Pioneer House
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 415 P Street, Sacramento, California 95814
- CMS Provider Number
- 555542
- Inspections on file
- 33
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Pioneer House during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, documented as lacking decision-making capacity and assessed as high risk for elopement, refused the wander management system (WMS), yet the care plan did not include specific interventions to monitor safety, address the mental illness diagnosis, or reduce elopement risk. Progress notes showed the resident was restless, agitated, and on high elopement risk, but staff did not document monitoring strategies. When the resident was discovered missing, an LPN did not announce Code Pink, administration was not notified for more than two hours, and police were notified several hours later, contrary to facility policy requiring immediate Code Pink, prompt administration notification, and police notification if the resident was not located after 30 minutes. Staff interviews confirmed the absence of WMS use, difficulty monitoring residents leaving the floor, and lack of a Code Pink announcement, while the DON acknowledged the missing care plan interventions and the failure to follow the elopement procedures.
A resident with extensive burn wounds and homelessness was discharged without arrangements for home health nursing, food, or transportation for follow-up care. The facility did not contact community resources, provide written instructions, or ensure the resident could manage her medical needs post-discharge. Staff interviews confirmed the lack of individualized discharge planning and failure to meet the resident's health and safety needs.
A resident with severe cognitive impairment and a history of wandering was not wearing a required wander guard device for multiple shifts, despite physician orders and care plan directives. Staff failed to ensure the device was in place or to document its absence, resulting in the resident leaving the facility unsupervised and being found by law enforcement miles away without the device.
A resident with severe cognitive impairment and a history of aggression wandered unsupervised, entering other residents' rooms and physically assaulting two residents, resulting in pain, injury, and fear. Staff and residents reported that the aggressive resident was not adequately monitored, despite known risks and prior incidents, and the facility failed to protect residents from abuse as required by policy.
A resident with encephalopathy and dysphagia was not provided the therapeutic diet ordered by their physician, receiving a pureed meal instead of the prescribed soft and bite-sized texture. This discrepancy was confirmed by facility staff, including a CNA, LN, and the DON, highlighting a failure to adhere to the facility's policy on therapeutic diets.
A resident with multiple health conditions requiring substantial assistance for ADLs was unsafely discharged to a room and board facility without confirming necessary in-home supportive services (IHSS). The facility's SSD and DON failed to verify the availability of IHSS, relying instead on the resident's self-assessment and the room and board representative's understanding. This oversight led to the resident being unable to care for themselves, resulting in hospitalization.
A facility failed to complete and provide an inventory of personal belongings sheet to a resident upon admission, as required by policy. The resident, admitted with anxiety, confirmed that no inventory was conducted, and no copy was given. The DON acknowledged the lack of documentation, which could lead to the resident's belongings being lost or stolen.
A resident with a history of aggression and inappropriate behavior verbally threatened and physically assaulted another resident, causing injury and distress. Another resident experienced multiple episodes of sexual inappropriateness from the same resident. Despite awareness of the resident's behaviors, the facility failed to implement effective interventions to ensure the safety of the affected residents.
A facility failed to document the admission weight of a resident with dysphagia and severe protein-calorie malnutrition, as required by physician orders. The absence of this documentation was confirmed by the ADON, DON, and NC, and the facility could not provide their policy for Admission Assessment despite requests.
A resident, dependent on staff for grooming and hygiene due to cerebral infarction and muscle weakness, did not receive scheduled showers as per their care plan. The resident's care plan required bathing at least twice a week, but records showed only two showers were provided over a specified period. Facility staff confirmed the oversight, acknowledging the failure to adhere to the resident's care plan.
The facility failed to store medications in their original containers for 16 residents, as observed with unlabeled pills in plastic cups in a medication cart. A Licensed Nurse confirmed the safety concern, and the DON highlighted the risk of incorrect identification. Facility policy mandates medications remain in original packaging.
The facility failed to maintain food safety and sanitation standards, affecting 42 residents. Expired and unlabeled food items were found in the kitchen, and there were no temperature logs for certain storage areas. Ice and water dispensers were unclean, and food tray lids were improperly stored on a dirty oven top. The Dietary Manager confirmed these deficiencies.
The facility failed to maintain proper infection control practices, including housekeeping staff not changing gloves, lack of handwashing in the laundry room, and no corrective action for positive legionella tests. LN 1 and CNAs did not perform hand hygiene when passing lunch trays, and LN 1 did not follow Enhanced Barrier Precautions for a resident with spina bifida and paraplegia.
A resident's right to retain personal possessions was violated when their cell phone was taken without permission after they used it to call 911 due to unresponsive staff. The facility failed to investigate or document the incident, and the phone's whereabouts remain unknown, despite policies requiring prompt investigation of such issues.
A resident reported an incident of sexual and physical abuse to an LN, resulting in a bruise, but the facility failed to investigate or report the allegation. Interviews revealed staff were unaware of the abuse protocol, and the DON and ADM were not informed. The facility's policy requires immediate reporting and investigation, which was not followed, leaving the resident feeling unsafe.
A resident was served meals in polystyrene containers with plastic utensils without any documented orders or dietary instructions, leading to feelings of neglect and diminished self-worth. The DON and DM confirmed the lack of orders for this practice, acknowledging it as a dignity issue. The facility's policy on resident rights, which includes the right to a dignified existence, was not followed.
The facility failed to maintain secured handrails in the corridors of Unit A and Unit B, as required by regulations. Observations showed a resident with impaired cognition and difficulty walking using a walker in a corridor without handrails, and two other residents navigating another corridor also lacking handrails. The Maintenance Supervisor confirmed the handrails were removed for painting and repairs, with no timeline for reinstallation. The DON acknowledged the increased risk of falls and injuries due to the absence of handrails and admitted the facility lacked a policy for handrails.
The facility failed to ensure that call lights were within reach for two residents, placing them at risk of not being able to ask for assistance. The call lights were found bundled up in a basket above the bedside dresser, out of reach. Staff confirmed the call lights were out of reach and stated they usually place them within reach for resident safety. The facility's policy indicated call lights should be accessible when residents are in bed.
Failure to Prevent Elopement and Follow Elopement Procedures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement measures to prevent an avoidable elopement for a resident with schizoaffective disorder who was assessed as high risk for elopement and lacked decision-making capacity. The resident’s Wandering Risk Assessment identified a high elopement risk, and physician orders and admission documentation indicated the resident did not have capacity to understand choices and make decisions. The care plan documented that the resident was non-compliant with the wander management system (WMS) and was a fall risk, but it did not include nursing interventions for monitoring safety or reducing elopement risk, nor did it address the resident’s schizoaffective disorder or how related behaviors would be monitored. Progress notes documented that the resident refused the WMS and was on high elopement risk, with restlessness and agitation, but staff did not document monitoring interventions or best practices to keep the resident safe from elopement. On the date of the incident, a licensed nurse documented at 7:35 p.m. that the resident was not found in the facility, but there was no documentation that a Code Pink was announced as required by the facility’s elopement emergency procedures. The same nurse documented at 10:05 p.m. that the DON was notified the resident had left the facility, indicating an administration notification delay of more than two hours. A later progress note at 3:17 a.m. showed the DON faxed notification to the police department, exceeding the policy requirement to notify police if the resident is not located after 30 minutes. Staff interviews revealed that residents outside smoking after the main entrance doors locked at 5 p.m. needed to ring a doorbell for re-entry and that one CNA could not tell when residents left the floor if busy elsewhere and confirmed the resident did not wear a WMS and no Code Pink was heard. The DON confirmed the resident lacked capacity, was high risk for elopement, that the care plan did not address the mental illness diagnosis, and that there were no interventions for monitoring safety when the WMS was not worn. The facility’s policies required identification of residents at risk for wandering/elopement, inclusion of safety strategies in the care plan, and initiation of the elopement/missing resident emergency procedure, including announcing Code Pink, notifying administration, and notifying police if the resident was not located after 30 minutes.
Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was homeless and required ongoing care for multiple burn wounds. The resident, admitted with third-degree burns covering 20-29% of her body, muscle wasting, mobility disorders, and MRSA carrier status, was discharged without proper arrangements for home health nursing services, food, or transportation to follow-up medical appointments. The case manager/social worker did not contact homeless shelters or home health agencies, nor did she provide the resident with written discharge instructions or information for follow-up care. The resident was only verbally informed of her discharge the day before and was not advised of her right to appeal the discharge. The discharge plan was not individualized or reviewed with the resident, and the facility did not ensure that the resident's needs and preferences were met. The administrator attempted to secure a motel room for three nights but did not make a reservation or arrange for food, nursing care, or a long-term shelter solution. There was no documentation of a discharge plan or communication with the resident regarding the plan. The facility's own policy required a discharge summary and plan to be developed and reviewed with the resident and family at least 24 hours before discharge, but this was not followed. Interviews with facility staff, including the DON and wound nurse, revealed a lack of awareness and preparation for the resident's discharge needs. The wound nurse acknowledged that the resident would not be able to care for wounds on her back and had not provided any education or training for wound care. The facility's failure to coordinate post-discharge care, secure appropriate shelter, and provide necessary information and resources resulted in a discharge process that did not address the resident's health and safety needs.
Failure to Ensure Use of Wandering Device for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate supervision and ensure that a resident at high risk for elopement was wearing a required wandering device, as ordered by the physician and outlined in the care plan. The resident, who had severe cognitive impairment with a BIMS score of 4/15, a history of dementia, falls, and spinal fracture, was known to wander and exhibit exit-seeking behaviors. Staff interviews confirmed that the resident was supposed to wear a wander guard on the left ankle, which would trigger an alarm if the resident approached an exit. However, documentation in the Medication Administration Record (MAR) indicated that the resident was not wearing the device for six consecutive shifts prior to the incident. On the day of the incident, the resident was able to leave the facility unsupervised and without staff knowledge. The absence of the wandering device was confirmed by both staff and the resident's responsible party, who reported not seeing the device on the resident prior to the elopement. The resident was later found by law enforcement more than two miles from the facility, without the wandering device, and was returned to the facility. The facility's own policies required identification of residents at risk for wandering and implementation of safety interventions, including the use of a wander guard, but these were not followed in this case. Record reviews and staff interviews further revealed that nurses were expected to check and document the presence of the wandering device each shift, and to immediately replace it if missing. Despite these expectations, there was no documentation or action taken to ensure the device was in place during the period leading up to the resident's elopement. The failure to follow physician orders, care plan interventions, and facility policy directly led to the resident's unsupervised exit from the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two residents experiencing pain, injury, and fear for their safety. One resident with severe cognitive impairment, Alzheimer's disease, and a history of behavioral disturbances was known to wander unsupervised and had prior incidents of aggression. This resident entered another resident's room, touched personal belongings, ate food, and became physically aggressive when confronted, swinging her arms and making physical contact that resulted in redness on the other resident's neck. The affected resident, who had intact cognition and a history of depression and chronic pain, reported feeling abused and expressed fear, leading him to avoid activities and remain in his room for safety. In a separate incident, the same resident with cognitive impairment approached another resident in the dining room, touched her belongings, and slapped her on the back of the head when she tried to intervene. The resident who was struck, who had moderate cognitive impairment, hemiplegia, and mental health diagnoses, complained of pain and expressed feeling unsafe and wanting to leave the facility. Witnesses, including another resident and staff, confirmed the aggressive behavior and noted that the resident responsible for the incidents was not monitored at all times, despite being on special monitoring due to her known wandering and aggression. Staff interviews revealed that the facility did not provide sufficient supervision to prevent the aggressive resident from entering other residents' rooms or causing harm. Multiple staff members and residents reported that the aggressive resident frequently wandered unsupervised and that staff were often too busy to monitor her continuously. The facility's policy stated that residents have the right to be free from abuse, including abuse by other residents, but the observed incidents and staff accounts demonstrated a failure to uphold this standard.
Failure to Provide Correct Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician for one of the sampled residents, who was admitted with diagnoses including encephalopathy and dysphagia. The physician's order specified a regular diet with soft and bite-sized texture, but the resident received a meal with a pureed food item and a tray card indicating a mince moist diet. This discrepancy was confirmed during observations and interviews with a Certified Nurse Assistant (CNA), a Licensed Nurse (LN), a kitchen staff member, and the Director of Nursing (DON). The facility's policy on therapeutic diets, which requires that diet orders match the terminology used by the food and nutrition services department, was not followed. The DON acknowledged that the diet provided did not match the physician's order, and the kitchen staff confirmed that the mince moist and soft, bite-sized diets are different orders. This failure had the potential to impact the resident's nutritional status, as the diet provided did not align with the resident's treatment plan and preferences.
Unsafe Discharge of Resident Without Adequate Support
Penalty
Summary
The facility failed to provide a safe discharge for a resident who was discharged to a room and board facility that did not meet their care needs. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, and a right leg above the knee amputation, required substantial assistance for activities of daily living (ADLs) such as toileting, showering, dressing, bed mobility, and transfers. Despite this, the resident was discharged without ensuring that the necessary in-home supportive services (IHSS) were in place, leading to the resident living in an unsafe environment. Interviews and record reviews revealed that the Social Service Director (SSD) and the Director of Nursing (DON) did not confirm the availability of IHSS before the resident's discharge. The SSD relied on the resident's self-assessment and the room and board representative's (RBR) understanding that IHSS would be provided, but did not verify this information. The resident's Minimum Data Set (MDS) indicated a need for substantial assistance, yet the discharge plan did not adequately address these needs, resulting in the resident being unable to care for themselves and eventually requiring hospitalization. The facility's policy and procedure for preparing a resident for discharge were not followed, as the post-discharge plan was not adequately developed or confirmed. The SSD did not document discussions with the RBR regarding the resident's functional abilities and the room and board's capacity to provide care. The lack of documentation and confirmation of IHSS services contributed to the unsafe discharge, as the resident was left without the necessary support to manage their ADLs independently.
Failure to Provide Inventory of Personal Belongings
Penalty
Summary
The facility failed to ensure that an inventory of personal belongings sheet was completed and a copy was provided to a resident upon admission. This deficiency was identified for one of the three sampled residents, who was admitted with a diagnosis that included anxiety. The review of the resident's Admission Record indicated that the Inventory of Personal Effects sheet, dated shortly after admission, lacked the resident's signature on the 'Certification of Receipt' portion. Furthermore, there was no documented evidence in the resident's closed record, nurse's notes, or admission record that the resident signed the inventory sheet or received a copy upon admission. During a telephone interview, the resident confirmed that an inventory of belongings was not conducted upon admission, and a copy of the inventory sheet was not provided. The Director of Nursing (DON) acknowledged that the facility could not provide documentation that the resident received a copy of the inventory sheet. The facility's policy and procedure for admitting residents, dated September 2013, required that all personal items be inventoried, recorded, and signed by the resident or a family member, with a copy provided to them. This failure had the potential for the resident's personal belongings to be lost or stolen.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, who had a known history of verbal aggression and sexual inappropriateness. Resident 3 was verbally threatened and physically assaulted by Resident 1, resulting in physical injury and emotional distress. Despite Resident 1's history of aggression, there was no documented evidence that the resident had been referred or evaluated by a psychiatrist as ordered by the physician. Resident 2 experienced multiple episodes of sexual inappropriateness from Resident 1. The facility's care plan for Resident 2 did not contain any interventions to ensure the resident's safety, despite the resident's report of feeling uncomfortable and dirty due to Resident 1's actions. The facility's staff, including the Assistant Director of Nursing, were aware of Resident 1's behaviors but failed to take adequate measures to protect Resident 2. Interviews with staff and residents revealed that Resident 1 had a history of inappropriate behavior, including making sexual advances towards staff and residents. Despite this, the facility did not implement effective interventions to prevent further incidents. The facility's policy on safety and supervision of residents was not adequately followed, leading to the failure to protect Residents 2 and 3 from abuse.
Failure to Document Admission Weight for Resident
Penalty
Summary
The facility failed to follow physician orders for a resident when the resident's weight was not measured at admission. The resident was admitted with diagnoses including dysphagia and severe protein-calorie malnutrition. A review of the resident's Order Summary Report (OSR) dated 10/31/24 indicated an order for an admission weight, which was not documented. During an interview and record review with the Assistant Director of Nursing, Director of Nursing, and Nurse Consultant, it was confirmed that there was no admission weight recorded for the resident, and thus no way to track potential weight loss. Additionally, the facility was unable to provide their policy and procedure for Admission Assessment, which should include documentation of a resident's admission weight, despite requests made on 11/26/24 and 11/27/24.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living (ADLs) independently, received the necessary services to maintain grooming and personal hygiene. The resident, admitted with diagnoses including cerebral infarction and muscle weakness, was dependent on staff for grooming and hygiene care and required assistance from one to two staff members for bathing. The resident's care plan indicated a preference for showers and required bathing at least twice a week. However, a review of the resident's bathing tasks revealed that the resident only received showers on two occasions within a specified period, with no bathing tasks completed for over a week. During an interview and record review, facility staff, including the Assistant Director of Nursing, Director of Nursing, and Nurse Consultant, confirmed the resident's dependency on staff for hygiene needs and acknowledged the failure to provide showers as scheduled. The facility's policy on supporting ADLs emphasized the necessity of providing appropriate care and services for residents unable to carry out ADLs independently.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in their original containers and in a safe manner for 16 sampled residents. During an observation and interview with a Licensed Nurse (LN) at Medication Cart 1, it was found that there were three 30 mL plastic cups in the top drawer, each containing two or more unlabeled and unidentified items. The LN confirmed that the plastic cups were not labeled and contained various pills, including a pink pill, a red liquid-gel pill, two orange-colored pills, and seven red and white liquid-gel pills. The LN acknowledged that medications should not be removed from their original packaging, citing this as a safety concern. In a subsequent interview with the Director of Nursing (DON), it was confirmed that medications are not to be removed from their original packaging, as this poses a safety hazard. The DON emphasized that the next nurse taking over the medication cart would not know what these pills are, highlighting the potential for incorrect identification and misuse. A review of the facility's policy and procedure on Medication Labeling and Storage indicated that medications and biologicals should be stored in their original packaging, and only the issuing pharmacy is authorized to transfer medications between containers. The policy also states that nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and medications may not be transferred between containers.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner for 42 residents. During an inspection, an expired half-gallon of milk, opened salad dressing, and creamer containers without open dates were found in the kitchen refrigerators. Additionally, full egg crates were found without received or expiration dates labeled. The Dietary Manager confirmed these observations and acknowledged that the items should have been labeled and the expired milk discarded. Furthermore, there were no temperature monitoring logs for the resident food freezer section and the dry storage room, which the Dietary Manager confirmed should have been in place. The inspection also revealed that the ice and water dispensers in the dining room were not clean, with white and brown residue observed on the surfaces. The Dietary Manager confirmed the unclean state of the dispensers. Additionally, lids used for covering prepared food on the steam table were stored on top of an unclean oven top, which was observed to have a dusty sticky residue. The Dietary Manager acknowledged the unclean surface and the improper storage of food tray lids. These findings indicate a failure to adhere to the facility's policies and procedures for food safety and sanitation.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to potential cross-contamination and infection risks. Housekeeping staff were observed dipping contaminated gloves into mop bucket sanitizing solution without changing gloves, which was confirmed by the housekeeper and the infection preventionist as cross-contamination. Additionally, the laundry room lacked a handwashing station, and staff did not use gowns when handling dirty laundry, failed to sanitize equipment after handling dirty laundry, and did not perform hand hygiene after glove removal or between resident room visits. Contaminated clothes hangers were also hung back on the clean linens cart. The facility was unable to provide evidence of timely corrective action following positive legionella tests in the water systems. A review of the facility's water management plan revealed a positive legionella testing report, but no evidence of corrective action or retesting was available. The infection preventionist confirmed that interventions and retesting were expected but not documented. Licensed Nurse 1 and Certified Nursing Assistants 2 and 3 did not perform hand hygiene when going in and out of residents' rooms while passing lunch trays. Additionally, LN 1 did not follow Enhanced Barrier Precautions when providing wound care for a resident with spina bifida and paraplegia, who had nephrostomy tubes and a sacral wound. The infection preventionist confirmed that staff should have worn gowns during high-contact care activities, as indicated by the Enhanced Barrier Precautions policy.
Failure to Maintain Resident's Right to Personal Possessions
Penalty
Summary
The facility failed to ensure a resident's right to retain and use personal possessions, specifically a cell phone, was maintained. The resident, who was admitted with diagnoses including intracerebral hemorrhage and hemiplegia, reported that their cell phone was taken away after they used it to call 911 due to unresponsive nursing staff at night. The resident was unaware of the current location of the cell phone. Interviews with the Social Services Director (SSD) and the Assistant Director of Nursing (ADON) confirmed that the resident was admitted with a cell phone and chargers, but the SSD admitted to not following up on the whereabouts of the phone after it was reportedly taken by firefighters. The facility's policies and procedures, which were reviewed, indicate that residents are allowed to retain personal possessions and that any complaints of misappropriation should be promptly investigated. However, the SSD and the Director of Nursing (DON) both acknowledged that they did not know the current location of the resident's cell phone, and no documentation was found regarding the outcome or location of the phone. The facility's failure to investigate and document the incident violated the resident's rights as outlined in their policies and procedures.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident, identified as Resident 21, who reported an incident of sexual and physical abuse to a Licensed Nurse (LN). Resident 21, who was admitted with diagnoses including intracerebral hemorrhage and hemiplegia, expressed feeling unsafe and neglected within the facility. The resident reported to LN 4 that two CNAs were involved in the alleged abuse, which resulted in a bruise on the resident's hand. Despite being a mandated reporter, LN 4 did not take appropriate action to report the sexual abuse allegation, considering it a non-emergency situation. Interviews with facility staff revealed a lack of understanding and execution of the facility's abuse reporting protocol. CNA 4 indicated she would report incidents to a nurse or supervisor but was unsure about the availability of an abuse binder. LN 2 stated she would notify the DON and ADM, check the policy for abuse reporting, and inform the state authorities, but was unaware of the location of the abuse binder. The DON and ADM were not informed of the incident and were unaware of the abuse allegation until the surveyor's review. The facility's policy requires all reports of abuse to be immediately reported to the administrator and relevant authorities, with thorough investigations conducted by management. However, the policy was not followed in this case, as the ADM, who is the abuse coordinator, was not notified, and no investigation was initiated. The failure to adhere to the policy resulted in the incident not being reported or investigated, leaving Resident 21 feeling unsafe and unsupported.
Resident Served Meals in Polystyrene Containers Without Justification
Penalty
Summary
The facility failed to provide an environment that supported the quality of life for one resident, identified as Resident 21, by serving meals in polystyrene containers with plastic utensils. This was observed during a visit to Resident 21's room, where the resident expressed dissatisfaction and a lack of understanding as to why meals were served in this manner. The resident felt neglected and expressed feelings of hopelessness, indicating a negative impact on their self-worth and well-being. Upon review of Resident 21's records, it was confirmed by both the Director of Nursing (DON) and the Dietary Manager (DM) that there were no physician orders or dietary instructions specifying the use of polystyrene containers and plastic utensils for this resident. The DON acknowledged that this practice was a dignity issue, potentially making the resident feel singled out. The facility's policy on Resident Rights, which emphasizes the right to a dignified existence and participation in care planning, was not adhered to in this instance.
Absence of Secured Handrails in Facility Corridors
Penalty
Summary
The facility failed to ensure that the corridors in Unit A and Unit B had firmly secured handrails, as required by the California Code of Regulations. This deficiency was identified through observations, interviews, and record reviews. During an observation, a resident with severely impaired cognition and difficulty walking was seen using a walker in the Unit A corridor, which lacked secured handrails. The resident confirmed the absence of handrails and expressed that having them would enhance safety by providing support for balance. Further observations revealed that two residents were seen navigating the Unit B corridor, which also lacked secured handrails. The Maintenance Supervisor confirmed that the handrails had been removed over three weeks prior for painting and repairs, with no clear timeline for reinstallation. The Director of Nursing (DON) acknowledged that the handrails had been absent for over a month and admitted to not having a specific date for their return. Additionally, the facility did not have a policy or procedure in place regarding handrails. The absence of handrails in the facility's corridors posed a potential risk of increased falls and injuries for residents using these areas. The DON, who started working at the facility after the handrails were removed, agreed that the lack of handrails heightened the risk of falls and injuries. The facility's failure to comply with the regulation requiring firmly secured handrails in corridors was evident, as confirmed by the observations and interviews conducted during the survey.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach and easily accessible for two residents, placing them at risk of not being able to ask staff for assistance. Resident 2, who has dementia, a history of falling, and glaucoma, and Resident 4, who has dementia, chronic kidney disease stage 3, and hypertension, were observed to have their call lights bundled up and placed in a black basket above the bedside dresser, out of their reach. During an interview, a Certified Nurse Aide confirmed the call lights were out of reach and stated that they usually place the call lights within reach so that residents feel safe and can call for assistance. The Administrator also confirmed that staff are expected to always place the call lights within reach of the residents. The facility's policy and procedure on answering call lights indicated that call lights should be accessible to residents when in bed.
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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