However, the treatment nurse confirmed that the resident had not been receiving the medication for some time, and the Assistant Director of Nursing acknowledged that the orders for Ciclopirox 8% were not present in the resident's chart and had not been implemented since mid-July. The delay in obtaining and reviewing the podiatrist's office visit notes contributed to the failure to transcribe and carry out the physician's orders in a timely manner. The facility's staff, including the ADON and DON, recognized that the absence of the medication order and the lack of follow-through on the podiatrist's recommendations resulted in the resident not receiving the prescribed treatment for her toenail fungus.
Failure to Obtain and Implement Physician Orders for Antifungal Treatment
Penalty
Summary
The facility failed to obtain and act upon Office Visit Summaries from outpatient physician visits for a resident, resulting in a lapse in prescribed treatment for onychomycosis (toenail fungus) of both great toes. The resident, who had a history of type 2 diabetes and moderate cognitive impairment, was under ongoing care for toenail fungus, with orders from an outside podiatrist to continue Ciclopirox 8% External Solution for an extended period. Despite these orders, the facility did not secure timely documentation from the podiatrist visits on two occasions, leading to a gap in the resident's treatment regimen. Observations and record reviews revealed that the resident's toenails remained thick and discolored, and the resident experienced emotional distress and depression related to the condition. Progress notes indicated that family members raised concerns about the toenails, and the wound care specialist confirmed the diagnosis of onychomycosis. Although the podiatrist provided clear instructions to continue the antifungal treatment, the facility did not maintain current orders for the medication, and the treatment was not administered for approximately two months. Interviews with facility staff, including the treatment nurse, Assistant Director of Nursing, and Director of Nursing, confirmed that there was confusion and lack of awareness regarding the process for obtaining and following up on Office Visit Notes. The Office Visit Summaries were not present in the resident's chart in a timely manner, and staff were unaware that the orders for Ciclopirox 8% had lapsed, resulting in the resident not receiving the prescribed treatment. The delay in obtaining and implementing physician orders led to a failure to provide appropriate care as directed by the resident's physician.
Failure to Provide Timely Psychiatric Evaluation and Monitoring for Depression
Penalty
Summary
The facility failed to ensure that a resident exhibiting signs and symptoms of depression received necessary behavioral health care and services as ordered. The resident, who had a history of mental and behavioral disorders, was admitted with diagnoses including a history of trauma and a colostomy. Multiple assessments and care plans identified the resident as being at risk for depression, with documented symptoms such as loss of interest in activities, excessive sleepiness, and feelings of sadness. Orders for psychiatric evaluation were placed on three separate occasions, but there was no documentation that the resident was seen by a psychiatrist until several months after the initial order. Despite clear care plan interventions requiring psychiatric consultation and monitoring of depressive symptoms, the facility did not arrange for timely psychiatric evaluations or consistently monitor and document the resident's behavioral health status. Interviews with the resident revealed ongoing depressive symptoms, including a desire to sleep all day, loss of interest in activities, and emotional distress. The resident reported communicating these feelings to staff and requesting psychiatric support, but did not receive the ordered consults in a timely manner. Staff interviews indicated a lack of awareness and follow-through regarding outstanding psychiatric consult orders. The Social Services Director was unaware of previous consult orders and did not document pending psychiatric visits. The Assistant Director of Nursing and Director of Nursing confirmed that the psychiatric consults were not completed as ordered and that there was no behavior monitoring as outlined in the care plan. The facility's own policy required provision of necessary behavioral health services and timely referrals, but these were not carried out, resulting in the resident experiencing worsening depressive symptoms.
Call Light Not Accessible to Resident with High Fall Risk
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. During an observation, the resident was seen searching for her call light, which was found wedged between the mattress and fitted sheet, out of her reach. The Assistant Director of Nursing confirmed that the call light was not accessible and acknowledged that it should have been within the resident's reach for safety reasons. The Director of Nursing also stated that call lights should be accessible to residents to allow them to request assistance in a timely manner. The resident involved had a history of neurocognitive disorder with Lewy bodies, adult failure to thrive, a history of falls, and severely impaired cognition. Her care plan specifically identified her as being at high risk for falls and required that her call light be placed within reach and that she be encouraged to use it for assistance. The facility's policy also required staff to ensure the call device was accessible before leaving the room. The failure to follow these protocols resulted in the resident being unable to call for help when needed.
Plan Of Correction
F550 Corrective Action Assigned CNA was inserviced 1:1 by DSD on 05/27/25 on Resident Rights, including the importance of keeping the call light within reach at all times. Assigned LVN was inserviced 1:1 by DSD on 05/27/25 on Resident Rights, including the importance of keeping the call light within reach at all times. Identification of Others at Risk All residents of this facility have the potential to be affected by this deficiency. The DSD has made observation rounds on 05/27/25 on call lights being within reach. All call lights were within reach. Process to Prevent Recurrence The DON and DSD have inserviced nursing and facility staff between 05/27/25 and 05/30/25 on Resident Rights, including the importance of keeping the call light within reach at all times. The Guardian Angels will observe the placement of the call lights during their routine rounds. Results will be reported to the Administrator for any needed follow-up. Monitoring Process The Administrator will provide results of the observation rounds to the QA&A committee during the monthly meeting. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 06/12/25
LVN Worked Multiple Shifts with Inactive License Due to Lapse in Verification
Penalty
Summary
The facility failed to ensure that one of its Licensed Vocational Nurses (LVN) maintained an active license in accordance with state law. Review of records showed that the LVN worked a total of 61 shifts over a period of several months while her license was inactive due to failure to renew. The issue was discovered when the Director of Nursing (DON) was notified by the state licensing board that the LVN's license was inactive. The LVN had mistakenly selected the inactive option instead of renewal during the online renewal process and did not verify the status of her license, assuming it was renewed because her payment was processed. The facility's policy required Human Resources (HR) to verify employee licenses upon hiring and monthly thereafter, and to notify the facility of any approaching expiration dates or inactive licenses. However, the HR department did not identify that the LVN's license had become inactive, and the LVN continued to be scheduled and worked multiple shifts without a valid license. The deficiency was identified through interviews and review of timecards, licensing records, and facility policies.
Plan Of Correction
Corrective Action LVN 2: LVN license was updated to active on 05/08/2025. Identification of Others at Risk All residents of this facility have the potential to be affected by this deficiency. A review of 25 RN and LVN licenses status has been done by the DON on 05/06/2025. All licenses were active. Process to Prevent Recurrence The DON has inserviced the licensed nurses between 05/7/2025 and 5/10/2025 on the importance of keeping their nursing license active. The DON/designee will check the status of the licensed nurses' licenses monthly X3 months and annually thereafter. Results of monthly review will be reported to QA&A committee. Monitoring Process The DON will report the results of the nursing license reviews to the QA&A committee monthly. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting x3 months. Complete Date: 06/11/2025
Failure to Document and Timely Intervene in Wound Care and Skin Integrity
Penalty
Summary
The facility failed to provide and document appropriate wound care and prevention measures for two residents with significant skin integrity issues. For one resident admitted with a stage 4 pressure ulcer of the sacral region and severe cognitive impairment, physician orders directed daily wound care using normal saline, medical-grade honey, and foam dressing. However, there was no documentation in the Treatment Administration Record (TAR) indicating that these treatments were provided on specific dates as ordered. Another resident, also with severe cognitive impairment and dependent on staff for hygiene, was admitted with moisture-associated skin damage (MASD) to the sacral region and buttocks. Upon admission, the initial nursing assessment identified MASD but did not document wound measurements or type, failing to establish a baseline for monitoring. Additionally, although MASD was identified on admission, a physician order for barrier cream was not obtained until three days later, delaying appropriate intervention. Interviews with nursing staff and the Director of Nursing confirmed that wound measurements should have been documented upon admission and that barrier cream should have been ordered and applied immediately when MASD was identified. The facility's own policy requires timely assessment, documentation, and intervention for skin injuries, as well as documentation of treatments as they are administered. These requirements were not met for the two residents in question.
Plan Of Correction
Corrective Action Resident 1: was discharged on 12/3/2024. Resident 2: returned from the hospital on 4/29/25. Treatments are in place for all skin conditions. Identification of Others at Risk All residents of this facility that have skin conditions have the potential to be affected by this deficiency. The Medical Records Director has reviewed the TARs for the month of May. 16 active residents with skin conditions were identified. Treatment orders were documented, no further follow-up needed. The DON has reviewed the TARs for the month of May and compared skin conditions identified upon admission against the TAR for 8 active residents. Skin conditions identified upon admission had treatment orders in place. No further follow-up was needed. The DON has inserviced the licensed nurses and the Skin IDT Committee members between 5/16/25 and 5/20/25 on the facility policy Skin And Wound Monitoring and Management, including identifying and documenting skin conditions upon admission and starting those treatments timely, and the need to document skin treatments when provided on the TAR. The Medical Records Director will review the TARs daily (M-F) for 30 days for completion. Results will be forwarded to the DON for needed follow-up. The DON/Designee will review daily (M-F) newly admitted residents to ensure that identified skin conditions have treatment orders in place. Monitoring Process The DON will provide results of the daily skin reviews to the QA&A committee during the monthly meeting for 3 months. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 5/20/2025 The DON has inserviced the licensed nurses and the Skin IDT Committee members between 5/16/25 and 5/20/25 on the facility policy Skin And Wound Monitoring and Management, including identifying and documenting skin conditions upon admission and starting those treatments timely, and the need to document skin treatments when provided on the TAR. The Medical Records Director will review the TARs daily (M-F) for 30 days for completion. Results will be forwarded to the DON for needed follow-up. The DON/Designee will review daily (M-F) newly admitted residents to ensure that identified skin conditions have treatment orders in place. Monitoring Process The DON will provide results of the daily skin reviews to the QA&A committee during the monthly meeting for 3 months. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 5/20/2025
Failure to Implement Effective Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as a high risk for falls, was adequately protected from falls and injuries. The resident's care plan, dated 7/5/2024, did not include specific interventions to prevent falls, and it was not reviewed or revised after the resident experienced a fall on 8/20/2024. Despite being on anticoagulant therapy, which increased the risk of bleeding, the care plan lacked detailed precautions to prevent falls and related injuries. The resident, who had a history of atrial fibrillation, repeated falls, and dementia, was admitted to the facility with a medium fall risk score. However, the care plan identified the resident as a high fall risk due to recurrent falls and attempts to get up unassisted. The facility's policy required individualized care plans with measurable objectives and timeframes for residents at risk of falls, but this was not implemented effectively for the resident. The resident's fall on 10/24/2024 resulted in significant injuries, including a subdural hematoma and a spinal fracture, necessitating hospitalization and surgical interventions. Interviews with facility staff revealed that the resident required frequent monitoring and supervision due to poor safety awareness. However, the care plan did not include measures such as assigning a 1:1 sitter or implementing frequent visual checks, which could have mitigated the risk of falls. The Director of Nursing acknowledged that these interventions should have been part of the care plan, indicating a lapse in the facility's adherence to its fall management policy.
Inadequate Supervision Leads to Multiple Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who was at high risk for falls, resulting in three unwitnessed falls within a month. The resident, who had a history of cerebral infarction, dementia, and atrial fibrillation, required supervision or assistance for activities of daily living and was on anticoagulant medication, increasing the risk of complications from falls. Despite being identified as a high fall risk, the resident was not consistently monitored, particularly while using the restroom, leading to multiple incidents of falling. The resident's care plan included interventions such as frequent visual checks and assistance with transfers, but these were not adequately implemented. On several occasions, the resident attempted to go to the bathroom unassisted, resulting in falls. Interviews with staff revealed inconsistencies in understanding the resident's need for 1:1 supervision, with some staff providing privacy without maintaining visual contact, contrary to the care plan requirements. The facility's policy on fall management emphasized the need for an environment free of accident hazards and appropriate interventions to prevent falls. However, the lack of consistent supervision and adherence to the care plan contributed to the resident's repeated falls. The Director of Nursing acknowledged that frequent monitoring and visual checks were necessary to reduce the risk of falls, but these measures were not effectively implemented for the resident.
Failure to Document and Monitor Sitter Intervention for Fall-Risk Resident
Penalty
Summary
The facility failed to document and monitor the effectiveness of interventions for a resident at high risk for falls, who was assigned a 1:1 sitter. The resident, who had diagnoses including cerebral infarction, dementia, and atrial fibrillation, was admitted with fluctuating decision-making capacity and mild cognitive impairment. Despite requiring supervision for activities of daily living, the facility did not have a care plan or physician's order for the sitter, and there was no documentation of the sitter's effectiveness in preventing falls. Interviews with the Director of Nursing (DON) and other staff revealed that the resident had multiple falls and required constant redirection. The DON acknowledged the absence of a care plan for the sitter and stated that the charge nurse should document any episodes of the resident attempting to get up unassisted. However, there was no documentation of such monitoring, and the facility's policy indicated that the care plan should reflect when a resident is assigned to the Sitter Program. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) involved in the resident's care reported that the resident frequently attempted to get up unassisted and was noncompliant with using the call light. Despite the presence of a sitter, there was no formal documentation of the resident's behaviors or the effectiveness of the sitter intervention. The Director of Staff Development (DSD) also confirmed the lack of monitoring and documentation, emphasizing the need for a care plan to prevent falls effectively.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program by not ensuring that all staff, including registry staff, were tested for COVID-19 according to local health department guidance. Interviews with Certified Nurse Assistants (CNAs) revealed that registry staff did not perform COVID-19 tests prior to starting their shifts. The local health department's guidance required two rounds of facility-wide testing for all staff and residents, and emphasized the importance of wearing well-fitting masks and proper use of personal protective equipment (PPE). The Infection Prevention Nurse (IP) was unaware if registry staff were tested before their shifts, despite the facility's policy requiring testing on specific days and prior to shifts. Additionally, the facility did not provide COVID-19 protocol in-services to all staff shifts, as only day shift staff received training. The Director of Nursing (DON) acknowledged that all staff should receive infection control practice in-services to stay updated with current information and to address any questions. The facility's policy, dated May 2023, indicated that the Infection Prevention and Control Program should follow national standards to prevent and control infections. These failures increased the risk of cross-contamination and the spread of COVID-19 within the facility and the community.
Failure to Resolve Call Light Response Grievances
Penalty
Summary
The facility failed to resolve grievances related to call light response times for a resident, leading to repeated complaints. The resident, who was admitted with a diagnosis including removal of right ankle internal fixation, had intact cognition and required moderate assistance with activities of daily living. Despite filing grievances in December 2024 and January 2025 about lengthy call light response times, particularly during the night shift, the issue persisted. The Director of Staff Development provided in-service training to staff on the importance of timely call light responses, but the problem was not resolved. Interviews revealed that the Social Services Director acknowledged the issue was related to shifts staffed by registry CNAs, making it difficult to ensure prompt responses. The Administrator admitted that the recurring grievance should have been included in the Quality Assurance and Performance Improvement plan, with call light response times monitored to prevent recurrence. The facility's grievance policy required immediate action to resolve concerns and prevent further violations, but this was not effectively implemented, resulting in the continued deficiency.
Failure to Monitor and Treat Nephrostomy Tube and Suprapubic Catheter
Penalty
Summary
The facility failed to ensure proper monitoring and treatment of a resident's nephrostomy tube and suprapubic catheter. The resident, who was admitted with diagnoses of hydronephrosis and obstructive uropathy, had physician orders for the nephrostomy tube to be cleansed with normal saline, patted dry, and secured with a dry dressing daily, and for the suprapubic catheter to be cleansed with normal saline, rinsed, and dried every shift. However, the Treatment Administration Record (TAR) indicated that these treatments were not completed from January 8 to January 10, 2025. Interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that there should have been orders for monitoring and treatment of the resident's nephrostomy tube and suprapubic catheter. The LVN and DON acknowledged that the treatments were not performed as required, and the sites should have been monitored for signs of infection, dislodgement, and cleaned and dressed daily. The facility's policy and procedure indicated that the charge nurse or director of nursing services should place orders for all prescribed treatments, which was not adhered to in this case.
Failure to Prevent Stage III Pressure Injury
Penalty
Summary
The facility failed to prevent the development of a Stage III pressure injury in a resident who was assessed at moderate risk for skin injury upon admission. The resident, who had intact skin at the time of admission, developed a pressure ulcer on the sacro-coccyx area. The facility did not implement the care plan intervention to turn and reposition the resident every two hours, which was crucial to relieve pressure and prevent skin breakdown. The resident's medical history included conditions such as a fracture of the greater trochanter of the right femur, osteoporosis, type 2 diabetes mellitus, and impaired mobility, which increased the risk of pressure injuries. Despite these risk factors, the facility did not adhere to its policy and procedure for skin and wound monitoring and management, which required repositioning to prevent pressure injuries. Interviews with the resident and nursing staff confirmed that the resident was not repositioned as required, leading to the development of the pressure ulcer. The deficiency was further highlighted by the lack of documentation indicating that the resident was turned and repositioned every two hours. The care plan was not updated with new interventions when the pressure injury was identified, and the facility's failure to follow its own procedures contributed to the resident's condition. The Director of Nursing acknowledged the importance of repositioning to prevent pressure injuries and confirmed that the care plan should have been updated to reflect necessary interventions.
Inappropriate Modification of RNA Programs by Unqualified Staff
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Aide (RNA) programs for two residents were modified by qualified and competent staff. For Resident 27, the RNA program was altered by two Restorative Nursing Assistants (RNA 1 and RNA 2) who independently decided to assist the resident with motorized exercise device exercises without a proper order. Despite the resident's request, they did not notify a licensed nurse or the Rehabilitation Department, which was necessary for reassessment and modification of the RNA program. The RNAs acknowledged that they were not qualified to modify the RNA program and should have followed the existing orders, which only included applying splints and performing passive range of motion exercises. For Resident 31, RNA 3 independently modified the RNA program by applying a splint to the resident's right hand without a physician's order. The resident had orders for sit-to-stand exercises, but no order for the application of a splint. RNA 3 admitted that there should have been an order for the splint application, and the Director of Staff Development confirmed that any modifications to the RNA program should be communicated to the Director of Rehabilitation for reassessment by a qualified therapist. The facility's policies and procedures clearly state that only licensed therapists are qualified to establish and modify RNA programs. The RNAs are expected to implement the RNA treatment program as ordered and are not permitted to make independent modifications. The failure to adhere to these protocols resulted in the potential for harm and injury to the residents, as the RNAs lacked the necessary qualifications and training to modify the RNA programs safely.
Failure to Update Informed Consent and Ensure Medical Diagnosis for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent for a psychotropic medication was updated for one resident, and that another resident had a medical diagnosis indicated for the use of a psychotropic medication. For the first resident, the informed consent for Seroquel, a psychotropic drug, was not updated to reflect the current order. The resident was admitted with diagnoses including bipolar disorder and anxiety disorder, and the informed consent was last signed on 2/20/2024 for a different dosage and reason than what was currently being administered. The Licensed Vocational Nurse (LVN) acknowledged that the informed consent did not match the current order, which could lead to the resident receiving medication for the wrong reasons. The interim Director of Nursing (DON) confirmed that informed consent for psychotropic medications should be updated every six months or when the order changes. The facility's policy, as well as guidance from the California Department of Public Health, requires written informed consent for psychotropic drugs and renewal every six months. The failure to update the informed consent could result in the resident receiving unnecessary medication, potentially violating their right to refuse treatment. For the second resident, the facility failed to ensure that a medical diagnosis was documented for the use of Haloperidol, a psychotropic medication. The resident was admitted with an anxiety disorder and had severe cognitive impairment. The medication was ordered for schizophrenia, but the Registered Nurse Supervisor confirmed that there was no diagnosis of schizophrenia in the resident's medical records. The Director of Nursing emphasized the importance of having a medical diagnosis to justify the use of psychotropic medications, as per the facility's policy, which prohibits administering such drugs without a documented condition.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications appropriately for three residents during a medication pass, resulting in a medication error rate of 22.58%. Resident 24 and Resident 69 were both observed swallowing chewable aspirin tablets instead of chewing them as prescribed. This error was confirmed by LVN 2, who acknowledged that swallowing the aspirin could affect its absorption and effectiveness. The Director of Nursing (DON) interim also confirmed that medications should be administered as ordered to ensure their effectiveness. Resident 140 experienced multiple medication errors during the same medication pass. The resident, who had a gastrostomy tube, was administered five different medications crushed and mixed together, contrary to the facility's policy. LVN 2 admitted that each medication should have been administered separately to monitor for any adverse reactions. The DON reiterated that medications should be given one at a time via the G-tube to ensure proper administration and monitoring. The facility's policies on medication administration were not followed, leading to these errors. The policy for administering chewable aspirin was not adhered to, and the procedure for administering medications via a feeding tube was also violated. These lapses in following established protocols contributed to the high medication error rate observed during the survey.
Failure to Administer Medications Individually via G-tube
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering medications individually via a G-tube. A Licensed Vocational Nurse (LVN) was observed crushing and mixing five different medications together before administering them to a resident through a G-tube. This practice was contrary to the facility's policy, which requires medications to be administered separately with a flush of water between each to ensure safety and effectiveness. The resident involved had a history of a stroke and was using a gastrostomy tube for medication administration. The medications in question included Losartan, Olanzapine, Paroxetine, Quetiapine, and Carvedilol, which were prescribed for conditions such as hypertension, psychotic features, depression, and mood disorders. The Director of Nursing confirmed that medications should be administered one at a time to monitor for any adverse reactions and ensure resident safety.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe handling and storage of medications for two residents. In the first instance, a registered nurse observed a medicine cup with an unidentified white pasty substance and a tongue depressor on the bedside table of a resident with severe cognitive impairment. The resident required supervision and assistance with daily activities, including eating and personal hygiene. The presence of the medication at the bedside was acknowledged by the RN as unsafe, and the Director of Nursing confirmed that leaving medications at residents' bedsides was against safety protocols. In the second instance, a licensed vocational nurse found an opened Budesonide Inhalation foil envelope without an open date in a medication cart. The medication, used for treating COPD, should be used within 14 days of opening according to the manufacturer's instructions. The absence of an open date could lead to the administration of an ineffective dose. The interim Director of Nursing acknowledged the importance of adhering to the manufacturer's guidelines to ensure the medication's effectiveness. The facility's policy on medication storage, updated in 2017, requires medications to be stored securely and according to the manufacturer's recommendations.
Deficiencies in Food Labeling and Hair Net Usage
Penalty
Summary
The facility failed to ensure proper labeling of open dates for seven seasoning containers in the kitchen. During an observation and interview, it was noted that these containers were not marked with open dates, which is necessary to ensure that food items are used before their expiration dates. The Dietary Supervisor confirmed that the facility's policy requires opened food items to be labeled with an open date. This oversight in labeling could potentially lead to the use of expired food items, posing a risk of food-borne illnesses. Additionally, the facility did not ensure that staff wore hair nets properly while handling dishes in the dishwashing area. During an observation, it was found that a Dietary Aid had exposed hair around the right ear and shoulder, which was not fully covered by a hair net. The facility's policy on dress code requires that hair nets be worn properly to prevent hair from falling into food. The Dietary Supervisor acknowledged that the Dietary Aid should have covered her hair completely to prevent contamination.
Unqualified Personnel Conduct Joint Mobility Assessments
Penalty
Summary
The facility failed to ensure that Joint Mobility Assessments (JMA) for three residents were completed by qualified personnel, specifically a Physical Therapist (PT) or Occupational Therapist (OT). Instead, an Occupational Therapy Assistant (OTA), who was also the Director of Rehabilitation (DOR), performed these assessments independently. This practice was not in compliance with the Occupational Therapy Practice Act and the California Code of Regulations, which require that such assessments be conducted by licensed therapists and not by OTAs independently. For Resident 15, who was admitted with diagnoses including quadriplegia, muscle weakness, and muscle spasms, the OTA performed the JMA independently, noting a decline in range of motion (ROM) in both knees and ankles. The OTA admitted to possibly collaborating with an OT but had no documented evidence of such collaboration. Similarly, for Resident 29, who had a left-hand contracture and muscle weakness, the OTA conducted the JMA without supervision, despite the resident's severe cognitive impairment and functional ROM limitations. The OTA confirmed that she was not qualified to perform these assessments independently. Resident 34, who had left-sided hemiplegia and hemiparesis following a cerebral infarction, also had their JMA conducted by the OTA without proper supervision. The OTA noted changes in the resident's ROM but again lacked documentation of OT involvement. Interviews with the OT and the Director of Nursing (DON) confirmed that the OTA's actions were outside the scope of practice, potentially leading to inaccurate assessments and inappropriate care recommendations. The facility's policies and procedures, as well as state regulations, clearly outlined that JMAs should be performed by licensed therapists, highlighting the deficiency in the facility's adherence to these guidelines.
Inaccurate Documentation of Restorative Nursing Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aide (RNA) services were accurately documented for two residents, leading to a deficiency in the provision of necessary care. For Resident 27, the RNAs did not accurately document passive range of motion (PROM) exercises as required by the physician's order. Despite the order for PROM exercises to be performed on both arms, the RNAs only applied splints to the resident's hands and did not perform the exercises. This discrepancy was confirmed during interviews and record reviews, where the RNAs admitted to not being aware of the PROM order and inaccurately documenting the services provided. Resident 31 also experienced a lack of accurate documentation regarding the application of a splint to the right hand. Although the resident was observed wearing the splint on multiple occasions, RNA 3 confirmed that there was no documentation to reflect the application of the splint. This lack of documentation could potentially impact the resident's care and the facility's ability to track the effectiveness of the interventions provided. The Director of Nursing (DON) acknowledged the importance of accurate documentation to reflect the services provided and the effectiveness of interventions. The facility's policy on ROM and contracture prevention emphasized the need for appropriate documentation to address program goals and resident tolerance. However, the grouped RNA orders for PROM and splinting led to confusion and inaccurate documentation, as the RNAs did not have a clear method to document when one task was completed and not the other.
Infection Control Deficiencies in PPE Usage and Documentation
Penalty
Summary
The facility failed to provide annual documentation verifying the review of their Infection Prevention and Control Program (IPCP) policies and procedures. During interviews and record reviews, it was found that the sign-in sheet for the IPCP policies updated in January 2024 was undated and lacked a title indicating which policies were reviewed. The Director of Staff Development (DSD), who was also the interim Infection Preventionist Nurse (IPN), and the Director of Nursing (DON) acknowledged the absence of proper documentation and the need to update the sign-in sheet to reflect the reviewed policies. The facility also failed to ensure that staff wore appropriate personal protective equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). Observations revealed that the DSD/IPN, a Licensed Vocational Nurse (LVN), and a Certified Nurse Assistant (CNA) did not wear isolation gowns while providing direct contact care to two residents on EBP. Resident 1, who had an indwelling medical device, and Resident 40, who had a stage 3 pressure injury, were both on EBP due to their conditions. Despite the requirement for PPE during high-contact care activities, staff were observed not adhering to these protocols. Interviews with the DSD/IPN and LVN confirmed the oversight in wearing isolation gowns during care activities. The DSD/IPN admitted to not wearing an isolation gown while providing direct care to Resident 1 and acknowledged the importance of following infection control protocols to prevent the spread of infection. Similarly, the LVN admitted to forgetting to don an isolation gown while administering wound care to Resident 40. The DON emphasized the importance of adhering to proper infection control protocols to prevent infection spread within the facility.
Failure to Conduct Quarterly IDT Care Conference
Penalty
Summary
The facility failed to conduct the quarterly Interdisciplinary Team (IDT) care conference for Resident 25, involving the resident's family member, Family Member 1 (FM 1). Resident 25 was admitted with diagnoses including type 2 diabetes, dementia, and Alzheimer's disease, and was dependent on staff for all activities of daily living due to severely impaired cognition. The last documented IDT care conference for Resident 25 was on November 14, 2023, which was confirmed to be overdue by Registered Nurse (RN) 1. FM 1 reported that the facility staff used to inform the family about the resident's care and held IDT meetings every three months, but this practice had stopped, and FM 1 could not recall the last meeting. The Director of Nursing (DON) stated that IDT care conferences were supposed to be completed on admission and quarterly to ensure family involvement in the resident's care plan. The facility's policy and procedure on comprehensive resident-centered care plans, revised in February 2023, indicated that the resident's family should participate in the development of the care plan, and every effort should be made to accommodate their availability. However, the facility failed to adhere to this policy, resulting in a violation of Resident 25 and FM 1's rights to be informed and participate in the resident's plan of care.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to assess a resident's capability to self-administer medications, which is a requirement for ensuring safe medication practices. The resident, who was diagnosed with asthma and allergic rhinitis, was observed self-administering Azelastine nasal spray, Spiriva inhalation solution, and Symbicort inhalation aerosol without documented assessment by the facility's team. The resident's medical records indicated the capacity to understand and make decisions, but there was no documentation of an assessment to determine if self-administration was appropriate. Interviews with facility staff, including the medical records director and the interim Director of Nursing, revealed that there was no documentation supporting the resident's ability to self-administer medications safely. The facility's policy requires that residents who wish to self-administer medications must be assessed by the interdisciplinary team, and the results must be recorded in the resident's medical record. The policy also states that medications authorized for self-administration should be labeled accordingly, which was not done in this case.
Failure to Obtain Consent and Order for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of physical restraints, specifically bolsters at the foot of the bed, and did not obtain informed consent or a physician's order for their use. The resident, who was admitted with diagnoses including type 2 diabetes, dementia, and Alzheimer's disease, was observed to have bolsters and side rails on their bed. While the side rails had the necessary orders, assessments, and consent, the bolsters did not. This oversight was identified during an observation and interview with a registered nurse, who acknowledged that the bolsters could be considered a restraint as they restrict the resident's movement. The Director of Nursing confirmed that any device preventing a resident's free movement requires consent, assessment, and a physician's order. The facility's policy on physical restraints, revised in February 2023, defines restraints as any device that restricts a resident's freedom of movement and requires informed consent and a physician's order. The failure to follow these procedures for the bolsters resulted in a violation of the resident's rights to be free from restraints.
Failure to Report Unknown Injury
Penalty
Summary
The facility failed to report an unknown injury of a resident to the California Department of Public Health (CDPH). The incident involved a resident with severe cognitive impairment and multiple medical conditions, including type 2 diabetes, dementia, Alzheimer's disease, and contractures. On February 9, 2023, a certified nurse assistant observed the resident's left lower leg bent inward, possibly indicating a fracture. Despite this observation, the facility's administrator did not report the incident, believing it was not reportable. This decision was contrary to the facility's policy, which requires reporting injuries of unknown source to the appropriate authorities. The resident was taken to a general acute care hospital's emergency department on February 8, 2023, where the deformity was noted, and a social work consult was conducted due to the unexplained injury. The facility's interim Director of Nursing later confirmed that unknown injuries should be reported within the legally required timeframe. The facility's policy on abuse prevention and prohibition outlines that injuries of unknown source must be reported when the source is unobserved, unexplained by the resident, and suspicious due to the injury's extent, location, or frequency.
Failure to Investigate and Report Unknown Injury
Penalty
Summary
The facility failed to investigate and report an unknown injury for a resident, identified as Resident 25, who was observed with a potentially fractured left lower leg. The incident occurred on 2/9/2023 when a CNA reported the abnormality to a supervisor, who confirmed the leg appeared bent inward. Despite this observation, the facility did not conduct a documented investigation or report the incident to the California Department of Public Health (CDPH) within the required five working days. The resident, who was nonverbal with advanced dementia, was taken to a general acute care hospital emergency department, where the injury was noted as unexplained, prompting a social work consult. The facility's policy on abuse prevention and prohibition requires that all injuries of unknown source be reported to relevant agencies and thoroughly investigated. However, during interviews, the administrator admitted to not reporting the incident, believing it was not reportable, and there was no evidence of an investigation by the previous Director of Nursing. The interim Director of Nursing acknowledged the requirement to report unknown injuries within the legal timeframe. The failure to investigate and report the injury hindered CDPH's ability to investigate the incident timely and posed a risk of other unknown injuries going unreported.
Failure to Complete PASARR Screening for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed for a resident upon their readmission on July 1, 2023. This resident, identified as Resident 55, was admitted with diagnoses of schizoaffective disorder and bipolar disorder, conditions that necessitate a Level II PASARR. The Minimum Data Set (MDS) for Resident 55, dated September 20, 2024, indicated that the resident's cognition was moderately impaired. Despite these indicators, the required PASARR screening was not conducted upon the resident's readmission. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the oversight. The ADON acknowledged that based on the resident's mental health diagnoses, a Level II PASARR was necessary, and an updated Level I PASARR should have been completed upon readmission. The DON emphasized the importance of accurate and timely completion of PASARR as mandated by law. A review of the facility's policy, revised in February 2023, reiterated the requirement for PASARR completion for every resident upon admission to ensure appropriate referrals for specialized services.
Lack of Care Plan for Splint Application
Penalty
Summary
The facility failed to initiate a care plan for a resident requiring the assistance of a Restorative Nursing Assistant (RNA) for splinting. The resident, who was admitted with diagnoses including hemiplegia and contracture of the right hand, was observed wearing a splint on multiple occasions. However, there was no documented order or care plan for the RNA to apply the splint, as confirmed by both the RNA and the Occupational Therapist (OT). The RNA stated that they performed sit-to-stand exercises and applied the splint daily, but acknowledged the absence of an order for the splint application. The OT and the interim Director of Nursing (DON) both emphasized the necessity of having an order and care plan for splint application to ensure proper frequency, duration, and technique, thereby preventing risks such as skin breakdown. The facility's policy on Comprehensive Person-Centered Care Planning requires a care plan with measurable objectives and timeframes for each resident's needs, which was not adhered to in this case. This oversight had the potential to negatively impact the resident's care and safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewater Skilled Nursing Center | 0.4 mi | ★★★★★ | 21 | 0 |
| Alamitos Belmont Health And Rehabilitation | 0.7 mi | ★★★★★ | 16 | 1 |
| Colonial Care Center | 0.8 mi | ★★★★★ | 35 | 0 |
| Pacific Palms Healthcare | 1.2 mi | ★★★★★ | 41 | 0 |
| Long Beach Post Acute | 1.2 mi | ★★★★★ | 18 | 0 |
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