Freedom Village Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Forest, California.
- Location
- 23442 El Toro Road, Lake Forest, California 92630
- CMS Provider Number
- 555391
- Inspections on file
- 17
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Freedom Village Healthcare Center during CMS and state inspections, most recent first.
A resident experienced significant weight loss and the RD recommended nutritional interventions, but there was a nine-day delay in communicating these recommendations to the physician, resulting in a delay in implementing necessary care. Facility staff acknowledged the failure to relay the RD's recommendations in a timely manner.
A resident's medical record inaccurately documented their fall history, indicating no falls in the last six months despite evidence of a fall prior to admission. This discrepancy was confirmed by an LVN and the ADON, who noted that such inaccuracies could lead to misinterpretation and delay in services, posing a risk to the resident's care.
A resident reported an allegation of physical abuse against two CNAs. Despite the facility's policy requiring suspension of staff accused of abuse, the CNAs continued to work during the investigation period, although they were not assigned to the resident. The DON acknowledged that the CNAs should have been suspended to ensure resident safety.
A facility failed to monitor a resident's safety and psychosocial well-being or develop a care plan after the resident reported an abuse allegation involving two CNAs. The resident alleged rough handling and inappropriate behavior by the CNAs. The facility did not conduct the required 72-hour monitoring or establish a care plan to address the resident's needs, as confirmed by interviews with the RN and DON.
The facility failed to ensure food safety and sanitation in the kitchen, risking food-borne illnesses for 42 residents. Observations included unsanitary kitchen utensils, improper glove use by a dietary aide, and a juice machine lacking an air gap for backflow prevention. These issues were acknowledged by facility leadership.
A resident with impaired mobility and requiring maximal assistance for transfers was injured when a CNA transferred them alone, contrary to the care plan. The resident's leg was caught during the transfer, resulting in a right ankle fracture. The CNA was unaware of the two-person assist requirement, and it was noted that other staff had also been assisting the resident without additional help.
A resident was found with Voltaren gel at their bedside without a physician's order or care plan for self-administration, contrary to facility policy. The resident was applying the gel independently, despite not being assessed as a candidate for safe self-administration. An RN confirmed the lack of necessary documentation and orders.
The facility failed to document and update advance directives for three residents, risking treatment against their wishes. A resident's advance directive was not placed in the medical record, another's was not followed up on, and a third's POLST was not updated to reflect a formulated directive.
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNOC) after the termination of Medicare Part A services for two residents. One resident's representative was notified about the last covered Medicare day but was given the wrong notification form. Similarly, another resident's representative was informed of the last covered day but also received the incorrect form. The SSD confirmed that the representatives were informed but not given the correct Advance Beneficiary Notification (ABN).
A resident experienced a 5.32% weight loss in one month, but the facility failed to conduct a nutritional assessment, involve a dietitian, update the care plan, or notify the physician and family. Staff confirmed that no change of condition was initiated, and the weight loss was not documented as required by facility policy.
The facility failed to ensure accurate reconciliation of controlled medications in the Omnicell, as required by their P&P. Controlled substances were not counted daily, leading to discrepancies in the Cycle Count Non-Compliant Report. Interviews with pharmacy staff and the DON confirmed that only 'touched' medications were counted, contrary to policy, posing a risk for medication diversion.
A resident was administered Colace without verifying stool patterns, contrary to the facility's policy. The LVN did not check the point click care dashboard or consult with the CNA, and a list of residents with loose stools was not provided. The DON confirmed these findings.
A resident with Parkinson's disease and dementia was prescribed Nuplazid for psychosis without documented evidence of behavioral monitoring or non-pharmacological interventions. The care plan lacked details on the use of the medication for paranoid ideation, and the DON confirmed the absence of necessary documentation and monitoring.
The facility failed to properly store and label medications, with issues including unrefrigerated eye drops, mixed storage of internal and external medications, and unlabeled inhalation medication. Additionally, expired medication was found, and a nurse left medications unattended during administration. These deficiencies were confirmed by staff during observations.
The facility failed to ensure the DSS overseeing the satellite kitchen was qualified, as required by California Code. During a survey, issues were found in both the main and satellite kitchens, including unclean equipment and lack of an air gap for a juice machine, potentially affecting 42 residents. The administrator acknowledged these findings.
A resident with a documented allergy to cucumber was served cucumber during lunch, despite the facility's records indicating the allergy. The Dietary Service Supervisor confirmed the oversight and acknowledged the need to replace the allergenic item. The resident stated that consuming cucumber would lead to vomiting and illness.
The facility failed to educate staff and visitors on safe food handling for outside food, risking foodborne illnesses for residents. The DSS did not provide specific guidance on cooking and cooling temperatures, and the DSD/IP only reminded staff to label food properly. Education was limited to CNAs, and licensed staff were not informed about safe food handling practices.
A facility failed to provide necessary hospice care for a resident, including missing weekly CHHA visits and lacking documentation in the hospice log. The hospice RN was also absent from a care conference. The DON confirmed these deficiencies.
The facility's QAA committee failed to document action plans for previously identified deficiencies in respiratory care and medication storage. The DON could not provide evidence of procedures for labeling and changing respiratory equipment or logs for medication storage checks. An LVN reported only checking medications weekly, not daily as required.
The facility failed to maintain accurate infection surveillance, with discrepancies in reported infections for residents. Infection control practices in the laundry room were inadequate, with clean linens in contact with personal items. Additionally, a nurse did not follow proper hand hygiene during medication administration, and improper Foley catheter care was observed, with the catheter tip not cleaned after use.
The facility failed to document the offer and discussion of influenza and pneumococcal vaccines for two residents who lacked decision-making capacity. Consent forms were incomplete, and there was no evidence of discussions about the risks and benefits of the vaccines, posing a risk of disease acquisition.
The facility failed to maintain essential temperature logs for the Omnicell Anatomic Drug Dispensing system, as required by their policies. Despite placing a work order to replace a faulty thermometer, night shift nurses left the temperature log incomplete, potentially affecting residents' medications. Interviews with the DON and an RN confirmed the importance of daily temperature recording.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for a resident and two others. A resident was prescribed ciprofloxacin for a UTI despite meeting criteria for gastroenteritis, without informing the physician. Another resident received azithromycin for a cough without confirming infection criteria. A third resident was given Augmentin for pneumonia, meeting criteria for gastroenteritis, without physician notification. The facility's IP failed to review antibiotic use effectively, and the DSD/IP and RN confirmed these findings.
The facility failed to provide adequate respiratory care for two residents. A resident's nasal cannula was not stored properly, and another resident's nasal cannula and storage bag were not dated as required by facility policy. These deficiencies were confirmed by LVNs during observations and interviews.
The facility did not follow the main menu for 42 residents, serving an alternate menu without notifying them. The Director of Food and Nutrition Services confirmed the deviation from the planned menu and the lack of resident notification.
Delay in Physician Notification of RD Recommendations Following Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident received timely and appropriate services to maintain optimal nutritional status. Specifically, the resident experienced a weight loss of 6 pounds (4.3%) over six days, as documented in the medical record. The registered dietitian (RD) conducted a nutrition assessment and recommended daily multivitamin with minerals, snacks three times daily, and Glucerna shakes with meals due to inadequate oral intake. These recommendations were documented on 9/9/25. However, the RD's recommendations were not communicated to the physician until nine days later, resulting in a delay in obtaining the necessary physician orders for the interventions. Facility policy required timely monitoring and intervention for undesirable weight changes, but the charge nurses did not relay the RD recommendations to the physician as required. This delay was acknowledged by both the LVN and the DON during interviews, confirming that the resident did not receive the recommended nutritional interventions in a timely manner.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one of the sampled residents, identified as Resident 1. The deficiency was identified during a review of the facility's policies and procedures, which require that all services provided to residents, progress toward care plan goals, and any changes in the resident's condition be documented accurately in the medical record. Resident 1, who was admitted to the facility with moderately impaired cognition, had a documented fall prior to admission. However, the fall risk assessment inaccurately indicated that Resident 1 had no history of falls within the last six months. The inaccuracy in the fall risk assessment was confirmed during interviews with LVN 1 and the ADON. LVN 1 acknowledged that the assessment should have reflected a history of one to two falls, rather than none, and noted that such inaccuracies could lead to misinterpretation. The ADON also confirmed the error and expressed concern that inaccurate documentation could delay necessary services. This failure to maintain an accurate medical record posed a risk to Resident 1's care, as it could lead to inadequate fall prevention measures being implemented.
Failure to Suspend CNAs During Abuse Investigation
Penalty
Summary
The facility failed to adhere to its abuse protocol during an investigation of an alleged physical abuse incident involving a resident. The resident, who was capable of making her own medical decisions, reported an allegation of physical abuse against two CNAs. According to the facility's policy, staff members accused or suspected of abuse should be suspended pending the completion of the investigation. However, the facility did not suspend the two CNAs involved in the allegation during the investigation period. The investigation file showed that the CNAs continued to work, although they were not assigned to the resident who made the allegation. The facility's staffing sheets confirmed that the CNAs worked during the investigation period but were given different assignments. The Director of Nursing acknowledged that the CNAs should have been suspended to ensure the safety of the resident and other residents in the facility.
Failure to Monitor Resident After Abuse Allegation
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and/or maintained her highest practicable physical well-being. Specifically, the facility did not monitor the resident's safety and psychosocial well-being or develop a care plan after the resident reported an abuse allegation. The resident alleged that two CNAs were rough while changing her diaper and laughed at her during the incident. Despite this report, the facility did not conduct the required 72-hour monitoring of the resident following the abuse allegation. The medical record review revealed that there was no care plan established to address the resident's safety and psychosocial well-being after the abuse allegation. Interviews with the RN and the DON confirmed these findings, acknowledging that the resident's medical record should have included a care plan and 72-hour monitoring by nursing and social services. This oversight had the potential to impact the resident's receipt of necessary care and services.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitation requirements in the kitchen, posing a risk of food-borne illnesses to 42 residents. Observations revealed unsanitary conditions, including multiple metal sheet trays and baking pans with solid black residue, a whisk with a burnt handle, a melted spatula, a cracked spatula, and heavily marred cutting boards. Additionally, a gray plastic bin holding clean kitchen tools was found with water and black particles on the inner bottom surface. These conditions violate the USDA Food Code 2022, which mandates that utensils and food contact surfaces must be clean, durable, and easily cleanable. Further observations showed that a dietary aide handled clean plates with the same gloves used for dirty dishes without changing gloves or washing hands, increasing the risk of cross-contamination. Additionally, a juice machine lacked an air gap for backflow prevention, as required by the USDA Food Code 2022, which could lead to contamination of the juice provided to residents. These deficiencies were verified by the Maintenance Technician and acknowledged by the facility's Administrator, DON, and DSS.
Failure to Implement Two-Person Assist Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff implemented a two-person assist for transfers as required by the care plan for a resident, resulting in an injury. The resident, who had impaired mobility and required substantial or maximal assistance for transfers, was transferred by a single CNA from a shower chair to a bed. During this transfer, the resident's leg was caught between the nightstand, leading to a right ankle fracture. The CNA was unaware of the requirement for a two-person assist, and it was noted that other staff had also been assisting the resident without additional help. The resident's medical records indicated a history of generalized weakness and deconditioning, necessitating extensive assistance for transfers. The care plan, developed by the Case Manager and verified by the Director of Rehabilitation, clearly stated the need for a two-person assist due to the resident's right knee osteoarthritis and decreased activity tolerance. Despite these documented needs, the staff failed to adhere to the care plan, resulting in the resident's injury.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safety of self-administration of medications for one resident, identified as Resident 24. During an observation, two tubes of Voltaren gel, a topical pain medication, were found at the resident's bedside without a physician's order or care plan addressing self-administration. The facility's policy requires an assessment by the interdisciplinary care team to determine if self-administration is safe and appropriate, and to document this in the resident's care plan. However, Resident 24's medical records did not contain evidence of such an assessment or documentation. Interviews with the resident and a registered nurse (RN 1) revealed that the resident was applying the Voltaren gel independently for knee pain, despite not being deemed a candidate for safe self-administration according to a prior assessment. RN 1 confirmed the absence of a physician's order or care plan for self-administration, indicating a lapse in following the facility's policy and procedures for medication management.
Failure to Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that advance directive information was documented and offered to three residents, leading to potential treatment against their wishes. For Resident 22, the facility did not obtain and place a copy of the advance directive in the medical record, despite the POLST indicating its existence. The Social Services Director (SSD) confirmed the absence of the document and acknowledged not contacting the family for a copy. Similarly, Resident 24's advance directive was not available in the medical record, even though assessments indicated its existence and a family member's intention to provide it. The SSD admitted the oversight. For Resident 25, the POLST was not updated to reflect the formulation of an advance healthcare directive, despite documentation of its existence. The SSD verified this discrepancy during a review.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNOC) after the termination of Medicare Part A services for two nonsampled residents, identified as Resident 45 and Resident 47. For Resident 45, the admission record indicated that the last covered day of Medicare Part A services was on August 3, 2024. Although the resident's representative was notified about the last covered Medicare day on May 17, 2024, they were incorrectly given a copy of the CMS 20052 SNF Beneficiary Protection Notification Review instead of the Advance Beneficiary Notification (ABN). Similarly, for Resident 47, the admission record showed that the last covered day of Medicare Part A services was on May 15, 2024. The resident's representative was informed of the last covered Medicare day on May 13, 2024, but was also provided with the CMS 20052 SNF Beneficiary Protection Notification Review instead of the ABN. During an interview and concurrent medical record review on October 22, 2024, the SSD confirmed that the representatives of both residents were informed of the last covered day for Medicare but were not given a copy of the ABN.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to provide timely intervention for a resident who experienced significant weight loss. Resident 22, who was part of a sample reviewed for weight loss, lost 5.32% of their body weight in one month. Despite this significant weight change, there was no assessment from nutritional services, no intervention from a registered dietitian, no care plan developed, and no notification to the resident's physician or family. This lack of action was contrary to the facility's policy and procedures, which require a Nutrition at Risk Review, physician and family notification, and care planning with nutritional goals when significant weight loss is identified. During an interview and medical record review, it was confirmed that the facility's staff, including RN 2 and LVN 1, did not initiate a change of condition for Resident 22. The staff acknowledged that the resident's weight loss was not documented in a care plan, nor was there a progress note indicating that the physician or family had been notified. The facility's process involves using a communication board on the electronic health record system to document changes, but this was not done for Resident 22. The failure to follow these procedures had the potential to result in continued nutritional decline and negative outcomes for the resident.
Failure in Controlled Medication Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate reconciliation and disposal of medications, specifically controlled substances. The facility's policy and procedure (P&P) required that controlled medications in the Omnicell, an automatic drug delivery system, be counted and verified daily by authorized staff. However, it was found that the facility did not comply with this requirement, as evidenced by discrepancies in the Cycle Count Non-Compliant Report. The report listed several controlled medications, such as acetaminophen-cod #3, alprazolam, hydrocodone-acetaminophen, hydromorphone, lorazepam, morphine sulfate, oxycodone, pregabalin, temazepam, tramadol, and zolpidem tartrate, which had not been counted for extended periods, some dating back several months. Interviews with the pharmacy staff and the Director of Nursing (DON) revealed that the night shift nurses were only counting controlled medications that were categorized as 'touched' during their shift, contrary to the facility's P&P that required all controlled substances to be counted daily. The DON confirmed that the facility was not compliant with the daily counting requirement, leading to the risk of medication diversion. The findings were verified through document reviews and interviews, highlighting a significant lapse in the facility's medication management practices.
Failure to Monitor Stool Softener Administration
Penalty
Summary
The facility failed to ensure proper monitoring of a nonsampled resident's medication regimen, specifically concerning the administration of a stool softener, Colace. The facility's policy requires that medication administration be in accordance with applicable laws and that licensed nurses confirm the Medication Administration Record (MAR) reflects the most recent medication order. However, during an observation, a Licensed Vocational Nurse (LVN) administered Colace to a resident without verifying if the resident was experiencing loose stools, as required by the medication order. The LVN admitted to not checking the resident's stool pattern through the facility's point click care dashboard or consulting with the Certified Nursing Assistant (CNA) on duty. The LVN also mentioned that a list of residents with loose stools, which is typically provided, was not available to her that day. This oversight was confirmed during an interview and concurrent medical record review with the Director of Nursing (DON), who verified the findings.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 25, was free from unnecessary psychotropic medications. Resident 25, who was admitted with diagnoses including Parkinson's disease and unspecified dementia, was prescribed Nuplazid, an antipsychotic medication, for psychosis related to Parkinson's disease manifested by paranoid ideation. However, there was no documented evidence of behavioral monitoring for episodes of paranoid ideation or any non-pharmacological interventions provided for Resident 25. Additionally, the care plan did not address the use of Nuplazid for the manifestation of paranoid ideation or include documentation of non-pharmacological interventions. During an interview and medical record review with the Director of Nursing (DON), it was confirmed that there was no documentation of Resident 25's episodes of paranoid ideation, nor was there any monitoring of these episodes or documentation of non-pharmacological interventions. The DON also verified the absence of a care plan for the use of Nuplazid medication for psychosis related to Parkinson's disease manifested by paranoid ideation. This lack of documentation and care planning indicates a failure to adhere to the facility's policy on antipsychotic medication use and informed consent, which requires that non-pharmacological interventions be attempted and documented before considering antipsychotic medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. Resident 7's eye drop medication was not refrigerated as required, and Resident 22's cough medication was stored alongside a topical ointment, contrary to the facility's policy of separating internal and external medications. Additionally, Resident 686's inhalation medication lacked an opened date label, violating the facility's policy. The bottom drawer of Medication Cart 1 was found unclean, with spill residue and dried medication debris. Furthermore, expired medication was found in the medication storage room, specifically a bottle of aspirin with an expiration date of January 2024. During a medication administration observation, a licensed nurse left medications for Resident 27 unattended on two occasions. The nurse left two eye drop medications on the resident's overhead table while performing other tasks, such as washing hands and calling for assistance. This action was against the facility's policy, which states that medications should not be left unattended. These deficiencies were verified by the staff present during the observations, including a licensed vocational nurse, the director of nursing, and a registered nurse.
Unqualified DSS and Kitchen Deficiencies
Penalty
Summary
The facility failed to ensure that the Dietetic Services Supervisor (DSS) responsible for overseeing the satellite kitchen was qualified to manage the day-to-day functions of the food services department. This deficiency was identified during a recertification survey conducted from October 21 to October 24, 2024. The DSS was responsible for managing the skilled nursing facility's (SNF) satellite kitchen, where food was prepared in the main kitchen and then transported to the SNF. The main kitchen was managed by an executive chef, and a registered dietitian (RD) was employed part-time, working two days a week. However, the facility's documents did not provide evidence that the DSS met the qualifications required under the California Code, Health and Safety Code - HSC S 1265.4. During the survey, multiple issues were found in both the main and satellite kitchens, including unclean and improperly maintained kitchen utensils and equipment, as well as a failure to ensure an air gap for a juice machine. These deficiencies had the potential to negatively affect the health and well-being of 42 residents who consumed food prepared in the kitchen. The facility's administrator acknowledged these findings during an interview conducted on October 23, 2024.
Resident Served Allergenic Food Despite Known Allergy
Penalty
Summary
The facility failed to ensure that a resident with a known food allergy was not served an allergenic item, leading to a deficiency. Resident 27, who has an allergy to cucumber as documented in their dietary communication dated 4/12/24, was observed eating lunch independently on 10/21/24 and was served cucumber on their main plate. During an interview and diet card review with the Dietary Service Supervisor (DSS), it was confirmed that the resident had an allergy to cucumber. The DSS acknowledged the error and stated they would replace the cucumber. Resident 27 later confirmed in an interview that consuming cucumber would cause them to vomit and become ill.
Deficiency in Safe Food Handling Education
Penalty
Summary
The facility failed to ensure that education was provided to staff and family/visitors on safe food handling of outside food, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. The facility's policy allowed food to be brought in by visitors and family, but there was a lack of comprehensive education on safe food handling practices. The DSS stated that she informed residents and visitors about how long food could be kept in the refrigerator but did not provide specific guidance on proper cooking and cooling temperatures or distribute literature on safe food handling. The DSD/IP admitted to only reminding staff to label food properly and ensure it was appropriate for the resident's diet, without providing in-depth education on safe food handling practices. The in-services were limited to CNAs and did not include licensed staff, who were responsible for reheating food. LVN 2 confirmed that she did not educate visitors on safe food handling, and reheating was done by kitchen staff, not licensed staff or aides. The facility's leadership, including the Administrator and DON, acknowledged these findings.
Failure to Provide Required Hospice Services
Penalty
Summary
The facility failed to provide necessary hospice care and services for a resident, identified as Resident 22, who was part of a sample reviewed for hospice services. The deficiencies included the failure to ensure that the resident received a hospice aide visit once per week as ordered by the physician. Additionally, the hospice log lacked documentation regarding the Certified Home Health Aide (CHHA) visit. Furthermore, the hospice Registered Nurse (RN) was not included in the resident's Care Conference/Care Plan Meeting. The facility's policy and procedure for hospice services, revised in November 2024, outlined the responsibilities of hospice providers and the facility in managing the resident's care. However, a review of the medical records and facility documents revealed that the CHHA visits were not conducted as required, with no visits documented from March to October 2024, except for a few in May. The Director of Nursing (DON) confirmed these findings. Additionally, the hospice case manager was unable to attend a care conference meeting, and there was no documentation of hospice involvement in the resident's care conference.
Deficiencies in Respiratory Care and Medication Storage
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee identified and developed action plans to address deficiencies noted in the previous recertification survey. Specifically, the facility did not have documented evidence of action plans to correct issues related to respiratory care and medication storage. These deficiencies were cited again during the current recertification survey, indicating a lack of effective corrective measures. The absence of documentation for the respiratory care process, such as labeling and dating respiratory equipment, and the lack of a documented medication storage improvement process were highlighted during interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). During the survey, the DON was unable to provide documentation to support the training and procedures claimed to be in place for respiratory care, such as labeling and changing respiratory tubing. Similarly, the DON could not provide logs or documentation for the medication storage checks that were supposed to be conducted daily by the charge nurse. An LVN interviewed stated that he only checked his medication chart once a week and only reviewed the morning medications he would administer, rather than the entire cart. This inconsistency in practice and lack of documentation contributed to the repeated citation of deficiencies in respiratory care and medication storage.
Infection Control Deficiencies in Surveillance, Laundry, and Hygiene Practices
Penalty
Summary
The facility failed to maintain an accurate infection surveillance program for September and October 2024. Several discrepancies were noted in the Infection Surveillance Reports, where residents were documented with incorrect infections. For instance, Resident 20 was reported to have a urinary tract infection but met the criteria for gastroenteritis. Similarly, Resident 25 was documented with pneumonia but met the criteria for gastroenteritis. These inaccuracies were confirmed by the Director of Staff Development/Infection Preventionist (DSD/IP) and Registered Nurse 1/Infection Preventionist (RN 1/IP), who acknowledged that the Infection Control Surveillance should be accurate for effective reporting and intervention. In the facility's laundry room, infection control practices were not properly implemented. Observations revealed that clean linens were in contact with personal items such as a radio, charger, sweater, and hat, which were placed on the folding area. This was verified by the Director of Housekeeping, indicating a breach in maintaining a sanitary environment for handling clean laundry. Additionally, there were lapses in hand hygiene practices by a licensed nurse (LVN 1) during medication administration for a resident. LVN 1 failed to perform hand hygiene after removing gloves and before donning new ones, as well as after touching potentially contaminated items like a TV remote and call light. Furthermore, improper Foley catheter care was observed for another resident, where the catheter tubing tip was not cleaned after draining urine, and the urinal was inadequately rinsed and stored. These practices were confirmed by the involved staff and the DSD, highlighting a failure to adhere to infection control protocols.
Failure to Document Vaccine Offer and Discussion
Penalty
Summary
The facility failed to ensure that two residents were offered the influenza and pneumococcal vaccines in accordance with CDC guidelines. Resident 4, who lacked the capacity to make medical decisions, had a blank consent form for the pneumococcal vaccine, and there was no documentation of refusal or discussion of risks and benefits with the resident or their representative. Although the facility claimed that Resident 4 was offered the PPV 23 vaccine, they could not provide evidence of this offer or any related discussions. Similarly, Resident 25, also lacking decision-making capacity, had declined both the influenza and pneumococcal vaccines, as indicated by marks on their consent forms. However, there was no documentation to support that the risks, benefits, and potential side effects of the vaccines were discussed with the resident or their representative. The facility's staff confirmed these findings during interviews, and the lack of documentation posed a risk of the residents acquiring influenza and pneumonia.
Failure to Maintain Temperature Logs for Drug Dispensing System
Penalty
Summary
The facility failed to maintain essential temperature logs for the Omnicell Anatomic Drug Dispensing system, which is crucial for ensuring the safe operating conditions of the equipment. According to the facility's policies and procedures, medications and biologicals should be stored at appropriate temperatures as per the United States Pharmacopeia guidelines and manufacturer guidance. The facility's policy also requires daily monitoring of the temperature in medication storage areas. However, a review of the Automated Drug Delivery System (ADDS) Daily Temperature and Cycle Count Log revealed multiple instances where the temperature gauge was either blank or not working during the night shift across several months. Interviews with the Director of Nursing (DON) and a registered nurse (RN) confirmed that the temperature should be recorded daily. Despite placing a work order to replace the faulty thermometer, the night shift nurses continued to leave the temperature log incomplete. The DON and RN acknowledged that failing to accurately record temperature monitoring could potentially affect the residents' medications. The facility's Pharmacy ADDS Checklist also indicated that any concerns, such as temperature excursions, should be reported to the DON and pharmacy, with documentation of who was notified and the actions taken to resolve the issues.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, leading to inappropriate use of antibiotics for one sampled resident and two nonsampled residents. Resident 20 was prescribed ciprofloxacin for a urinary tract infection despite meeting the McGeer's Criteria for gastroenteritis, with no documented evidence that the physician was informed of the discrepancy. Similarly, Resident 9 was given azithromycin for a cough without documentation indicating whether the infection met the criteria for a true infection. Resident 25 was prescribed Augmentin for pneumonia, although the resident met the criteria for gastroenteritis, and there was no evidence that the physician was informed of this inconsistency. The facility's Infection Preventionist (IP) or designee was responsible for reviewing antibiotic utilization as part of the antibiotic stewardship program, but failed to identify and address these inconsistencies. During interviews, the Director of Staff Development/Infection Preventionist (DSD/IP) and a registered nurse (RN 1/IP) confirmed the findings and acknowledged that the facility should have notified the physician or obtained clarification for the use of antibiotics when residents did not meet the criteria. The Administrator and Director of Nursing (DON) also acknowledged these findings, indicating a lapse in the facility's adherence to its own policies and procedures regarding antibiotic use.
Inadequate Respiratory Care Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 17 and Resident 22, as observed during a survey. For Resident 17, the nasal cannula tubing was not stored in a sanitary manner when not in use. It was observed hanging on the concentrator instead of being stored in a bag, as required by the facility's policy. This observation was confirmed by LVN 3 during an interview, and the Director of Nursing (DON) was informed of the findings. For Resident 22, the facility did not date the nasal cannula tubing and respiratory storage bag, which is a requirement according to the facility's policy on oxygen administration. The policy mandates that oxygen equipment should be changed and dated every Sunday by the night shift staff. During an observation, it was noted that Resident 22's nasal cannula and storage bag were undated and unlabeled. This was verified by LVN 2 during a concurrent interview. These deficiencies in respiratory care practices had the potential to affect the respiratory health and well-being of the residents receiving such care.
Failure to Follow Main Menu and Notify Residents
Penalty
Summary
The facility failed to ensure that the main menus were followed for all 42 residents who consumed food prepared in the kitchen. According to the facility's policy and procedure titled 'Menu Alternatives' dated 2018, the Director of Food and Nutrition Services is responsible for supervising meal preparation and ensuring the menu is followed and served as planned. However, on the specified date, the lunch main menu, which included Burgundy Beef Tenderloin Tips, Parslied Noodles, and Seasoned Spinach, was not served. Instead, the alternate menu, which included Turkey Pot Pie and Seasoned Spinach, was prepared and served without notifying the residents of the menu change. This was confirmed through observation and interviews with the Director of Food and Nutrition Services, who acknowledged the deviation from the planned menu and the lack of resident notification.
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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