Eastern Plumas Hospital- Portola Campus Dp/snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Portola, California.
- Location
- 500 First Street, Portola, California 96122
- CMS Provider Number
- 555433
- Inspections on file
- 25
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Eastern Plumas Hospital- Portola Campus Dp/snf during CMS and state inspections, most recent first.
A resident with multiple health conditions and an amputation was injured when a CNA transferred her without the required slide board and second staff member, contrary to her care plan and posted instructions, resulting in a fractured ankle. Additionally, two shower rooms were found with unlocked cabinets containing new razors and an overfilled sharps container with used razors accessible to residents, posing further safety risks. Staff confirmed these practices did not meet safety standards.
Surveyors observed that three shower rooms were inadequately maintained, with chipping paint, rust, unclean areas around tubs and toilets, and improper storage of cleaning equipment and used razors. Staff, including a CNA, a licensed nurse, the ADON, and the DON, confirmed that the rooms were not clean or maintained to acceptable standards, in violation of facility policy requiring cleaning and disinfection between uses.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
Surveyors found that the ice machine and the cupboard it sat upon were not maintained in a sanitary condition, with significant mineral buildup, debris, and unclean surfaces observed. Maintenance staff and the Director of Plant Management confirmed the presence of buildup and debris, indicating a failure to follow the facility's cleaning policy for kitchen equipment.
Staff did not adhere to infection control protocols during medication administration and feeding. A nurse used a writing pen to open a medication bottle, and another brought a medication box into a resident's room, placing it on a surface without a barrier. Additionally, a CNA assisted two residents with eating and touched various potentially contaminated surfaces without performing hand hygiene between tasks. These actions were confirmed by staff and leadership as breaches of infection control policy.
Nurses and nurse aides lacked the appropriate competencies to care for every resident in a way that maximizes each resident's well-being, resulting in care that did not support residents' highest level of physical, mental, and psychosocial well-being.
Staff did not follow a physician-ordered fortified diet for a resident, as the intended fortification (an extra pat of margarine) was not incorporated into the meal and was not offered to the resident by CNAs, who were unaware of its purpose. The DON confirmed staff were not trained on this requirement, and the RD expected fortification to be part of the recipe, not served separately.
A resident with severe cognitive impairment and high fall risk was left unsupervised after being observed in an unsafe position. Staff failed to assist the resident to safety, did not perform a post-fall assessment, and delayed notifying the physician after the resident was found on the floor in pain. The resident sustained a fractured hip, required hospitalization and surgery, and experienced significant pain and decline.
A resident with severe cognitive impairment and multiple health conditions experienced a fall and reported pain in her left arm and hip. Staff did not promptly assess her condition, failed to notify the physician in a timely manner, and administered acetaminophen ordered only for mild pain despite the resident experiencing moderate to severe pain. The resident remained in pain for several hours, did not eat, and was later found to have a fractured hip. Facility policies for post-fall assessment and pain management were not followed.
A resident with multiple comorbidities experienced a fall resulting in significant pain, but staff failed to promptly notify the physician and responsible party as required by facility policy. The LPN delayed notification for several hours, and documentation of required notifications was incomplete. The resident was later found to have a left hip fracture, and the delay led to unnecessary pain and suffering.
A resident in an LTC facility, admitted with age-related debility and other conditions, experienced a disrespectful interaction with the DON, who responded to a light-hearted comment by saying, 'I could let you sit in a wet diaper.' This was perceived as disrespectful, especially given the resident's history of conflicts with the DON. The facility's policy emphasizes treating residents with dignity, and the incident was corroborated by the ADON and a community advocate.
A resident with Alzheimer's and dementia developed a pressure ulcer on her left heel due to the facility's failure to provide timely and appropriate care. Despite identifying the ulcer, there was a 47-day delay in notifying the physician and obtaining a wound care order. Inadequate documentation and communication, along with the absence of a formal wound care policy, contributed to the deficiency.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential care gaps. One resident, with Alzheimer's and dementia, was inaccurately marked as not at risk for pressure ulcers, missing a prevention care plan. Another resident, with quadriplegia and existing pressure ulcers, was not documented correctly in the MDS, despite ongoing treatment. These inaccuracies could lead to uninformed staff and inadequate care interventions.
Two residents with Alzheimer's and dementia were not provided adequate oral hygiene care, resulting in visible hygiene issues such as food residue and buildup on their teeth and tongues. Despite requiring maximal assistance, one resident missed oral care for 22 shifts, while the other had no intervention plan for care refusal. Staff interviews revealed systemic neglect, particularly during night shifts, and missing records confirmed the lack of consistent care.
The facility's nursing staff failed to maintain the Antibiotic Stewardship Program, resulting in missing and incomplete documentation for several residents. This included essential information such as dates, medical record numbers, and antibiotic details, hindering the facility's ability to monitor and minimize antimicrobial resistance. The Infection Preventionist and DON confirmed the deficiencies, which compromised the facility's infection control efforts.
The facility failed to maintain the Ice/Water Dispensing machine and the dishwashing machine's drain, leading to potential health risks. The Ice/Water machine had a buildup of black residue on the nozzle, and the dishwashing machine's drain overflowed due to a clog. The issues were not reported or addressed in a timely manner, impacting resident health.
A resident's jewelry was taken by a housekeeper who wore and pawned it, causing distress to the resident. The resident, with decreased mental functioning, had placed the jewelry in a cup before an X-ray procedure. The facility staff, including the ADON and DON, investigated after the resident's daughter reported the missing items. A Restorative Nurses Aid discovered photos online of the housekeeper wearing the jewelry, leading to the housekeeper's admission and the eventual return of the items.
The facility did not maintain handrails in the corridors for 10.5 months due to a renovation project. During a survey, it was noted that sections of the corridors lacked handrails. The Director of Plant Operations confirmed the removal of handrails for renovations and was unaware of the regulatory requirement for their presence.
Failure to Prevent Accidents and Secure Hazards
Penalty
Summary
The facility failed to protect residents from accident hazards and did not provide adequate supervision to prevent accidents. One resident with significant medical conditions, including heart disease, lymphoma, a history of falls, osteoporosis, and an above-the-knee amputation, was transferred from her bed to a wheelchair by a CNA without the use of the required slide board and without a second staff member assisting. The resident's care plan, posted instructions, and therapy documentation all specified that a slide board and two-person assist were necessary for safe transfers. Despite this, the CNA attempted a stand-and-pivot transfer, which the resident could not safely perform due to her single leg and pain, resulting in a fall and a fractured ankle that required emergency room treatment. Additionally, the facility did not ensure the safety of shower rooms, as two out of three rooms were observed to have unlocked and open cabinets containing new disposable razors and an overfilled sharps container with used razors protruding from the opening. These items were easily accessible to residents, creating a risk of injury. Multiple staff, including a licensed nurse, the assistant director of nursing, and the director of nursing, confirmed that razors and sharps should not be left accessible in this manner. The facility's own policies and standard procedures, as well as external guidelines referenced by staff, required the use of proper equipment and secure storage of hazardous items to ensure resident safety. The observed failures directly resulted in a resident injury and created the potential for further harm to other residents.
Failure to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in three of three resident shower rooms, as evidenced by multiple observations of inadequate maintenance and cleanliness. Surveyors found paint chipping from walls and ceilings, missing paint and rust on door jambs, and rust on bolts, screws, and nuts securing tubs and toilets to the floor. In one shower room, a dry, flaky substance, possibly shampoo, was found spilled and dried on the bottom shelf of an open cupboard, with clean towels stacked on top. The foot of the bathtub and the area around the toilet were also unclean. Used razors were observed protruding from an almost full sharps container, and used hard bristle brushes intended for floor cleaning were left hanging on shower safety handrails in multiple rooms. Staff interviews confirmed the observations, with a CNA stating that the hard bristle brush should not be left on the handrails where residents could come into contact with it, and that the rooms were not maintained to acceptable standards. Both a licensed nurse and the assistant director of nursing acknowledged that the shower rooms were not adequately maintained or clean. The director of nursing also confirmed these findings upon review of the rooms and photographic evidence. The facility's own policy required cleaning and disinfecting of shared equipment and areas between each use, which was not adhered to in these instances.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Unsanitary Ice Machine and Surrounding Area
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions for kitchen equipment, specifically the ice machine. The ice machine was found to have a significant amount of mineral buildup on the tray and inside the ice spout, as well as debris in the internal cabinet area. Additionally, the cupboard supporting the ice machine was unclean, with visible buildup, water, splash marks, and debris. These findings were confirmed during multiple observations and interviews with maintenance staff and the Director of Plant Management, who acknowledged the presence of buildup and debris and agreed that the machine and surrounding area appeared unclean. A review of the facility's policy on cleaning and sanitizing ice machines indicated that all ice machines should be properly maintained and cleaned, including the tray and spout, and that exterior scaling should be removed as needed. Despite this policy, the observed conditions did not meet these standards, as the ice machine and its surrounding area were not clean to sight or touch. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Failure to Follow Infection Control Standards During Medication Administration and Resident Feeding
Penalty
Summary
Staff failed to follow infection control standards during medication administration and resident feeding, as observed and confirmed through interviews and record reviews. In one instance, a nurse was unable to remove a safety seal from a new liquid medication and used a writing pen to puncture and scrape the inside edge of the bottle opening. The nurse later acknowledged that this was inappropriate and could cause an infection control issue. The facility's policy on standard precautions requires measures to reduce the risk of infection transmission, but this was not followed in this case. In another event, a nurse brought a medication in its manufacturer’s box into a resident’s room and placed it directly on the bedside table without a barrier. After administering the medication, the nurse returned the medication to the box and placed it back in the medication cart with other boxed medications. The nurse confirmed that the medication box is porous and cannot be thoroughly cleaned, identifying this as an infection control issue. Facility leadership, including the Assistant Director of Nursing and Director of Nursing, confirmed that these actions were not in line with infection control expectations. Additionally, a certified nursing assistant was observed assisting two residents with eating in the dining room and touching potentially contaminated surfaces such as wheelchair handles, chairs, other residents’ trays, and countertops without performing hand hygiene between these actions. The assistant admitted to not considering the need for hand sanitizing after touching these surfaces. Facility policy requires hand hygiene after touching patient surroundings and before feeding, but this was not adhered to during the observed meal service.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in residents not receiving care in a manner that supports their highest level of physical, mental, and psychosocial well-being.
Failure to Follow Physician-Ordered Fortified Diet for Resident
Penalty
Summary
Staff failed to follow a physician-ordered therapeutic fortified diet for one of six sampled residents on such diets. Specifically, the dietary manager was observed plating food for a resident requiring a fortified diet but did not add any fortification to the main entrée, instead placing an extra pat of margarine on the tray. The margarine, intended as the fortification, was not incorporated into the food but left on the tray alongside the napkin. When the tray was presented to the resident, the certified nursing assistant did not offer the margarine and was unaware it was part of the fortified diet order. Another CNA also did not know that the butter pat was intended as fortification, stating that residents could eat whatever they wanted. The Director of Nursing confirmed that nursing staff were not aware of the role of the butter pat in the therapeutic diet and had not received training to ensure its use for residents requiring fortified diets. The registered dietitian stated that her expectation was for additional calories to be incorporated into the recipes, not simply presented as margarine pats on the tray. Facility policy required that individuals needing supplemental nutrition be served a suitable high calorie/high protein diet, with nursing staff supervising delivery and consumption of supplements and recording this in the medical record. These steps were not followed for the resident in question.
Failure to Prevent and Respond to Resident Fall Results in Serious Injury
Penalty
Summary
A resident with a history of dementia, Parkinsonism, osteoporosis, traumatic brain injury, and severe cognitive impairment was identified as high risk for falls, with documented balance problems and poor safety awareness. Despite these risks, the resident was left unsupervised after being observed by a CNA leaning over and reaching for the floor while seated. The CNA did not assist the resident to a safe position or ensure her safety before leaving, and subsequently, the resident was found on the floor by a housekeeper, with no staff present in the hallway or at the nurse's station. After the fall, staff failed to perform a post-fall assessment or take vital signs, and the resident's care plan did not include specific interventions for unwitnessed falls. The nurse and CNA lifted the resident from the floor without assessing for injury, despite the resident expressing pain and being unable to bear weight. The nurse did not notify the physician or the resident's responsible party at the time of the incident and delayed communication until the end of the shift. The Director of Nursing later acknowledged that the facility's post-fall policy was not followed and that the incident should have been treated as a fall, regardless of the care plan's note about the resident sitting on the floor. As a result of the fall, the resident sustained a displaced left hip fracture, requiring hospital admission and surgery. Following the injury, the resident experienced significant pain, a decline in physical, social, and mental well-being, and became completely dependent on staff for assistance. The failure to provide adequate supervision, timely assessment, and appropriate post-fall interventions directly contributed to the severity of the resident's injury and subsequent decline.
Failure to Provide Timely Assessment and Appropriate Pain Management After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including dementia, parkinsonism, osteoporosis, and a history of traumatic brain injury, experienced a fall in the facility. Staff failed to promptly assess the resident for a change in condition after the fall, despite the resident expressing pain in her left arm and hip. Instead of conducting an immediate assessment as required by facility policy, staff lifted the resident from the floor and placed her in a chair while she complained of pain. No vital signs or neurological assessments were performed at the time, and the physician was not notified immediately of the incident or the resident's complaints of pain. Following the fall, the resident continued to express moderate to severe pain, was unable to bear weight, and refused food. Staff administered acetaminophen, which was only ordered for mild pain, despite the resident reporting moderate pain levels. The medication was ineffective, and the resident's pain persisted for several hours. Documentation shows that the resident did not eat lunch or dinner due to her pain, and her pain was not adequately reassessed or managed according to the facility's pain management policy. The physician was not notified of the resident's ongoing pain and change in condition until several hours after the incident, and only after the pain had escalated to severe levels. Interviews with staff and witnesses confirmed that the resident was in visible distress, repeatedly vocalized her pain, and was unable to participate in normal activities. The lack of timely assessment, inadequate pain management, and delayed physician notification resulted in the resident experiencing prolonged pain and discomfort. The facility's own policies regarding post-fall assessment, pain management, and change in condition notification were not followed, directly contributing to the deficiency identified in the report.
Failure to Promptly Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to promptly identify and notify the physician and responsible party of a change in condition for a resident who experienced a fall resulting in new onset pain. According to the facility's policy, any accident involving a resident that results in injury requiring provider intervention, or a significant change in the resident's physical, mental, or psychosocial status, requires immediate assessment and notification of the primary provider, resident representative, and the resident. In this case, the resident, who had a history of dementia, parkinsonism, hearing loss, osteoporosis, and traumatic brain injury, fell from her chair and landed on her left side. Staff observed the resident in pain, crying, and expressing discomfort during and after being assisted back into her chair and later transferred to bed. Despite clear signs of pain and distress, the licensed nurse on duty did not notify the primary physician or the resident's responsible party at the time of the incident. Instead, the nurse waited until the end of her shift to send an email to the medical director, resulting in an eight-hour delay before the physician was made aware of the situation. The physician reported that the initial notification lacked critical details, such as the time of the incident and a proper assessment, and was not informed that the resident had fallen or was experiencing pain with movement. The responsible party was also not notified until later in the evening, just before the resident was sent to the emergency department. Documentation review revealed that required notifications to the physician and family were not completed or documented as done on the facility's alert charting forms. The director of nursing confirmed that there was no documentation of timely notification to the primary physician or responsible party following the change in the resident's condition. The delay in notification and treatment resulted in the resident experiencing unnecessary pain and suffering, and subsequent evaluation in the emergency department revealed an acute displaced subcapital left femoral neck fracture.
Resident's Right to Dignity Compromised by Disrespectful Staff Interaction
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination when a staff member, specifically the Director of Nursing (DON A), spoke to a resident in a manner perceived as disrespectful. The incident involved Resident 1, who was admitted to the facility with conditions such as age-related debility, arthritis, and heart disease, and required substantial assistance for daily activities. During an interaction on or around February 27, 2025, Resident 1, who is cognitively intact, made a light-hearted comment to DON A and LVN B, referring to them as 'Wonder Woman and Hercules.' In response, DON A remarked, 'I could let you sit in a wet diaper,' which Resident 1 interpreted as disrespectful, especially given their history of conflicts. The facility's policy on elder abuse reporting emphasizes treating residents with dignity and respect, explicitly defining verbal abuse as a form of abuse. Interviews with the Assistant Director of Nursing (ADON B) and a volunteer community advocate (ADV C) corroborated the resident's account of the incident. ADON B acknowledged that such a statement would be disrespectful and contrary to the facility's policy, while ADV C confirmed the ongoing tension between Resident 1 and DON A, noting that Resident 1 is a reliable source of information. The incident highlights a failure to maintain a respectful and home-like environment for the resident, as required by the facility's policies.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and appropriate care for a pressure ulcer that developed on a resident's left heel. The resident, who was admitted with Alzheimer's disease and dementia, was initially assessed as not having any pressure ulcers. However, a pressure ulcer was later identified by a licensed nurse, who noted a black, dry blister on the resident's heel. Despite this observation, there was a significant delay in notifying the physician and obtaining a wound care order, which occurred 47 days after the initial identification of the ulcer. The facility's documentation and communication practices were inadequate, contributing to the deficiency. The Director of Nursing and other staff members confirmed that there was no consistent documentation of the wound's condition, such as its stage, size, or any discharge. The facility lacked a specific policy for skin assessment, wound care, or pressure ulcer management, and staff relied on online resources instead of formal training. Additionally, the resident's care plan included interventions like floating the heels and using booties, but there was no evidence that these measures were consistently implemented. The facility's failure to accurately assess the resident's risk for pressure ulcers and to document and communicate the wound's condition led to a lack of timely intervention. The resident's medical records showed discrepancies, such as being marked as not at risk for pressure ulcers despite a Braden Scale score indicating otherwise. The lack of a coordinated approach to wound care and the absence of a wound care nurse or formal training further exacerbated the situation, resulting in the development and progression of the pressure ulcer.
Inaccurate MDS Assessments for Skin Conditions
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the skin status of two residents, leading to potential gaps in care. Resident 1 was admitted with a history of Alzheimer's disease and dementia and was assessed with a Braden Scale score indicating a risk for pressure ulcers. However, the MDS completed by a retired RN inaccurately marked Resident 1 as not at risk for pressure ulcers, resulting in the absence of a pressure ulcer prevention care plan. Resident 3, diagnosed with quadriplegia and existing pressure ulcers on the buttocks, was also inaccurately assessed in the MDS. The MDS, completed by the same retired RN, failed to document the presence of pressure ulcers, despite the resident being under treatment for these conditions since a previous diagnosis. This discrepancy was confirmed during a review with the Director of Nursing (DON). These inaccuracies in the MDS assessments for both residents could lead to staff being uninformed about the residents' true health status, potentially affecting the care interventions required. The facility's policy and the CMS guidelines emphasize the importance of accurate MDS assessments to ensure appropriate care planning, which was not adhered to in these cases.
Failure to Provide Adequate Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary oral hygiene care for two residents, leading to visible hygiene issues. Resident 1, who has severe cognitive impairment due to Alzheimer's disease and dementia, was observed with food from the previous day stuck between her teeth and on her tongue, along with a yellowish buildup on her tongue. Her family member reported never witnessing staff provide personal hygiene care during visits. Resident 1's medical records indicated she required maximal assistance for oral hygiene, yet there were 22 shifts where she did not receive oral care. Resident 2, also diagnosed with Alzheimer's disease and dementia, was observed with a thick yellowish substance on her tongue and blue cake residue around her mouth from the previous night. Despite having a care plan that aimed to keep her clean and well-groomed, there was no intervention plan for when she refused oral care. During an interview, Resident 2 expressed difficulty accessing water and locating the call light, indicating a lack of assistance in meeting her basic needs. Interviews with staff revealed systemic issues in providing oral care, with CNAs acknowledging that oral hygiene was often neglected, especially during night shifts. The Director of Nursing confirmed the absence of an ADL policy and acknowledged missing records for oral care. The facility's job postings outlined expectations for CNAs to provide oral hygiene, yet these duties were not consistently fulfilled, as evidenced by the observations and staff admissions.
Incomplete Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility's nursing staff failed to update and maintain the Antibiotic Stewardship Program (ASP), which is crucial for identifying, tracking, and monitoring infections and antibiotic use among residents. This deficiency was identified through interviews and record reviews, revealing that the ASP log was missing or incomplete for several residents. Specifically, the log lacked essential information such as dates, medical record numbers, dose and duration of antibiotics, start and stop dates, clinical indications, and diagnosis. The absence of this information hindered the facility's ability to analyze, monitor, and minimize the emergence and spread of antimicrobial resistance. The review of medical records for multiple residents indicated that urinalysis tests were ordered, and culture and sensitivity results showed positive findings for various bacteria, including Escherichia coli and Staphylococcus aureus. However, the ASP log failed to document critical details such as the date of culture and the date and initials of nurses who faxed information to the pharmacy. This lack of documentation was confirmed by the Infection Preventionist and the Director of Nursing, who acknowledged that the ASP log was incomplete and needed to be updated to ensure the safe and appropriate use of antimicrobial agents. The facility's policies and procedures outlined the responsibilities of the Infection Preventionist and the Antimicrobial Stewardship Committee in monitoring and managing infections and antibiotic use. Despite these guidelines, the facility did not adhere to its own policies, resulting in missing and incomplete data in the ASP log. This failure compromised the facility's ability to effectively track antibiotic use and resistance trends, potentially leading to inappropriate antibiotic use and increased risk of antimicrobial resistance among residents.
Failure to Maintain Equipment Leads to Health Risks
Penalty
Summary
The facility failed to maintain the Ice/Water Dispensing machine according to the manufacturer's recommendations, resulting in a buildup of moist, black residue on the water supply nozzle. This issue was identified during an observation in the resident's kitchenette, where a white paper towel was used to wipe the nozzle, revealing the residue. The Biomed staff confirmed that the nozzle should have been clean and acknowledged that the machine was last cleaned by an outside contractor on 2/1/24, as per the manufacturer's guidelines. However, the service manual indicated that more frequent maintenance might be necessary. The Activities Director confirmed that residents obtained drinking water from this machine. Additionally, the facility did not maintain a functioning drain for the dishwashing machine, leading to water spilling onto the floor. During an observation in the kitchen, the Dietary Aide demonstrated that the dishwasher's drain required a stop-and-go method to prevent overflow. The Dietary Manager confirmed the ongoing issue with the drain and admitted to not reporting the problem to the Maintenance Director, who later identified a clogged drain as the cause of the overflow. The Maintenance Director noted that a similar issue had been repaired approximately six months prior, but was not informed of the current problem.
Housekeeper Takes and Pawns Resident's Jewelry
Penalty
Summary
The facility failed to protect a resident from abuse when a housekeeper took the resident's jewelry, wore it, and then pawned it. The resident, who was admitted with diagnoses including heart failure and a history of falling, required assistance for daily needs and was alert but had decreased mental functioning, scoring 8 out of 15 on the BIMS Test. The incident occurred when the resident placed her two gold necklaces in a Dixie cup before going for an X-ray procedure, and they were missing upon her return. The resident's daughter reported the missing necklaces, prompting a search by the facility staff. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were involved in the investigation, which revealed that a Restorative Nurses Aid (RNA) found photos on Facebook of the housekeeper wearing necklaces identical to those of the resident. The housekeeper admitted to taking and pawning the necklaces, which were eventually returned to the resident. The incident caused anxiety and stress for the resident, who had sentimental attachment to the jewelry, particularly a necklace given by her late husband.
Failure to Maintain Corridor Handrails During Renovation
Penalty
Summary
The facility failed to maintain handrails in the corridors for a period of 10.5 months, from June 6, 2023, until April 25, 2024. During an onsite visit from April 24 to April 26, 2024, the surveyor observed that sections of the corridors lacked handrails affixed to the walls. In an interview on April 25, 2024, the Director of Plant Operations confirmed that all handrails were removed on June 6, 2023, due to a major renovation project on the corridor walls. He also stated that the facility had been replacing the old handrails with new ones over the past two weeks, but the project was not yet completed. Furthermore, he admitted to being unaware of the regulatory requirement for corridor handrails to be in place.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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