Landmark Medical Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and implementation of ordered monitoring after a resident-on-resident altercation. One resident with schizophrenia and major depressive disorder reported that another resident came from behind, stated there was a spider on the resident’s arm, and pinched the upper arm hard. Progress notes documented that the resident who was pinched became nervous around the aggressor following the incident. Both residents were assessed as having intact cognition and were largely independent in activities of daily living, with supervision needed only for personal hygiene. Following the altercation, the charge nurse notified the physician and obtained an order for the aggressor to receive 1:1 monitoring for two hours, followed by every 15-minute monitoring for two hours, due to physically assaultive behavior toward a peer. The physician’s order specified that this monitoring was to be documented in the electronic health record (Point Click Care) or on a 1:1 monitoring form. However, the charge nurse did not enter the 1:1 order into the electronic health record and did not assign a 1:1 sitter to the resident as required. Interviews and record review confirmed that the ordered 1:1 monitoring and subsequent Q15-minute checks were not initiated or documented in Point Click Care, contrary to the facility’s policy for timely and accurate 1:1 and Q15-minute monitoring documentation. The registered nurse supervisor and the DON both stated that facility policy required obtaining a 1:1 order for the aggressor after such an incident and initiating the monitoring in the electronic health record so that assigned CNAs could provide continuous direct line-of-sight observation and document every 15 minutes. Because the order was not entered, the aggressor was left unmonitored for more than two hours after the order was obtained.

Penalty

No penalty information released

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

Summary

The facility failed to prevent resident-to-resident abuse involving two residents who were assaulted by another resident with a known history of aggressive and assaultive behavior. One resident, who had diagnoses including schizoaffective disorder and moderate cognitive impairment, exhibited escalating agitation and aggression, including punching doors and displaying assaultive behavior toward both staff and peers. Despite these behaviors, the resident was removed from one-to-one (1:1) monitoring after a period of time, based on the discontinuation of suicidal ideation, even though the resident continued to display assaultive tendencies. Following the removal from 1:1 monitoring, the resident physically assaulted two other residents on separate occasions. In the first incident, the resident struck another resident on the head with a food tray while that resident was eating breakfast. In the second incident, the same resident hit another resident on the head and pulled their hair during a smoke break on the facility's patio. Both incidents were unprovoked, and staff interviews confirmed that the resident had a pattern of aggressive outbursts and that 1:1 monitoring was intended to prevent such harm. The affected residents experienced pain and psychological distress as a result of these assaults. One resident reported feeling unsafe and afraid of further assaults, expressing ongoing discomfort and fear for their safety. Documentation and interviews indicated that the facility's failure to maintain appropriate supervision and monitoring, as outlined in their own policies and follow-up investigation report, directly led to these incidents of abuse and the resulting harm to the residents.

Penalty

No penalty information released

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

Summary

A facility failed to ensure that a resident with a history of major depressive disorder, schizoaffective disorder, bipolar disorder, and substance abuse was properly monitored according to its own policies and procedures. The resident had active orders for every 15-minute (q15) monitoring due to a previous attempt to leave the facility without permission (AWOL). Despite these orders and the facility's policy requiring staff to physically enter the resident's room and maintain a clear line of sight every 15 minutes, surveillance footage and documentation revealed that the assigned CNA did not perform the required checks. The CNA remained seated outside the resident's room for extended periods and falsified documentation by recording checks that were not performed. On the morning of the incident, the resident was last seen entering their room, and approximately 16 minutes later, was found by another CNA hanging from a sprinkler head using a bed sheet. Immediate resuscitation efforts were initiated, and emergency services were called. The resident was transferred to a general acute care hospital, where they were declared brain dead two days later due to prolonged cardiac arrest and cerebral edema resulting from asphyxiation. Interviews with staff and review of facility policies confirmed that the required q15 monitoring and room checks were not conducted as mandated. The facility's policies specified that staff must physically enter the room, check the bathroom, and ensure the resident's safety and well-being. The CNA responsible for the checks was terminated for failing to follow these procedures and for falsifying records. The deficiency was directly linked to the lack of adequate supervision and failure to follow established monitoring protocols for a resident at high risk for self-harm.

Penalty

No penalty information released

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

Summary

The facility failed to ensure an environment free from physical abuse for two of six sampled residents. In the first incident, one resident with diagnoses including paranoid schizophrenia and major depressive disorder punched another resident in the dining room while unsupervised. The aggressor claimed the other resident repeatedly asked for money, which led to the altercation. The victim denied any prior interaction and reported feeling frustrated and upset after being punched. Staff were not present inside the dining room at the time, as they were occupied with sanitizing residents' hands at the doorway, which left the residents unsupervised during the incident. In the second incident, another resident was hit on the left side of the face by a peer while attempting to move out of the way near a doorway. Both residents involved had psychiatric diagnoses, and one had a history of inattentive or disorganized thinking. The aggressor reported being provoked by cursing and being blocked in the doorway, leading to a physical altercation. A CNA witnessed the event, noting that both residents tried to get past each other before the aggressor struck the other resident. The victim experienced mild pain and was administered Tylenol for relief. The facility's policy and procedure on physical assault requires immediate reporting of all forms of abuse, including resident-to-resident assaults, and emphasizes the need to provide a safe and secure environment. However, in both incidents, lapses in supervision and monitoring contributed to the occurrence of physical abuse between residents. Staff interviews confirmed that the absence of direct supervision in common areas, such as the dining room, may have allowed these altercations to occur.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement individualized, person-centered care plans for four residents, resulting in unmet needs related to activities of daily living (ADLs), oral/dental care, smoking, and management of post-traumatic stress disorder (PTSD). For one resident, care plans addressing compliance with ADLs and oral/dental care were not properly implemented. Observations revealed the resident had a dry crust around the lips and significant buildup and discoloration on the teeth. Interviews with staff indicated that while oral hygiene supplies were provided, there was no follow-through to ensure the resident completed oral care, and staff were not instructed to monitor or prompt the resident as required by the care plan. Another resident who smoked did not have a care plan addressing smoking, despite documentation of nicotine dependence and a facility policy requiring such a plan. The resident was observed smoking under staff supervision, but both the RN and DON confirmed that a care plan for smoking was missing. Facility policy specified that a care plan should be in place to address nicotine dependence, safety, and smoking cessation education, but this was not done. Two additional residents with documented diagnoses of PTSD did not have care plans addressing this condition. Both residents' records and care plans were reviewed, and it was confirmed by nursing staff and the DON that care plans for PTSD were not created. Facility policy required the development of trauma-informed care plans when trauma was identified, but this was not followed. The lack of appropriate care plans for these residents meant that their specific needs related to PTSD were not addressed, and staff did not have guidance for managing symptoms or providing consistent care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two residents with documented diagnoses of Post Traumatic Stress Disorder (PTSD) received care that addressed their individual trauma experiences, as required for trauma-informed and culturally competent care. Both residents were admitted with PTSD and other mental health conditions, and their Minimum Data Set assessments indicated that they were cognitively intact and independent with activities of daily living and mobility. Despite these documented diagnoses, neither resident had a care plan (CP) specifically addressing PTSD. During interviews, a Licensed Vocational Nurse confirmed that care plans should have been created for these residents to address signs and symptoms, maintain well-being, provide coping strategies, and guide staff in delivering consistent care. The absence of PTSD-specific care plans meant that staff did not have guidance to recognize or address the residents' trauma, even if the exact trauma was not disclosed. The Director of Nursing also acknowledged that the facility was responsible for developing care plans tailored to each resident's trauma and unique experiences, and that the lack of such plans meant the residents' trauma-informed needs were not fully addressed. A review of the facility's policy on trauma-informed care indicated that care should be provided in a manner that accounts for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. However, the facility did not implement these policies for the two residents in question, resulting in a deficiency related to the provision of trauma-informed and culturally competent care.

Penalty

No penalty information released

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

Summary

The facility failed to properly store food items in a manner that would prevent foodborne illness in the kitchen. During an observation with the Dietary Supervisor, five out of forty-seven apples were found to be spoiled, exhibiting wrinkled skin, bruising, broken skin, and a soft texture. Additionally, one out of sixteen onions was found flattened in a brown liquid with a foul odor. The Dietary Supervisor acknowledged that these items were not fit for consumption and should have been removed during routine inspections, as required by the facility's policy. The policy specified that produce should be inspected on Mondays and Thursdays, and any spoiled or damaged items should be immediately discarded. Further, the facility did not ensure that employees kept personal belongings out of the kitchen area. An employee's cellphone and keys were observed left unattended on a table near the refrigerator. The Dietary Supervisor confirmed that staff had been instructed multiple times to store personal items in lockers to prevent potential food contamination, and another cook confirmed that keeping cellphones in the kitchen was unsanitary and against facility policy. The facility's policy required all personal belongings to be kept in employee lockers.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was informed and provided with information regarding housing alternatives after discharge, violating the resident's right to be informed about their treatment and discharge planning. The resident, who was cognitively intact and independent in daily activities, expressed a desire to leave the facility and return to the community, specifically mentioning missing family and wanting to know more about the discharge process. Documentation showed that the resident was in discharge planning, with referrals made to a local contact agency and acceptance into an outside rehabilitation program, but there was no evidence that the resident was informed of these developments or given a projected date for housing. Interviews and record reviews confirmed that the Social Services Director was aware of the resident's acceptance into a rehabilitation program and the ongoing wait for a bed, but admitted there was no documentation indicating the resident had been informed of these updates. Facility policies required residents to be actively engaged and informed in their care and discharge planning, but this was not followed in this case, as the resident remained unaware of the status and timeline of their discharge despite ongoing planning and referrals.

Penalty

No penalty information released

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

Summary

The facility failed to provide a radio in a timely manner to a resident with schizoaffective disorder, bipolar type, and insomnia, despite documented preferences and care plans indicating that listening to music was very important to the resident. The resident was admitted with intact cognition but had inattentive or disorganized thinking and was able to independently perform activities of daily living. The resident's activity assessment and care plan both highlighted music as a significant interest, and the resident repeatedly requested a radio from the Social Services Director (SSD), stating that not having one was causing boredom and depression. The SSD was responsible for making purchases for residents and stated that shopping trips for such items were conducted on a quarterly basis, despite facility policy indicating monthly shopping. The SSD explained that the resident's request for a radio was made after the cutoff for the last shopping trip and that the resident would have to wait until the next scheduled trip. The facility's policy and the SSD's statements revealed a discrepancy between the stated frequency of shopping and actual practice, resulting in the resident's needs and preferences not being accommodated in a timely manner.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that eyeglasses were made available to a resident with multiple visual impairments, as indicated in the optometry consultation and the care plan for impaired visual function. The resident was admitted with diagnoses including right eye keratopathy, bilateral nuclear cataract, bilateral glaucoma, presbyopia, and schizoaffective disorder. The care plan specified that the resident should use appropriate visual devices, such as glasses, to promote participation in activities of daily living, and staff were instructed to remind the resident to wear glasses and ensure they were in good condition. An optometry consult recommended bifocal glasses to improve the resident's vision and quality of life, and both the Minimum Data Set (MDS) and History and Physical (H&P) confirmed the need for corrective lenses. Despite these documented needs, multiple observations and interviews revealed that the resident did not have access to their glasses. The resident reported that their glasses were missing and had not been replaced, and staff members, including CNAs and an LVN, confirmed they had not seen the resident with glasses and could not locate them in the resident's room or at the nurse's station. The Director of Nursing also acknowledged the importance of the resident having glasses and confirmed their absence. The facility's policy stated that residents have the right to necessary accommodations and support for daily living, but this was not upheld in the resident's case.

Penalty

No penalty information released

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

Summary

The facility failed to accurately document a one-to-one (1:1) monitoring for two hours after an altercation involving a resident. This deficiency was identified during a review of the resident's records, which showed that the 1:1 monitoring was ordered by a physician following an altercation with another resident. The resident, who was readmitted with diagnoses including schizophrenia and major depressive disorder, was supposed to be under continuous observation for two hours, followed by monitoring every fifteen minutes. However, the facility was unable to provide documentation of this monitoring as required. Interviews with the facility's Administrator and Medical Records staff revealed that the 1:1 monitoring order was incorrectly entered into the electronic documentation system, Point Click Care (PCC), by the staff. The Quality Assurance Nurse confirmed that the Licensed Vocational Nurse responsible for initiating the monitoring did so incorrectly, resulting in the absence of required documentation. The facility's policies and procedures clearly outlined the process for carrying out such orders, but these were not followed, leading to the deficiency in documentation.

Penalty

No penalty information released

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

Summary

The facility failed to provide immediate cardiopulmonary resuscitation (CPR) to a resident who was a full code when found unresponsive. The resident, who had diagnoses including paranoid schizophrenia, bipolar disorder, and obesity, was discovered unresponsive in their room by a Certified Nursing Assistant (CNA). Despite being CPR certified, the CNA did not initiate CPR, instead leaving the room to inform a Licensed Psychiatric Technician (LPT). The LPT, upon entering the room and finding the resident unresponsive, also did not start CPR immediately but instead sought assistance from a Licensed Vocational Nurse (LVN). The delay in initiating CPR was further compounded when the LVN, upon arrival, also failed to start CPR immediately. It was not until the Director of Staff Development (DSD) entered the room and instructed the LPT and LVN to begin CPR that the procedure was started. By this time, several minutes had passed since the resident was first found unresponsive. The emergency medical technicians (EMTs) arrived shortly after and took over the resuscitation efforts, but the resident was pronounced dead shortly thereafter. The facility's policy required that CPR be administered immediately to any resident found unresponsive unless there was an advance directive stating otherwise. In this case, the resident did not have an advance directive, and the facility's default policy was to treat all residents as full code. The failure to adhere to this policy and the delay in providing CPR were identified as deficiencies by the California Department of Public Health, which noted that the facility's noncompliance had caused or was likely to cause serious harm or death to the resident.

Removal Plan

• The Director of Nursing and Administrator provided in-service education to all nursing staff on duty, focusing on the protocol for providing CPR to an unresponsive resident.
• In-service training included: Nursing staff first on scene of the unresponsive resident will begin to administer CPR while calling for a Code Blue and the location of the resident.
• Staff not administering CPR will call 911 immediately.
• Nursing staff first on scene will not discontinue CPR until another nursing staff member that is CPR certified takes over doing CPR or paramedics arrive; whichever is first.
• Staff is not to leave the unresponsive resident until expiration has been verified by paramedics.
• The Director of Nursing reviewed all current residents' code status and documentation of no advanced directive by responsible party was all residents' charts. All current residents are full code status.
• The facility updated its Emergency Response Policy to clearly state that any staff member who discovered an unresponsive resident must immediately alert the nearest nursing staff and remain with the resident.
• The Director of Nursing conducted in-service training to licensed staff, nursing aid, and CNAs. The staff not present will be in-serviced immediately upon return to the facility.
• Code Blue Drills will be conducted randomly by the Director of Nursing on various shifts to ensure proficient and competent knowledge of Emergency Response Procedures.
• The Staff Developer will conduct audits of staff (across all departments when applicable) to assess knowledge of emergency response procedures and CPR protocol.
• Emergency Response Procedures will be a part of orientation training for all new nursing staff.
• The Quality Assurance Nurse will review all emergency response incidents for proper adherence to protocol.
• The Staff Developer will report the monitoring plan results during the Quality Assurance and Assessment meeting. The Quality Assurance and Assessment committee will review the effectiveness of the interventions and make any necessary adjustments to the plan. Monitoring will be on an ongoing basis until sustained compliance is achieved, as evidenced by compliance in all audits and drills.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LPT 1) conducted hourly visual checks for five residents during the night shift, as required by the facility's policies and procedures. CNA 1 was responsible for monitoring Resident 4 on a one-to-one basis and was also assigned to care for residents in multiple rooms. However, CNA 1 only conducted visual checks at the start of the shift and did not perform further checks throughout the night. Instead, CNA 1 monitored the residents by sitting in the hallway and observing when residents left their rooms, which did not comply with the facility's policy for hourly monitoring. LPT 1, who was new to the facility, did not conduct visual checks on Resident 1, as the resident was not identified as critical. LPT 1 was under the impression that CNAs were responsible for checking residents in their assigned zones. The facility's Director of Nursing (DON) stated that staff should document the location of residents during hourly checks, but CNA 1 documented Resident 1's location without conducting the required visual checks. The facility's policies indicated that CNAs should conduct hourly in-room inspections in teams of two, but this procedure was not followed. The facility's policies also included the use of a security wand for monitoring, which was not available on the night in question due to repairs. This system was intended to replace hourly room checks by allowing staff to check each resident room every 15 minutes. Despite this, the facility's policy for hourly monitoring remained unchanged, requiring CNAs to observe and document the location of each resident in their assigned section. The failure to adhere to these policies resulted in a deficiency related to the supervision and safety of the residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Certified Nurse Assistant 1 (CNA 1) and Licensed Psychiatric Technician 1 (LPT 1) demonstrated competency during a medical emergency involving a resident who was found unresponsive on the floor. The incident involved a resident with diagnoses including paranoid schizophrenia, bipolar disorder, and obesity, who was admitted with intact cognition and no impairments in upper or lower extremities. During the emergency, LPT 1 initially assessed the situation as requiring assistance from a more experienced nurse and left the resident to seek help, while CNA 1, upon discovering the resident, also left to notify LPT 1 without initiating immediate CPR. The report highlights that the facility was unable to provide 37 out of 74 CPR certificates for direct care staff, indicating a lack of verification of current CPR training for all staff members. The Administrator acknowledged the absence of these certificates and attributed it to the Director of Staff Development's need to print them from emails. Additionally, there was no evidence of a current skills competency evaluation for CNA 1, as confirmed by the Director of Nursing, who stated that such evaluations should be conducted upon orientation and annually. The facility's policy and procedure require nursing staff to have competency skills evaluations completed upon orientation and annually, with additional evaluations as needed. However, the lack of evidence for CNA 1's current evaluation and the incomplete CPR certification records suggest a failure to adhere to these policies. This deficiency had the potential to delay treatment and CPR delivery to the resident and could affect all other residents in the facility.

Penalty

No penalty information released

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

Summary

The facility failed to protect the rights of two residents from abuse, as outlined in their policy and procedure on elder and dependent adult abuse. Resident 1 was subjected to unwanted physical contact when Resident 2 kissed her on the neck without consent. This incident was observed by a Licensed Psychiatric Technician and confirmed through video footage. Resident 1, who had no cognitive impairments and was independent in daily activities, reported feeling disgusted by the incident. Resident 2, who also had no cognitive impairments, admitted to the act, stating he thought Resident 1 needed a friend. In a separate incident, Resident 4 was subjected to intimidation and physical aggression by Resident 3, who spat on Resident 4 and threatened her by raising a chair as if to throw it. Resident 3, who was moderately impaired in cognitive skills, admitted to the altercation. Video footage confirmed the spitting and threatening behavior. Resident 4, who had no cognitive impairments, reported feeling scared during the incident. The facility's policy, revised in March 2024, mandates the protection of residents from all forms of abuse, including physical and sexual abuse. However, the facility failed to uphold this policy, resulting in emotional distress for Residents 1 and 4. These incidents highlight a breach in the facility's duty to ensure a safe environment for its residents.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of sexual abuse involving two residents to the California Department of Public Health, the Ombudsman, and local law enforcement within the required two-hour timeframe. Resident 1, who had no cognitive impairments, reported that Resident 3, who was moderately impaired in cognitive skills, had kissed Resident 1 on the neck and touched Resident 1's breasts. This incident was not reported immediately as required by the facility's policy and procedure on elder and dependent adult abuse. The Group Leader Counselor (GLC) was informed by Resident 1 about the incident around March 2024 but did not notify the Administrator (ADM). The GLC informed the Program Director (PD), who also did not document or report the incident, as they could not substantiate the claim. The ADM later acknowledged that all allegations of abuse should be reported within two hours, but this protocol was not followed, resulting in a delay in notification and potential risk to Resident 1.

Penalty

No penalty information released

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

Summary

The facility failed to thoroughly investigate and document an allegation of sexual abuse involving two residents. Resident 1, who had no cognitive impairments, reported that Resident 3, who was moderately impaired in cognitive skills, kissed Resident 1 on the neck and placed hands on Resident 1's breasts. This incident was reported to a Group Leader Counselor (GLC) by Resident 1, who then informed the Program Director (PD). However, the PD did not document the incident or the results of any investigation, and the exact date of the report was not remembered by the staff involved. The facility's policy and procedure on Elder/Dependent Adult Abuse required immediate investigation and documentation of any abuse allegations, including interviewing all involved parties and maintaining documentation for a specified period. The Administrator acknowledged that the investigation was not thorough and that proper documentation was not maintained. This lack of action and documentation was a violation of the facility's policy, potentially leaving Resident 1 vulnerable to further abuse.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from physical abuse, specifically unwanted anal digital penetration, by another resident. Resident 1, who was admitted with diagnoses including schizoaffective disorder and depression, reported being raped by Resident 2. Resident 1 was independent in daily activities and had clear communication abilities, although they were described as cooperative but confused with tangential thought processes. The incident was reported after Resident 1 alleged that Resident 2 had penetrated them without consent, causing physical and emotional trauma. Resident 2, who also had a diagnosis of schizoaffective disorder and depression, was cognitively intact and independent in daily activities. However, their judgment and insight were impaired. Resident 2 confessed to the act during a private conversation with a counselor and later during an interview, admitting to the unwanted sexual contact with Resident 1. The facility's policy on the prevention of sexual abuse clearly defines non-consensual sexual contact as abuse, which includes unwanted intimate touching and sexual assault. Interviews with facility staff, including a primary counselor, assistant program director, licensed vocational nurse, and the administrator, confirmed the occurrence of the abuse and the violation of Resident 1's rights. The facility's policy emphasizes the protection of residents from all forms of abuse, including sexual abuse, which was not upheld in this instance. The deficiency resulted in Resident 1 experiencing both physical and emotional abuse, highlighting a failure in the facility's duty to protect its residents.

Penalty

No penalty information released

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

Summary

The facility failed to protect two residents from abuse, as evidenced by incidents involving inappropriate touching and physical aggression. On August 16, 2024, a resident inappropriately touched another resident's vaginal area in the hallway outside a room. The resident who was touched reported feeling uncomfortable and withdrew from social activities following the incident. Interviews with staff revealed that there was a lack of monitoring and intervention when residents were observed asking for money, which could have prevented the inappropriate contact. In a separate incident on the same day, another resident was pushed on the back by a peer in the hallway near the Nurse's Station. The resident who was pushed reported feeling scared and unsafe around the aggressor. The aggressor was supposed to be under 1:1 monitoring due to a history of physically assaultive behavior, but the assigned staff was not positioned appropriately to prevent the incident. Surveillance video confirmed that the staff failed to intervene when the residents began exchanging words, leading to the physical altercation. The facility's policies and procedures regarding abuse prevention and physical assault were not adequately followed, resulting in these incidents. The staff did not maintain the required distance between residents or provide the necessary supervision to prevent abuse. The facility's failure to adhere to its own policies and ensure a safe environment for residents contributed to these deficiencies.

Penalty

No penalty information released

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

Summary

The facility failed to protect two residents from physical abuse, resulting in an altercation between them. On August 11, 2024, Residents 1 and 2 were involved in a physical confrontation where Resident 2 pushed Resident 1, and Resident 1 retaliated by pushing Resident 2. This incident led to both residents falling to the floor, with Resident 1 sustaining an abrasion on the right forearm. The altercation occurred in Room A, where both residents were found arguing by staff after hearing commotion. Resident 1 was admitted with diagnoses including schizoaffective disorder, pneumonia, and major depressive disorder. The Minimum Data Set (MDS) indicated moderate cognitive impairment, requiring supervision for decision-making. Progress notes and care plans documented the altercation and the resulting injury to Resident 1, who experienced mild pain from the abrasion. The care plan also noted Resident 1 as a victim of resident-to-resident abuse. Resident 2, also diagnosed with schizoaffective disorder, type 2 diabetes mellitus, and major depressive disorder, was similarly assessed as moderately impaired in cognitive skills. The care plan for Resident 2 documented physically assaultive behavior and identified Resident 2 as both a perpetrator and victim of abuse. The facility's policy on physical assault emphasized the need for a safe environment, which was not upheld in this incident.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a system for safeguarding prescribed medications, including controlled substances, for all residents. This deficiency was identified through observations, interviews, and record reviews, revealing that accountability records for controlled substances were not maintained. Specifically, the facility did not use individual controlled drug records (CDR) for accurate accountability of controlled medications for several residents. Medications such as lorazepam, clonazepam, zolpidem, lacosamide, and clobazam were involved, and the lack of proper documentation and accountability posed a risk of medication errors and potential drug diversion. Additionally, the facility did not ensure that medication carts and cabinets containing controlled medications were locked and secured when not in use. Controlled medications were stored together with noncontrolled medications in medication carts at two nursing stations, and the access keys were not properly managed. This lack of security allowed unauthorized access to medications, further compromising the safety and accountability of controlled substances. The facility's Director of Nursing (DON) and other staff members acknowledged the absence of a robust system for controlled medication accountability and inadequate staff training on controlled medication management. The facility's policies and procedures were not followed, and there was no system in place to ensure that all doses of controlled medications were administered as prescribed or to reconcile discrepancies between the original quantity delivered and the quantity destroyed.

Removal Plan

• All controlled medications for the sampled residents were secured in a locked box within the medication cart.
• A routine count sheet was created for each resident that received controlled medications.
• All routine narcotic medications were moved to a locked box within the medication cart with individual counting sheets for each medication.
• The DON and the new Pharmacy Consultant conducted a facility-wide audit to identify all residents that received controlled medications. The same immediate actions taken for the sampled residents were implemented for all residents that received controlled medications.
• A root cause analysis was conducted, including interviews with nursing staff, review of medication administration records, and analysis of current policies and procedures.
• A new controlled medication accountability system was implemented: Individual counting sheets for each resident's-controlled medication, Dual nurse sign-off for waste or refusal of controlled medications, Shift change audits of controlled medications.
• All controlled medications were stored in a locked box within a locked drawer in the medication cart.
• Narcotic keys were kept with the charge nurse and stored on their person until endorsed to the next licensed nurse during shift change.
• Licensed nurses would submit discontinued medications to the DON as soon as possible after the medication were discontinued or when the resident was discharged.
• The DON completed an inventory of all controlled medications currently on hand in the facility.
• Discontinued controlled medications were stored in a locked box bolted inside a locked drawer in the DON's office.
• The DON would count discontinued controlled medications with the licensed nurse and document the receipt on the narcotic sheet.
• A new pharmacy consultant from the facility's pharmacy provided in service training to all licensed staff on controlled medication management, storage, counting, documentation, and wasted controlled medication procedures.
• The facility would review policies on Medication Storage in the Facility, Medication Ordering and Receiving from Pharmacy, Controlled Medications, and Controlled Substance Prescriptions to reflect new procedures.

Penalty

No penalty information released

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

Summary

The facility failed to provide documented evidence that five residents or their legal representatives were informed and/or provided written information regarding Advance Directives (ADs). This deficiency was identified during interviews and record reviews. The absence of documentation had the potential to violate the residents' rights to formulate ADs and could lead to inappropriate or medically unnecessary care. Resident 24 was admitted with multiple diagnoses, including schizoaffective disorder and type 2 diabetes mellitus. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. However, there was no documented evidence that Resident 24 and their conservator acknowledged receipt of AD information. Similarly, Resident 48, who had moderate cognitive impairment, did not have a signed Acknowledgement of Advanced Directive (AAD) form, and the facility failed to follow up with the responsible party. Resident 89, with intact cognitive status, also lacked a signed AAD, and the facility did not have the admission packet on file. Resident 59, admitted with schizophrenia and other conditions, had an incomplete AAD not signed by the conservator. Resident 9, with intact cognition, also had an incomplete AAD without the responsible party's signature. The Medical Records Director acknowledged the importance of having documented evidence of AADs as per the facility's policy and procedure. The facility's brochure and policy on resident rights emphasized the importance of informing residents about their rights to make health care decisions, including the formulation of ADs.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement individualized person-centered care plans for two residents, Resident 10 and Resident 44, as per the facility's policy and procedures. Resident 10, who was admitted with diagnoses including paranoid schizophrenia, major depressive disorder, and severe impaired cognition, had multiple falls on several dates. Despite being at high risk for falls, as indicated in the Nursing Risk for Falls Evaluation, Resident 10's care plan was not updated after each fall. Interviews with the Quality Assurance Nurse and a Registered Nurse revealed that the care plans were not revised to include proper interventions after each incident, which is crucial for preventing future falls and evaluating the effectiveness of current interventions. Resident 44, admitted with schizophrenia, cataracts, tributary retinal vein occlusion, and legal blindness, also did not have an individualized care plan addressing their high risk for falls and blindness. Observations and interviews indicated that Resident 44 used hallway handrails for guidance due to blindness and required assistance with ambulation and activities of daily living. However, the care plan only indicated assistance as needed, rather than consistently addressing safety concerns related to blindness and fall risk. The Registered Nurse acknowledged that the care plan was not tailored to Resident 44's specific needs and did not ensure safety during various activities. The facility's policies on care plans and fall risk evaluations emphasize the importance of updating care plans to assist residents in achieving their highest practicable well-being. However, the care plans for Residents 10 and 44 were not adequately updated or individualized, potentially leading to unmet needs and inconsistent treatment. The failure to address these issues in the care plans could affect the residents' physical well-being and safety.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and care to prevent falls for a resident identified as high risk for falls. The resident, who was admitted with diagnoses including schizoaffective disorder and autonomic nervous system disorder, experienced multiple falls over several months. Despite being assessed as high risk for falls, the resident's care plan lacked specific interventions to address the recurrent falls, and the care plan was not revised following these incidents. The resident's history of falls included both witnessed and unwitnessed events, resulting in injuries such as a non-displaced fracture of the left foot. The facility's failure to update the care plan with new interventions after each fall contributed to the resident's continued risk. The resident's most recent fall resulted in a fracture, and the care plan was only updated post-injury to include measures such as using a wheelchair and post-operative shoes. Interviews with facility staff, including a Quality Assurance Nurse and a Registered Nurse, revealed that the facility did not identify the root cause of the resident's repeated falls. The staff acknowledged the resident's confusion and unstable gait, which increased the risk of falls. The facility's policy emphasized preventing falls, but the lack of specific interventions and failure to revise the care plan after each fall indicated a deficiency in implementing these policies effectively.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. On one of the sampled dates in July 2024, specifically on 7/28/2024, there was no RN present in the facility. This absence was due to the scheduled RN calling in sick, and no other RN was available to cover the shift. The Director of Nursing (DON) acknowledged the necessity of having an RN to assist with supervision, monitoring, and coordination of care, especially given the high number of resident incidents. The facility's policy and procedure did not explicitly state the requirement for an RN to be present for 8 consecutive hours daily. The Facility Assessment indicated a plan to have a part-time RN Supervisor during weekends and a full-time RN Supervisor during weekdays. The RN Supervisor's job description included duties such as conducting quarterly and admission assessments, supervising charge nurses and floor staff, following up on abnormal lab results, and assisting with medical doctor visits. However, the absence of an RN on the specified date meant these duties were not adequately covered, potentially impacting resident care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that three residents did not receive unnecessary psychotropic medications. For one resident, the facility did not accurately monitor specific target behaviors for medications such as Lithium, Prazosin, Vistaril, and Trileptal. The resident had multiple diagnoses, including schizoaffective disorder and PTSD, and exhibited various behaviors such as suicidal ideations, delusional ideations, and anxiety. However, the staff was unable to specify which behaviors were being monitored for each medication, making it difficult to justify the continued use of these medications or determine if a gradual dose reduction was appropriate. Another resident received duplicate therapy with physician orders for Haldol, Seroquel, and Lithium. Despite having episodes of responding to internal stimuli and other behaviors, the facility did not identify medication irregularities or make recommendations for the psychiatrist to address the duplicate therapy. The resident's medication administration records showed inconsistent episodes of the behaviors the medications were prescribed for, indicating a lack of proper monitoring and evaluation of the medication's effectiveness. The third resident, who was on three psychotropic medications, did not receive adequate behavioral monitoring. The facility's staff could not specify which behaviors were being monitored for each medication, and the psychiatrist confirmed that specific monitoring was necessary to evaluate the medication's effectiveness. The facility's policy required that behaviors be directly related to care plans and correspond with prescribed medications, but this was not followed, leading to the potential administration of unnecessary psychotropic medications.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two medication storage rooms were equipped with thermometers or thermostats, and did not monitor or maintain the temperature and humidity as required by the facility's policies and procedures. During observations, it was noted that the [NAME] Nursing Station Medication Storage Room and the East Nursing Station Medication Room lacked temperature monitoring devices. Interviews with staff, including a Licensed Psychiatric Technician (LPT), a Licensed Vocational Nurse (LVN), and a Registered Nurse (RN), revealed that the room temperatures were unknown and not documented, and that the rooms sometimes became very hot. The Director of Nursing (DON) confirmed that the facility had not been monitoring the medication room temperature or humidity conditions for over a year. The facility's pharmacy policies and procedures, dated May 2022, required that medication storage areas be kept free of extreme temperatures and humidity, with conditions monitored monthly by a consultant pharmacist or designee. The lack of temperature control and monitoring had the potential to compromise the efficacy and potency of medications stored in these rooms, potentially affecting the residents who required these medications.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the minimum required food holding temperature on the kitchen steam table, which was observed during a survey. Specifically, red enchilada sauce was held at 120 degrees Fahrenheit, below the required 135 degrees Fahrenheit. The Dietary Supervisor (DS) acknowledged that the steam table should maintain temperatures between 155-165 degrees Fahrenheit and confirmed that 135 degrees Fahrenheit is the minimum required holding temperature to prevent bacterial growth and foodborne illness. The DS was unable to provide information on the last calibration or service of the steam table, nor could they produce an invoice for such maintenance. The facility's undated Policy & Procedure on Temperature Control of Equipment mandates that steam tables be checked for proper working temperature and recorded on a log to ensure safe operation. Additionally, a bulletin from the California Department of Education emphasizes the importance of maintaining hot food at 135 degrees Fahrenheit or higher to prevent time and temperature abuse.

Penalty

No penalty information released

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

Summary

The facility failed to prevent physical abuse among residents, resulting in altercations involving three residents. Resident 73, diagnosed with schizoaffective disorder and hypothyroidism, was involved in an altercation with Resident 87, who also had schizoaffective disorder, morbid obesity, and asthma. The incident occurred when Resident 87, who was on 1:1 monitoring due to suicidal ideation and threatening behavior, became agitated and physically assaulted Resident 73 after a verbal exchange. Despite the presence of staff, the altercation escalated to physical violence, with both residents sustaining minor injuries. Resident 87 was on 1:1 monitoring due to a history of assaultive behavior and suicidal ideation. However, the monitoring was inadequate as the assigned CNA stepped out of the room, leaving the residents unsupervised. This lapse allowed Resident 87 to initiate a physical altercation with Resident 73, who retaliated. The staff's delayed response contributed to the continuation of the fight, highlighting a failure in maintaining a safe environment for the residents. Another incident involved Resident 57, who was hit by Resident 9 during a dispute. Both residents have a history of mental health issues, with Resident 57 having moderately impaired cognition. The altercation occurred near the nurse station, and staff intervention was required to separate the residents. The facility's failure to prevent these altercations and ensure adequate supervision and intervention measures contributed to the deficiency in providing an abuse-free environment.

Penalty

No penalty information released

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

Summary

The facility failed to notify the representative of a resident when the resident's physicians recommended cataract surgery. This oversight resulted in a delay in informing the resident's representative about the necessary eye treatment and services, thereby excluding the representative from participating in decision-making regarding the resident's care plan. The resident, who was under conservatorship due to legal blindness and other medical conditions, was not capable of making informed decisions about their health, which necessitated the involvement of the conservator. The resident's medical records indicated a history of schizophrenia, cataracts, retinal vein occlusion, and legal blindness. Despite the ophthalmologist's repeated recommendations for cataract surgery to improve visual function and assess the retina, the resident refused the surgery multiple times. The facility's Director of Nursing was unaware if the resident's conservator had been informed of these recommendations, which was a requirement given the resident's inability to make health decisions. The facility's policy stated that the rights of a resident adjudged incompetent should be exercised by the appointed conservator, highlighting the deficiency in communication and adherence to policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a safe and homelike environment for a resident when the bed light's pull-cord switch was not functioning. The resident, who was admitted with multiple diagnoses including psychoactive substance abuse and insomnia, had moderately impaired cognitive skills and was described as cooperative but confused with impaired judgment and insight. During observations, it was noted that the bed light's pull-cord was only three inches long and did not activate the light when pulled. This issue was confirmed by a CNA, who acknowledged that the maintenance staff should check the lights daily. The resident expressed feeling depressed due to the non-functioning light, as they preferred having lights similar to those in their home. The maintenance staff, during an interview, confirmed that the bed light was not working and that the issue was reported by the CNA. The facility's policy and procedure indicated that the maintenance department was responsible for ensuring all equipment, including lighting, was in working condition. The maintenance aide emphasized the importance of functioning bed lights for resident safety and security, especially at night. The facility's policy on resident rights also stated that residents are entitled to a safe, clean, comfortable, and homelike environment, which was compromised in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to notify the Ombudsman regarding the transfer or discharge of a resident, identified as Resident 96, which is a violation of the resident's rights. Resident 96 was admitted to the facility with diagnoses including schizophrenia and PTSD. The resident had moderate impaired cognition but was able to communicate clearly. On a physician's order dated 5/10/2024, Resident 96 was transferred to a higher level of care, and the discharge was documented in the progress notes. However, the facility did not have a Notice of Proposed Transfer/Discharge Form in the resident's chart, and there was no indication that the Ombudsman was notified of the transfer or discharge. During interviews, the Medical Records staff confirmed the absence of the required notification form and emphasized the importance of notifying the Ombudsman to advocate for the resident. The Social Service Designee admitted to not notifying the Ombudsman, citing a lack of awareness of the requirement. The facility's policy, revised in April 2024, clearly states the obligation to notify the Long-Term Care Ombudsman of facility-initiated discharges or transfers, which was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to revise the Comprehensive Care Plan (CP) for a resident, identified as Resident 84, following multiple fall incidents. Resident 84 was admitted with diagnoses including schizoaffective disorder, autonomic nervous system disorder, and a history of repeated falls. Despite several documented falls, including both witnessed and unwitnessed incidents resulting in injuries, the CP interventions were not updated to address these recurrent falls. The CP aimed to keep the resident free of complications related to falls, but the interventions remained unchanged despite the ongoing incidents. Interviews with the Quality Assurance Nurse (QAN) and a Registered Nurse (RN 1) revealed that the CPs for Resident 84 were not revised or updated to reflect the repeated falls. The QAN acknowledged the lack of documentation for revised interventions and emphasized the need for implementing strategies to prevent further falls. The facility's policy indicated that care plans should be updated quarterly or as resident needs mandate, but this was not adhered to in the case of Resident 84. The failure to revise the CP interventions hindered the staff's ability to evaluate the effectiveness of the action plan in preventing falls.

Penalty

No penalty information released

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

Summary

The facility failed to adequately address the nutritional needs of Resident 49, resulting in significant weight loss over a six-month period. Despite the resident's care plan indicating the need for encouragement to consume 80-100% of meals and the inclusion of specific dietary items such as bananas, these interventions were not consistently implemented. Observations revealed that Resident 49's meal trays did not always include the prescribed banana, and staff did not provide the necessary encouragement to increase meal intake. The resident expressed dissatisfaction with the food provided, preferring other options like pizza and lasagna, which were not accommodated. The facility's interdisciplinary team (IDT) meetings did not effectively address the resident's ongoing weight loss, with the last meeting occurring over a month before the survey. The Director of Nursing (DON) acknowledged the oversight in not conducting more frequent IDT meetings to reassess and update the resident's care plan. Additionally, the facility's policy to provide a Nutrition Education Group was not followed, as the program had been discontinued since July 2022, leaving a gap in the resident's nutritional education and support. Staff interviews indicated a lack of awareness and adherence to the resident's dietary orders, with some staff unaware of the requirement to include a banana in the resident's meals. The Registered Dietician had not conducted a Nutrition Assessment for over a year, missing an opportunity to reassess the resident's nutritional needs and adjust interventions accordingly. The facility's policies on weight management and carrying out medical orders were not effectively implemented, contributing to the resident's continued weight loss.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a monthly medication regimen review (MRR) was conducted by a licensed pharmacist for a resident on psychotropic medications. This deficiency was identified during a review of the facility's records, which showed that the Pharmacy Consultant did not review the resident's drug regimen for medication irregularities in February. Additionally, subsequent MRR reports from March to July did not contain any recommendations for medication irregularities for the resident. The resident in question, identified as Resident 23, was admitted with diagnoses including schizoaffective disorder, major depressive disorder, and psychoactive drug abuse. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and independence with transfers and mobility. The resident was prescribed multiple medications, including Haloperidol and Quetiapine Fumerate, for delusional ideations and mood disorders, as well as Lithium Carbonate for mood stabilization. Interviews and record reviews revealed that the facility's policy required a monthly MRR to monitor for medication irregularities, with critical issues to be reported to the ordering physician immediately. However, the Pharmacy Consultant failed to identify or report any irregularities in the resident's medication regimen, despite the potential for unnecessary medication and increased side effects from duplicate therapy. The Director of Nursing acknowledged the need for the pharmacy consultant to complete the MRR and make recommendations for the psychiatrist's final decision.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to infection control practices by not maintaining a resident's closet in an orderly manner, leading to clean clothes spilling out and touching the floor. This was observed during a survey where Resident 8's closet was found overflowing with clothes resting on footwear and the floor. Despite the resident's acknowledgment of the mess, staff did not assist in tidying up, although they were aware of the importance of maintaining cleanliness to prevent contamination. Resident 8, who has a history of schizoaffective disorder and COVID-19, was noted to have intact cognition according to a recent assessment. However, the resident expressed dissatisfaction with the state of their closet. The facility's Infection Preventionist confirmed that the clothes were considered dirty due to contact with the floor, highlighting a lapse in infection control. The facility's policies emphasize maintaining a safe and clean environment, yet these were not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the responsible party (RP) of a resident, who was under conservatorship, was provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine prior to its administration. This deficiency was identified during a review of the resident's records, which showed that the resident was admitted with diagnoses including schizophrenia, cataracts, tributary retinal vein occlusion, and legal blindness. The resident's progress notes indicated confusion, impaired judgment, and a tangential thought process, highlighting the resident's inability to make informed decisions independently. The review of the resident's immunization history revealed that the COVID-19 vaccine was administered without documented consent from the conservator. During an interview, the Infection Preventionist confirmed the absence of documentation or consent, emphasizing the importance of informed consent, especially for conserved individuals. The facility's policy required obtaining consent from the resident or conservator and providing education on the vaccine's risks and benefits, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to protect residents from physical abuse, resulting in incidents involving three residents. Resident 1 was pushed by another resident, Resident 2, in the hallway. This incident was unprovoked, as observed by a Certified Nursing Assistant (CNA) and confirmed by Resident 1. Resident 2, who has a history of schizoaffective disorder and major depressive disorder, admitted to pushing Resident 1 due to perceived mockery. The facility's records indicate that Resident 2 had a care plan for physically assaultive behavior, yet the incident still occurred. Resident 3 was punched by their roommate, Resident 4, who has schizoaffective disorder and major depressive disorder. Resident 4 became upset over a request from Resident 3 and initiated a physical altercation by hitting Resident 3 on the cheek. Despite Resident 4's moderate cognitive impairment and a care plan addressing resident-to-resident abuse, the facility did not prevent the assault. Interviews with both residents confirmed the altercation, with Resident 4 admitting to hitting Resident 3 with a closed fist. Resident 5 was repeatedly punched by their roommate, Resident 6, who has paranoid schizophrenia and major depressive disorder. Resident 6 admitted to the assault, which was triggered by anger over Resident 5's behavior. The attack resulted in bruising and swelling on Resident 5's forehead. Despite Resident 6's care plan for resident-to-resident abuse, the facility failed to prevent the incident. The facility's policy on protecting residents from abuse was not effectively implemented, as evidenced by these incidents.

Penalty

No penalty information released

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

Summary

The facility failed to report allegations of abuse for a resident to the California Department of Public Health, the Ombudsman, and local law enforcement within the required two-hour timeframe, as per the facility's policy and procedure. The resident, who was admitted with diagnoses including paranoid schizophrenia, major depressive disorder, and breast cancer, made allegations of sexual abuse on two occasions. Despite these allegations, the facility's Administrator did not report them, believing them to be delusions. The facility's policy, revised in January 2018, mandates that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately, or no later than two hours, to the appropriate authorities. The Administrator acknowledged the failure to report the allegations, which resulted in a delay of notification to the Department and had the potential for the resident to be subjected to further abuse.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy and procedure for monitoring a resident at risk for elopement, resulting in the resident leaving the facility unsupervised. The resident, who had a history of elopement and was assessed as at risk, was supposed to be monitored every 15 minutes by assigned CNAs. However, the CNAs did not maintain a clear line of sight or accurately document the resident's whereabouts as required by the facility's policy. On the day of the incident, the resident entered an unlocked Recreation Room without supervision and subsequently eloped from the facility by stacking chairs to climb onto the roof and then using facility fencing to exit the premises. The CNAs responsible for monitoring the resident falsely documented the resident's location without actually verifying it, leading to a delay in realizing the resident was missing. The facility's video surveillance confirmed the lack of staff presence and supervision during the critical time when the resident eloped. The resident's medical history included schizoaffective disorder, anxiety disorder, and major depressive disorder, with moderately impaired cognition. The resident was independent in some activities but required supervision for personal hygiene. The failure to monitor and supervise the resident as per the physician's order and facility policy resulted in the resident's unsupervised departure, which was not discovered until after lunch, despite inaccurate documentation by the CNAs.

Removal Plan

• The facility made every effort to locate Resident 1 by conducting searches and contacting local authorities.
• The facility updated its policy titled Q:15 Minute Monitoring to ensure staff have a clear line of sight and visually identify residents during checks.
• All residents admitted to the facility would be supervised on an hourly basis unless otherwise noted, every 15 minutes for safety.
• The facility installed a self-locking door hardware on the Recreation Room door and replaced chairs to prevent elopement.
• CNA 1 and CNA 2 responsible for failing to follow resident care documentation were suspended and terminated.
• The facility consulted to have motion sensor cameras installed on the patio.
• All staff were in-serviced on safety and Q:15-minute supervision requirements.
• The facility checked all doors for self-locking hardware and replaced any non-self-locking hardware.
• All staff would be required to unlock with a key to exit onto the patio, and all doors would require a key to unlock for entry.
• The DSD conducted safety and Q:15-minute supervision in-service training to all staff, to be conducted annually and upon hire.
• The Administrator conducted safety and Q:15-minute supervision in-service training to all social services staff.
• The QAN to review Q:15-minute documentation for accuracy and the QAA Committee to review compliance at quarterly meetings.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate documentation of a resident's location every 15 minutes as required by the physician's order for safety monitoring. The resident, who had diagnoses including schizoaffective disorder, anxiety disorder, and major depressive disorder, was supposed to be monitored every 15 minutes due to safety concerns. However, the facility's video surveillance revealed that the resident was unsupervised and able to leave the facility premises without staff noticing. The resident was seen on video surveillance climbing onto the roof and exiting the facility, which was not accurately documented by the staff. Certified Nurse Assistants (CNAs) 1 and 2 were responsible for documenting the resident's whereabouts but failed to do so accurately. CNA 1 admitted to documenting the resident's location without verifying it, as CNA 1 was on break during the time the resident was unsupervised. Similarly, CNA 2 documented the resident's location without knowing the actual whereabouts. The facility's policy required CNAs to maintain a clear and direct line of sight when documenting the resident's location, which was not adhered to, leading to inconsistencies and inaccuracies in the resident's medical record.

Penalty

No penalty information released

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

Summary

The facility failed to follow a medical doctor's order for a Buddy Splint for a resident with a nondisplaced fracture of the left fifth finger. The resident's care plan and medical orders indicated that a Buddy Splint should be applied to the left fourth and fifth fingers every shift. However, during observations and interviews, it was found that the Buddy Splint was not in place, and the resident's finger had not been taped for the last three to five days. The resident mentioned that the nurse had to order more tape, which had not yet arrived, leading to the splint not being applied as required. The Registered Nurse Supervisor confirmed that the Buddy Splint was not on the resident's fingers and acknowledged that it should have been per the MD order. The Director of Nursing also stated that the Buddy Splint is necessary to stabilize and support the affected finger and that not following the MD order could worsen the fracture. The facility's policy and procedure require carrying out all medical orders, which was not adhered to in this case.