Mar Vista Country Villa Healthcare & Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3966 Marcasel Ave, Los Angeles, California 90066
- CMS Provider Number
- 555726
- Inspections on file
- 62
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Mar Vista Country Villa Healthcare & Wellness during CMS and state inspections, most recent first.
A resident was re-admitted with multiple medical conditions, including sepsis, osteoarthritis, hypothyroidism, GERD, hypertension, and electrolyte and lipid disorders, and required supervision with eating and moderate assistance with toileting and transfers. Despite a physician order for RD evaluation, no admission weight was documented, and the RD instead used the most recent GACH weight as the baseline. Subsequent weights were entered later, and the MDS triggered a significant weight change based on comparison to the hospital weight, which was documented as a clinically significant loss. In interview, the RD confirmed that the absence of an admission weight led to reliance on the hospital weight and acknowledged that an admission weight should have been obtained by staff.
A resident with ESRD and type 2 DM, who had intact decision-making capacity, was subject to a proposed discharge for improved health without receiving a properly executed 30-day written notice. The notice in the record lacked the resident or representative’s signature, and it was not sent to the ombudsman as required by facility policy. The facility representative signed the notice shortly before the planned discharge, and the physician ordered discharge with HH and DME the next day. The resident reported feeling rushed and harassed to sign discharge paperwork on the same day as discharge, while an LVN stated he received last-minute notification of the discharge. The ombudsman confirmed the notice was not faxed until much later and that prior reminders about 30-day notice and documentation had been given, while the social services director and administrator described practices that did not align with the written policy for notifying the ombudsman.
A resident with dementia and multiple comorbidities, identified as a high fall and elopement risk, was left unsupervised due to insufficient staffing and staff reassignments during the night shift. The resident wandered outside and sustained an unwitnessed fall, resulting in a laceration that required hospital treatment. Staff interviews and record reviews indicated that the assigned CNA was diverted to provide 1:1 supervision for another high-risk resident, leaving the original assignment inadequately monitored.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with cognitive impairments and multiple diagnoses, including hypokalemia and COPD, experienced a significant change in condition when they confabulated stories of being raped by a CNA. The LVN documented the incident but failed to notify the physician or use the SBAR tool as required by the facility's policy, potentially delaying necessary care.
A resident with cognitive impairments reported being raped by a CNA, but the LVN who documented the allegation failed to report it to the DON or FA, as required by the facility's policies. Interviews revealed that key staff were unaware of the allegations, delaying an investigation and notification to authorities. The facility's policies mandate immediate reporting of abuse allegations, which was not followed in this case.
A facility failed to investigate a resident's allegations of abuse, as required by its policies and procedures. The resident, with cognitive impairments and requiring assistance for daily activities, reported being raped and touched by a CNA. Despite documentation by an LVN, the issue was not reported to the DON or FA, nor was an investigation initiated. The RNS, DON, and SSD were unaware of the allegations, highlighting a breakdown in communication and reporting. This failure delayed a State Agency inspection and risked unidentified abuse in the facility.
A resident with cognitive impairments and multiple health conditions reported being raped and touched by a CNA, but the facility failed to document and implement a comprehensive care plan addressing the incident. The LVN acknowledged the oversight, which violated the facility's policies on care planning and change of condition notification.
A resident with a history of verbal aggression and refusal of medication repeatedly provoked another resident, leading to a physical altercation. Despite having a care plan, the facility failed to effectively monitor and document the aggressive behavior or offer prescribed medications, resulting in a deficiency in care.
A resident with multiple health conditions reported missing incontinent briefs, which were not stocked by the facility. Despite informing the social worker and DSS, the issue was not promptly addressed, and the facility failed to investigate the grievance or offer alternative solutions. The facility did not adhere to its grievance policy, resulting in unresolved complaints.
A facility failed to maintain hospice visit records for a resident receiving hospice care. The resident had multiple health conditions and required assistance with daily activities. The facility's hospice binder lacked necessary hospice nursing and doctor visit notes, contrary to the facility's policy. Interviews revealed that the facility did not follow up to obtain these notes, potentially leaving nursing staff uninformed of changes recommended by hospice staff.
A resident with cognitive impairments eloped from the facility due to inadequate supervision and lack of alarm systems on exit doors. The resident, who required supervision for daily activities, was found missing during a CNA's rounds. Despite a search by staff, the resident was only located later at a bus stop. The facility lacked proper documentation of staff rounds and did not have a wander guard on the resident, contributing to the incident.
A deficiency in medication management was identified in an LTC facility when an LVN failed to replace missing medications for residents, leading to borrowing a Lidocaine patch from another resident and missing a Florastor dose. The LVN did not follow proper procedures for reordering medications, risking residents' pain management and supplement needs.
The facility failed to manage Glucose Quality Control Solution properly, leading to potential confusion and inaccurate blood sugar readings. An LVN found mismatched lot numbers and expired solutions in Medication Cart A, with no formal policy in place. The DON admitted uncertainty about expiration dates and acknowledged the risk of false readings causing harm to residents.
The facility failed to store food in a sanitary manner, risking foodborne illnesses. A resident had apple juice on the floor, posing an infection risk. Dented and unlabeled canned food was improperly stored with ready-to-use food. The unit refrigerator for residents' food was unlocked and contained expired items due to staff miscommunication about responsibilities.
The facility failed to ensure catheter drainage bags for two residents were placed inside dignity bags, violating their right to dignity. One resident with cognitive impairment had their catheter bag uncovered until the DON intervened, while another resident with dementia was observed with an exposed catheter bag in a wheelchair. This deficiency contravenes the facility's policy on maintaining residents' dignity.
A resident with dementia and other medical conditions was observed in a wheelchair with a urinary catheter drainage bag in open view, lacking a dignity cover. Staff interviews confirmed the absence of a dignity bag, which is required by the facility's policy to maintain resident dignity. The Director of Nursing acknowledged the necessity of a dignity bag for privacy and decency.
A resident with multiple health conditions, including legal blindness, was found with medications at their bedside without a physician's order or assessment for self-administration capability. Facility staff confirmed that residents should only have medications at bedside if cleared by a physician and evaluated for competence, which was not done in this case.
The facility failed to provide a quiet and homelike environment, affecting two residents' ability to sleep due to another resident's continuous screaming. Despite staff interventions, the noise persisted, and the facility lacked policies to address this issue.
A facility failed to complete a PASRR Level II assessment for a resident with multiple mental health diagnoses, as required by the PASRR Level I screening. The resident's care plans lacked individualized treatments, and staff interviews revealed no tracking system for required assessments. Facility policies outlined the need for such assessments, but the absence of a tracking log contributed to the oversight.
A resident with an indwelling catheter was found with yellow cloudy fluid and sediments in the tubing, indicating a possible infection. The facility failed to change the catheter bag as per the physician's order and did not notify the physician about the sediment, contrary to the facility's policy. This oversight placed the resident at increased risk for a urinary tract infection.
Two residents in an LTC facility did not receive the correct oxygen therapy as prescribed by their physicians. One resident, with multiple health issues, was found with a nasal cannula not placed correctly, while another resident with COPD received a higher oxygen flow rate than ordered. These errors were confirmed by nursing staff and acknowledged by the DON, highlighting a failure to follow the facility's oxygen therapy policy.
The facility did not complete annual performance evaluations for a CNA hired in 2001, as revealed during a record review with the DSD. The absence of evaluations for 2023 and 2024 was noted, with the DSD and DON emphasizing the importance of competencies for safe practices and proper resident care. The facility's policy requires competency assessments upon hiring, annually, and as needed.
The facility failed to follow infection control protocols for two residents. A resident's nasal cannula tubing was on the floor, and their oxygen humidifier was not changed weekly as required. Another resident's supra pubic catheter drainage bag was touching the floor. These lapses occurred despite facility policies mandating sanitary conditions and regular equipment changes.
The facility failed to ensure that the ADON, who is currently an LVN awaiting RN licensure in California, had the appropriate skills to train RN staff on resident care and assessment. The ADON conducted in-service training for CNAs, LVNs, and RNs, which was outside the LVN's scope of practice. Interviews with the DON and ADM confirmed that the ADON should not train RNs until obtaining an RN license, and future training will be conducted by the DON and an RN.
The facility's DSD transitioned from IPN to DSD without completing the required continuing education course, following the resignation of the previous DSD. This left the DSD without the necessary competencies to effectively manage the facility's educational programs.
The facility's governing body failed to report a change in the Administrator (ADM) as required by regulations. The ADM, who started in 10/2023, was also an ADM at another facility and could not provide documentation of the Change of Ownership (CHOW) application. The facility's policy requires reporting such changes within ten days, but this was not done, potentially affecting the safety and well-being of all 56 residents.
A resident with diabetes, chronic kidney disease, and depression experienced discomfort due to delayed lunch service at a facility. The delay was caused by logistical issues, as staff had to manually transport meal carts from the basement due to a non-functional elevator. This resulted in meals being served later than the scheduled time, affecting the resident's dignity and comfort.
A resident with severe cognitive impairment and identified as a fall risk fell and sustained injuries due to inadequate supervision and failure to follow care plan directives. The resident's bed was left in a high position with side rails up, and no floor mats were present, contrary to physician orders. The CNA left the resident unattended, leading to a fall and subsequent hospitalization for a head injury and laceration.
Failure to Obtain Admission Weight Led to Inaccurate Baseline and Triggered Weight Loss Variance
Penalty
Summary
The deficiency involves the facility’s failure to obtain an admission weight in accordance with professional standards of practice for one resident. The resident was re-admitted with multiple diagnoses including sepsis, osteoarthritis of the hip and knee, cognitive communication deficit, hypokalemia, hypothyroidism, hyperlipidemia, thrombocytopenia, vitamin D deficiency, GERD, hypertension, and a disorder of phosphorus metabolism. The resident’s MDS showed intact cognition, supervision or touch assistance needed with eating, and moderate assistance needed with toileting and transfers. A physician order dated 1/27/2026 requested an RD consultation to evaluate and treat as needed. However, the dietary profile dated 2/3/2026 showed no weights recorded, and there was no documented weight at the time of admission. Because an admission weight was not obtained, the RD used the most recent GACH weight of 110 lbs from 1/24/2026 as the baseline. A subsequent physician order dated 2/13/2026 called for weekly weights for four weeks. An IDT note dated 2/20/2026 documented that the MDS triggered a significant weight change, comparing the 110 lb hospital weight to later weights and identifying an approximate 19–19.2 lb loss, or 17.3%–17.5% change, which was described as clinically significant and placing the resident at risk for malnutrition, functional decline, dehydration, and increased morbidity. The RD’s care plan revision on 2/11/2026 listed weights of 110 lbs on 1/24/2026, 89.4 lbs on 2/4/2026, and 90.5 lbs on 2/9/2026, and documented a 20.6 lb/18.7% one-month loss. In interview, the RD stated there was no weight documented at admission, so the last hospital weight was used as the baseline, and acknowledged that ideally the RNA would obtain an admission weight and that the use of the hospital weight had triggered a weight loss variance.
Failure to Provide Timely 30-Day Written Discharge Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide proper written notice of a proposed transfer and discharge to a resident, the resident’s responsible party, and the state long-term care ombudsman at least 30 days prior to the proposed discharge date. The resident, who had type 2 diabetes mellitus and end-stage renal disease and was documented as having decision-making capacity with no cognitive impairment, was initially given a Notice of Proposed Transfer and Discharge dated early in the month stating that discharge was appropriate because the resident’s health had improved sufficiently. The notice in the record lacked the resident or representative’s signature and was not faxed to the ombudsman. The facility’s policy required that a copy of the notice be placed in the medical record and faxed to the ombudsman, and that when a transfer or discharge is initiated by the facility, notice be provided to the resident, responsible party, and ombudsman 30 days prior to discharge unless specific exceptions applied. Despite this, the facility representative did not sign the notice until late in the month, and the physician’s order to discharge the resident with home health and DME was entered the following day. The resident reported not recalling receiving the proposed discharge documents within the prior four weeks and stated feeling rushed and harassed to sign a document and be discharged the same day. The ombudsman confirmed the facility did not fax the notice of proposed discharge until the day after the resident interview and had previously reminded social services about the 30-day notice and record-keeping requirements. An LVN involved in discharge planning stated he usually received at least a week’s notice for discharges but was only given the resident’s discharge plan and notification the day before the planned discharge and was told the discharge had been moved up without further details. The social services director acknowledged that when the resident declined to sign the notice earlier in the month, it was not faxed to the ombudsman, and the administrator stated the notice did not need to be faxed because it was not considered a facility-initiated or involuntary discharge, contrary to the facility’s written policies.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Unwitnessed Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to maintain adequate supervision for a resident identified as a wanderer and at high risk for falls. The resident, an elderly female with multiple diagnoses including dementia, atrial fibrillation, and osteoarthritis, required hourly visual checks and wore a wander bracelet due to her high risk of elopement. Despite these interventions, the resident was able to leave her bed and room multiple times during the night, ultimately wandering outside onto the patio unsupervised, where she sustained an unwitnessed fall resulting in a laceration above her left eye that required hospital treatment and sutures. Review of records and staff interviews revealed that on the night of the incident, the certified nursing assistant (CNA) assigned to the resident was also tasked with being a 1:1 sitter for another high fall risk resident in a different room for several hours, leaving the original assignment unattended. The remaining CNA attempted to monitor both assignments but was also responsible for a large number of residents. Staff reported that during the night shift, there were fewer personnel available compared to the day shift, making it more difficult to provide adequate supervision for residents with high acuity and wandering behaviors. The resident's care plan included interventions such as a low bed, visual checks, and proximity to the nursing station, but no 1:1 sitter was assigned. Interviews with staff, including the charge nurse, director of staff development, and assistant director of nursing, confirmed that the resident was not identified as needing a sitter and that staffing assignments were adjusted due to a last-minute call-off. The facility's policy required adequate staffing to meet resident needs, but on the night in question, the combination of high resident acuity, staff reassignments, and reduced night shift staffing contributed to the failure to provide the necessary supervision, resulting in the resident's unsupervised exit and subsequent fall.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility staff failed to notify the physician of a change in condition for one of the residents, identified as Resident 1. This resident was admitted with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set indicated that Resident 1 had moderately impaired cognitive skills and required moderate to maximal assistance for activities of daily living. On a specific date, a Licensed Vocational Nurse (LVN) documented in the progress notes that Resident 1 confabulated stories about being raped and touched by a Certified Nursing Assistant. Despite this significant change in condition, the LVN did not report the incident to the physician or document the change using the SBAR communication tool as required by the facility's policy. The facility's policy on Change of Condition Notification mandates that residents, family, legal representatives, and physicians be informed of changes in a resident's condition in a timely manner. The policy specifies that the attending physician must be notified of any sudden and marked adverse change in a resident's condition that denotes a new problem or complication. The LVN acknowledged the failure to report and document the change in condition but was unsure why it was not completed. This oversight had the potential to delay necessary care, treatment, and services for Resident 1.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of abuse in accordance with state and federal law. This deficiency was identified during a review of a resident's records and interviews with facility staff. The resident, who had been readmitted to the facility with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease, had cognitive impairments and required significant assistance with activities of daily living. The resident reportedly confabulated stories of being raped and touched by a CNA, which was documented by an LVN in the resident's progress notes. Despite the documentation, the LVN did not report the allegations to the Director of Nursing (DON) or the Facility Administrator (FA), as required by the facility's policies. Interviews with the Registered Nursing Supervisor (RNS), DON, and Social Service Director (SSD) revealed that none of them were informed of the allegations. The RNS stated that if the LVN had reported the issue, an investigation could have been initiated, and the necessary authorities, including the local police, ombudsman, and Department of Public Health, could have been notified. The facility's policies and procedures, reviewed in June 2024, clearly state that all staff are mandatory reporters and must report any allegations of abuse immediately to the administrator or designated representative. The failure to adhere to these policies resulted in a delay of an onsite inspection by the State Agency, potentially leaving residents unprotected from possible abuse.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures by not ensuring an investigation was completed for a reasonable suspicion of abuse in accordance with state and federal law. This involved a resident who was admitted with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease. The resident's cognitive skills for daily decision-making were moderately impaired, requiring moderate to maximal assistance from staff for activities of daily living. The deficiency arose when a Licensed Vocational Nurse (LVN) documented in the resident's progress notes that the resident confabulated stories about being raped and touched by a Certified Nursing Assistant (CNA). Despite this documentation, the LVN did not report the issue to the Director of Nursing (DON) or the Facility Administrator (FA), nor did they initiate an investigation as required by the facility's policies. The Registered Nursing Supervisor (RNS), DON, and Social Service Director (SSD) were all unaware of the resident's allegations, indicating a breakdown in communication and reporting procedures. The facility's policy on abuse and neglect mandates that all reports of resident abuse, mistreatment, neglect, exploitation, injuries of unknown source, and suspicion of crimes be promptly reported and thoroughly investigated. The failure to adhere to these policies resulted in a delay of an onsite inspection by the State Agency, potentially leading to unidentified abuse within the facility and a failure to protect residents from possible abuse.
Failure to Implement Comprehensive Care Plan After Resident's Report
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who reported being raped and touched by a Certified Nursing Assistant (CNA). The resident, who had been readmitted to the facility with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease, had moderately impaired cognitive skills and required significant assistance with activities of daily living. Despite the resident's report to a Licensed Vocational Nurse (LVN), there was no documentation in the care plan addressing the incident. The LVN acknowledged the omission and confirmed that an individualized care plan should have been completed. The facility's policy on comprehensive person-centered care planning requires care plans to be reviewed and revised upon the onset of new problems or changes in condition. Additionally, the policy on change of condition notification mandates that a licensed nurse document and update the care plan to reflect the resident's current status. The failure to adhere to these policies resulted in a deficiency that could negatively impact the resident's health and safety.
Failure to Manage Resident Aggression Leads to Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, leading to a deficiency in care. Resident 3, who had a history of verbal aggression and refused medication, repeatedly provoked Resident 4 with unwanted verbal interactions. Despite having a care plan in place to manage Resident 3's behavior, the facility did not effectively monitor or document the resident's aggressive actions, nor did they offer or document the refusal of prescribed medications like Xanax to manage anxiety and aggression. Resident 3 was admitted with diagnoses including bipolar disorder and unspecified psychosis, and was known to exhibit provocative behavior towards staff and other residents. The care plan for Resident 3 included interventions to reduce verbal aggression and promote positive interactions, but these measures were not adequately implemented. Interviews with staff revealed that Resident 3 was often verbally abusive and did not adhere to facility policies or medical orders, contributing to ongoing conflicts with Resident 4. Resident 4, who was also admitted with a history of mood disorders, was subjected to repeated verbal taunts by Resident 3, leading to a physical altercation where Resident 4 threw ice at Resident 3. The facility's failure to manage Resident 3's behavior and document interventions or notify medical staff of behavioral instability resulted in an environment where verbal abuse occurred, placing Resident 4 and others at risk for further incidents.
Failure to Investigate and Resolve Resident's Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance regarding a resident's missing incontinent briefs. The resident, who was admitted with multiple diagnoses including COPD, morbid obesity, and chronic respiratory failure, reported that their diapers were being stolen. The facility did not stock the resident's size, so the hospice company ordered them. Despite the resident's complaint to the social worker and the Director of Social Services (DSS), the issue was not promptly addressed. The DSS was informed of the missing briefs and noted the resident's grievance in a report. However, the DSS did not ensure immediate action was taken, such as installing a lock on the resident's closet as promised. The Director of Nursing (DON) acknowledged the facility's lack of investigation into the allegation and failure to offer alternative solutions, such as ordering more briefs for the resident. The facility's grievance policy requires staff to take immediate action to prevent further violations of resident rights while investigating complaints. However, the facility did not adhere to this policy, as evidenced by the lack of investigation and resolution of the resident's grievance. The resident's complaint was not adequately addressed, and the facility did not follow through with the necessary steps to resolve the issue.
Failure to Maintain Hospice Visit Records
Penalty
Summary
The facility failed to maintain hospice visit records for a resident who was receiving hospice care. The resident, admitted in July 2024, had multiple diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, morbid obesity, heart failure, gout, major depressive disorder, gastro-esophageal reflux disease, glaucoma, and dependence on supplemental oxygen. The resident's Minimum Data Set indicated intact cognition but dependence on assistance for toileting, personal hygiene, and transfers. During an observation in December 2024, it was found that the facility's hospice binder lacked the resident's hospice nursing and doctor visit notes. Interviews with the Director of Nursing and the Director of Medical Records revealed that the facility did not have the hospice notes for the resident, and there was no follow-up to obtain them. The facility's policy required hospice notes to be included in the facility's progress notes and for nursing staff to be informed of any changes recommended by hospice staff. However, this documentation was missing, which was not in line with the facility's policy and had the potential to leave nursing staff uninformed of any changes recommended by hospice staff for the resident.
Resident Elopement Due to Inadequate Supervision and Lack of Alarms
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, leading to an elopement incident. The resident, who was admitted with diagnoses including metabolic encephalopathy, unspecified altered mental status, and diabetes, was cognitively intact but required supervision for daily activities. Despite this, the resident was able to leave the facility without staff knowledge, as the facility lacked proper alarm systems on exit doors and did not have a staff member monitoring the front desk during nighttime hours. On the night of the incident, a CNA discovered the resident missing during rounds and reported it to an LVN. The staff searched the facility and surrounding area but could not locate the resident. The resident was eventually found by an LVN at a bus stop later that morning. Interviews with staff revealed that the resident did not have a wander guard at the time of the incident, and there was no documentation of regular rounding on residents, which was supposed to occur every two hours according to facility policy. The facility's policies on resident safety and elopement were not followed, as there were no alarms on exit doors, and the resident did not have a wander guard. The lack of documentation for staff rounds further contributed to the failure to prevent the resident's elopement. The facility's Director of Nursing acknowledged these deficiencies and the potential risks associated with unsupervised resident elopement.
Medication Management Deficiency in LTC Facility
Penalty
Summary
The report identifies a deficiency in pharmaceutical services at the facility, specifically involving the failure of a Licensed Vocational Nurse (LVN) to replace missing medications for residents. The LVN did not replace a missing Lidocaine patch for one resident, leading to the borrowing of a patch from another resident, which risked depleting the second resident's supply. Additionally, the LVN failed to replace a missing Florastor supplement for another resident, resulting in a missed dose. The deficiency was observed during a medication pass when the LVN discovered the absence of the Florastor bubble pack in the resident's drawer and noted the missing Lidocaine patches in another resident's bag. The LVN attempted to address the issue by writing a note to the Registered Nurse Supervisor (RNS) to reorder the Florastor and borrowed a Lidocaine patch from another resident's supply. The RNS confirmed that borrowing medication from another resident is not permitted and outlined the procedure for reordering medications when supplies are low. The residents involved had various medical conditions requiring specific medications. One resident, who required Lidocaine patches for pain management during dialysis, reported experiencing pain when the patches were unavailable. The facility's policy clearly states that medications should not be used for any patient other than the one for whom they were prescribed, highlighting the importance of maintaining adequate medication supplies and following proper procedures for reordering and administering medications.
Improper Management of Glucose Quality Control Solution
Penalty
Summary
The facility failed to properly manage and label Glucose Quality Control Solution, leading to potential confusion and inaccurate blood sugar readings. During an observation, it was found that Medication Cart A contained a Glucose Quality Control Solution with an open date and a mismatched lot number between the solution bottle and its storage box. The Licensed Vocational Nurse (LVN) acknowledged that the Director of Nursing (DON) instructed staff that the solution expires 28 days after opening, but there was no policy reviewed by the LVN regarding this. The Glucose Meter Quality Control Results Log confirmed the 28-day expiration rule, but the facility lacked a formal policy and procedure for handling the Glucose Quality Control Solution. The DON admitted uncertainty about the expiration of the Glucose Quality Control Solution and confirmed that the facility did not have a policy for the glucometer or the solution. The absence of a clear policy and the use of expired solutions could lead to false glucose readings, potentially resulting in inappropriate insulin administration and harm to residents. The DON acknowledged the risk of false readings causing severe health issues, such as hypoglycemia, which could lead to coma. However, no specific corrective actions or follow-up measures were mentioned in the report.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to ensure food was stored in a sanitary manner, which could lead to foodborne illnesses. During a facility tour, a resident was observed with a bottle of apple juice on the floor by her bed, which was brought by a friend a few days prior. The resident, who has multiple medical conditions including diabetes and dysphagia, was assessed to have intact cognition and the capacity to make medical decisions. The Licensed Vocational Nurse noted that placing the juice on the floor posed an infection control issue, and the Director of Nursing stated that food brought by visitors should be stored in a communal refrigerator to prevent potential food poisoning. In the kitchen's walk-in food storage area, dented and unlabeled canned food was found stored alongside ready-to-use canned food. The Dietary Supervisor confirmed that dented or expired canned food should be separated and returned to the manufacturer or discarded to prevent accidental use. The facility's policy requires food items to be correctly labeled and dated, with dented or bulging cans placed in a separate storage area. The unit refrigerator used to store food brought by residents' families was found unlocked, with food dated beyond the allowed storage period. The Infection Preventionist and Director of Nursing stated that food should be discarded after 72 hours, but due to a miscommunication about staff responsibilities, expired food was not removed. The Administrator acknowledged the miscommunication, which led to the failure in maintaining the residents' refrigerator, resulting in expired food being accessible to residents.
Failure to Maintain Dignity with Catheter Bag Coverage
Penalty
Summary
The facility failed to ensure that catheter drainage bags for two residents were placed inside dignity bags, violating their right to dignity. Resident 50, who was readmitted with acute kidney failure, cognitive impairment, and other health issues, was observed with their catheter drainage bag not initially placed in a dignity bag. During an observation, the Director of Nursing was seen placing the catheter bag in a dignity bag, acknowledging the importance of maintaining the resident's dignity. Resident 46, diagnosed with dementia, mild cognitive impairment, and other health conditions, was observed in a wheelchair with their urinary catheter drainage bag visibly exposed and not covered by a dignity bag. The facility's policy emphasizes the importance of maintaining residents' dignity and quality of life, which includes keeping urinary catheter bags covered. The failure to adhere to this policy resulted in a deficiency concerning the residents' dignity.
Failure to Provide Dignity Bag for Catheter Compromises Resident's Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident by not providing a dignity bag cover for a urinary catheter drainage bag. The resident, who was admitted with diagnoses including dementia, mild cognitive impairment, muscle wasting, benign prostate hypertrophy, and obstructive and reflux uropathy, was observed in a wheelchair with the catheter drainage bag in open view, without a privacy cover. This observation was made during a tour, where the resident was seen using his legs to wheel himself around the facility, with the drainage bag hoisted and tucked in the back pocket of the wheelchair. Interviews with staff revealed that the Restorative Nurse Assistant (RNA) acknowledged the absence of a dignity bag and was unaware of who assisted the resident to the wheelchair. The Director of Nursing confirmed that a dignity bag should be provided for decency and privacy. The facility's policy on resident rights and quality of life prohibits demeaning practices and emphasizes the importance of covering urinary catheter bags to promote dignity. The failure to provide a dignity bag compromised the resident's right to be treated with dignity.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not left with a resident who was not capable of self-administering oral medications. Resident 29, who had multiple diagnoses including diabetes mellitus, dysphagia, congestive heart failure, atrial fibrillation, breast cancer, hearing loss, and acute angle-closure glaucoma, was observed with several medications on top of their bedside drawer. These medications included a nasal decongestant, pain relief ointment, antibiotic ointment, and a laxative. Despite Resident 29's statement that they were cleared by an ER doctor to have these medications at bedside, there was no evidence of a physician's order or an assessment by the interdisciplinary team to confirm the resident's capability to self-administer these medications safely. Interviews with facility staff, including an LVN and the DON, revealed that residents are only allowed to have medications at bedside if they have a physician's order and have been evaluated for competence in self-administration. The LVN expressed concerns about Resident 29's legal blindness and the potential for inaccurate self-administration, which could lead to health complications. The facility's policy requires an assessment of the resident's cognitive, physical, and visual ability to self-administer medications, which was not documented in this case.
Failure to Maintain a Quiet and Homelike Environment
Penalty
Summary
The facility failed to ensure a quiet, comfortable, and homelike environment for two residents, resulting in their inability to sleep or rest peacefully. Resident 210, who was admitted with hypertension and muscle weakness, reported being unable to sleep due to noise at night and during the day, caused by another resident's continuous screaming. This resident expressed concern for the screaming resident's well-being and feared that she might not receive help if needed. Similarly, Resident 48, who also had hypertension, muscle weakness, and hyperlipidemia, reported being unable to sleep at night due to the same issue. Both residents indicated that the screaming persisted until the day shift staff intervened. Observations confirmed that a resident was continuously screaming and yelling, with staff entering the room to calm the resident temporarily. However, the screaming resumed once staff left the room. Interviews with staff, including a CNA and a Registered Nurse Supervisor, revealed that the screaming resident frequently called for help, stopping only when checked on by staff. The facility lacked a policy and procedures to maintain a quiet, comfortable, and homelike environment, contributing to the deficiency.
Failure to Complete PASRR Level II Assessment for Resident
Penalty
Summary
The facility failed to ensure that a PASRR Level II assessment was completed for Resident 27, as required by the PASRR Level I screening. This oversight placed Resident 27 at risk of not receiving the necessary care and specialized services tailored to their mental health needs. The resident's care plans did not indicate any individualized rehabilitative treatments and services as required by the PASRR Level II for their mental health condition. Resident 27 was admitted and readmitted to the facility with multiple diagnoses, including metabolic encephalopathy, multiple sclerosis, major depressive disorder, bipolar disorder, paranoid personality disorder, and schizophrenia. Despite these conditions, the facility did not complete the necessary PASRR Level II assessment, which was indicated by the PASRR Level I screenings conducted on two separate occasions. The resident's medical records, including progress notes and psychosocial notes, highlighted ongoing mental health challenges and the need for specialized therapeutic interventions. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed a lack of a tracking system to monitor which residents required PASRR Level II assessments. The facility's policies and procedures outlined the need for such assessments and the role of the Interdisciplinary Team in reviewing and implementing recommendations. However, the absence of a tracking log and reliance on identifying residents with psychosis or on psychotropic medications as triggers for Level II assessments contributed to the oversight in Resident 27's case.
Failure to Change Catheter Bag and Monitor for Infection
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in care. The resident, who had a history of hypertensive chronic kidney disease, obstructive and reflux uropathy, and other conditions, was observed with yellow cloudy fluid and sediments in the catheter tubing. The facility's policy required the catheter bag to be changed per the physician's order, which was not adhered to, as the catheter bag had not been changed since the date written on it, 10/21/2024, despite the physician's order to change it per schedule and as needed. Observations and interviews with the Director of Nursing (DON) and other staff revealed that the catheter bag was overdue for a change, and the presence of sediment indicated a possible infection. The DON and other staff acknowledged that the sediment could be a sign of infection and that a physician should be notified immediately. However, the facility's records did not indicate that the catheter had been changed as required, and the staff failed to notify the physician about the sediment in the catheter tubing. The facility's policy and procedures for catheter care, revised on 6/10/2021, required nursing staff to assess the indwelling catheter for signs of infection, including cloudiness and sediment, and to notify the physician for clinical interventions. The failure to follow these procedures placed the resident at increased risk for a urinary tract infection, as the catheter bag was not changed according to the physician's order and facility policy, and the presence of sediment was not promptly addressed.
Oxygen Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents received the correct amount of prescribed oxygen as ordered by their physicians. Resident 7, who was admitted with multiple diagnoses including encephalopathy, diabetes mellitus, and dementia, was observed with an oxygen concentrator set at 3 liters per minute, but the nasal cannula was not placed on the resident's nostrils as required. Instead, it was found on the resident's chest, covered by linens. This oversight was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged the error and corrected it by placing the nasal cannula on the resident's nostrils. The Director of Nursing (DON) later confirmed that this failure could have led to desaturation and other serious health issues. Resident 2, who was admitted with chronic obstructive respiratory disease (COPD) and other respiratory conditions, was observed receiving oxygen at 3 liters per minute, contrary to the physician's order of 2 liters per minute. A Registered Nurse (RN) confirmed the discrepancy and acknowledged that administering oxygen at a higher rate than prescribed constitutes a medication error. The DON emphasized that oxygen is considered a medication, and incorrect administration could lead to complications such as hypercapnia. The facility's policy on oxygen therapy, dated 2017, mandates that oxygen be administered per physician orders to meet resident needs safely. Both incidents highlight a failure to adhere to these policies, resulting in potential risks to the residents' health. The facility's job description for Licensed Vocational Nurses also requires them to prepare and administer medication as ordered by the physician, which was not followed in these cases.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to complete annual performance evaluations for one out of five sampled staff members, specifically a Certified Nursing Assistant (CNA 2) who was hired on 10/29/2001. During a record review with the Director of Staff Development (DSD), it was found that there was no performance evaluation for CNA 2 for the years 2023 or 2024 in the employee file. The DSD acknowledged the importance of competencies to ensure staff are performing safe practices and are competent, noting the potential harm to residents if evaluations are not conducted. The Director of Nursing (DON) confirmed that performance evaluations are conducted annually and as needed to ensure staff have the proper skills to care for residents. The facility's policy on Staff Competency Assessment, revised on 3/17/2022, states that competency assessments should be performed upon hiring, during the employee's 90-day employment, annually, or any time new equipment or procedures are introduced and as needed.
Infection Control Lapses in Oxygen and Catheter Management
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, leading to potential infection risks. Resident 2's nasal cannula tubing was observed touching the floor, and the oxygen humidifier had not been changed since 10/13/2024, despite facility policy requiring weekly changes. Resident 2 was admitted with chronic obstructive respiratory disease, chronic respiratory failure with hypoxia, and heart failure, and was dependent on staff for various activities. During an observation, the Registered Nurse confirmed the humidifier's outdated status and acknowledged the risk of infection from tubing contact with the floor. Resident 50's supra pubic catheter drainage bag was found touching the floor, which could lead to infection. Resident 50 had been readmitted with acute kidney failure and a history of transient ischemic attack, and was also dependent on staff for daily activities. The Director of Nursing raised the bed to prevent the catheter bag from touching the floor, acknowledging the infection risk. The facility's policies on infection control and oxygen therapy emphasize maintaining a sanitary environment and changing equipment per guidelines, which were not followed in these instances.
Inadequate Training by LVN for RN Staff
Penalty
Summary
The facility failed to ensure that the Assistant Director of Nursing (ADON) and a licensed vocational nurse (LVN) possessed the necessary skills to train registered nursing staff on resident care and assessment. The ADON, who has been in the position since March 2024, does not hold a California registered nursing (RN) license and is currently licensed as an LVN while awaiting her RN credentials in California. Despite this, the ADON was responsible for conducting in-service education and training for Certified Nursing Assistants (CNAs), LVNs, and RNs, including topics such as abuse and falls. The facility's in-service records confirmed that the ADON provided training to the nursing staff, either independently or with the Director of Staff Development (DSD). Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the ADON was training RNs, which was acknowledged as being outside the scope of practice for an LVN. The DON stated that moving forward, only the DON and an RN would conduct in-service training for RNs, as LVNs are not authorized to train RNs. The ADM also recognized that the ADON should not be training RNs until she obtains her RN license in California. The facility's job descriptions and policies further highlighted the discrepancy, as the LVN's role is to provide nursing care under the supervision of an RN, and the ADON's responsibilities include assisting the DON and supervising nursing personnel.
DSD Lacks Required Competencies Due to Incomplete Training
Penalty
Summary
The facility failed to ensure that the Director of Staff and Development (DSD) possessed the necessary competencies and skill sets required to effectively plan, implement, direct, and evaluate the educational programs for all employees. This deficiency arose because the DSD transitioned from the role of Infection Preventionist Nurse (IPN) to DSD without completing the mandatory continuing education course required for the position. The transition occurred in March 2023 following the resignation of the previous DSD, leaving the current DSD to manage the responsibilities without the requisite training. The DSD acknowledged during an interview that she had not completed the necessary continuing education due to the abrupt transition and was in the process of handling the paperwork herself to obtain the required certificates.
Failure to Report Change in Administrator
Penalty
Summary
The facility's governing body failed to ensure that the Administrator (ADM), responsible for managing and overseeing the implementation of policies and procedures, reported a change in the Administrator as required by State and Federal regulations. This deficiency was identified through interviews and record reviews, revealing that the Electronic Licensing Management System (ELMS) listed a different name for the ADM of Skilled Nursing Facility 1 (SNF 1) as of 7/29/2024. The ADM, who started in 10/2023, was also serving as an ADM at another facility. During an interview, the ADM admitted to applying for the Change of Ownership (CHOW) with the State Department in 10/2023 but was unable to provide documentation of the application to the surveyor, claiming it was not a regulation to keep a copy. The facility's policy and procedure, titled Governing Body and revised on 5/23/2019, states that the Governing Body appoints a qualified Administrator licensed by the State of California, responsible for the facility's management and accountable to the Governing Body. The policy also requires the facility to submit a new application package to the California Department of Public Health whenever a change in ownership occurs, and all other changes must be reported to the Licensing and Certification District Office in writing within ten days of the change. The failure to report the change in Administrator had the potential to affect the safety and overall well-being of all 56 residents in the facility.
Delayed Meal Service Affects Resident Dignity
Penalty
Summary
The facility failed to provide timely meal service to a resident, which compromised the resident's dignity and comfort. The resident, who has type two diabetes mellitus, chronic kidney disease, and major depressive disorder, was observed waiting for a lunch tray past the scheduled meal time. The resident expressed irritation and discomfort due to hunger, as the lunch trays were consistently delivered late, often close to 1 p.m., despite the meal schedule indicating that lunch should be served at 12 p.m. The delay in meal service was attributed to logistical challenges faced by the staff. The facility's elevator was out of service, requiring certified nursing assistants to manually transport meal carts from the basement kitchen to the first floor via a steep ramp. This process was time-consuming and interfered with their ability to assist residents promptly. The facility's policy mandates that meals be served at regularly scheduled hours, and the failure to adhere to this schedule resulted in the resident's dissatisfaction and discomfort.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of a resident, leading to a fall and subsequent injuries. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was identified as a fall risk. Despite having a care plan and physician orders that required the bed to be in a low position and floor mats to be in place, these measures were not followed. The resident's bed was left in a high position with side rails up, and no floor mats were present, contrary to the care plan and physician orders. On the day of the incident, a Certified Nursing Assistant (CNA) left the resident unattended after providing care, with the bed in a high position and side rails up. The CNA stepped away to call for assistance in repositioning the resident, during which time the resident fell from the bed, sustaining a head injury and a laceration to the left eyebrow. The resident was subsequently transferred to a hospital for evaluation and treatment, where a CT scan revealed frontal scalp soft tissue swelling, and the resident received sutures for the laceration. Interviews with staff and other residents confirmed that the bed was not in the prescribed low position, and floor mats were absent at the time of the fall. The facility's policies on fall management and resident safety were not adhered to, as the necessary precautions to prevent falls were not implemented. The incident highlights a failure to follow established care plans and physician orders, resulting in harm to the resident.
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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