Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Professional Post Acute Center during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and dysphagia, who had previously indicated he did not want to self-administer medications, was found with a medicine cup labeled for a different bed on his overbed table containing three unidentified pills. The resident reported he had not requested to self-administer medications, was unsure if the pills were his, and had difficulty taking medications without assistance. An LN confirmed the cup was labeled for another resident and was unsure what the medications were, while another LN acknowledged that policy prohibits leaving medications at bedside or allowing self-administration without an IDT assessment. The interim DON verified there was no assessment authorizing self-administration for this resident and stated that, without such an assessment, staff should not allow the resident to self-administer medications, consistent with facility policies requiring physician and IDT determination of safety before self-administration.
Surveyors found that a resident with hemiplegia, hemiparesis, and dysphagia had a medicine cup labeled with the room number containing three pills left on the overbed table, and the resident reported not knowing if the medications were theirs or when they were left there. An RN confirmed the medications were at the bedside and stated staff should not leave medications unattended, while another nurse stated medications must be administered under observation. The IDON acknowledged that leaving medications at the bedside was not allowed under facility policy, which requires medications to be administered safely and stored securely, with any unauthorized bedside medications turned over to the charge nurse.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
A resident with mobility limitations was found to have their commode bucket covered with a blanket instead of a lid, as staff had not provided a proper cover. Both staff and the Infection Preventionist confirmed this practice was unsanitary and not in accordance with infection control policy, resulting in a breach of safe and sanitary environment standards.
A resident with a history of urinary tract infections and incontinence experienced bladder pain and blood-tinged urine for about a month, but nursing staff did not notify the provider, obtain a urinalysis, or monitor the hematuria as required by the care plan and facility policy. The resident was eventually sent to the hospital, where a UTI was diagnosed. Staff interviews confirmed that necessary assessments and notifications were not completed.
A resident with severe cognitive impairment was physically abused by another resident, resulting in bruising and pain. The incident was witnessed by staff, who intervened and reported the abuse. The facility's abuse prevention policy was not effectively implemented, leading to a substantiated abuse allegation.
A facility failed to implement a pharmacist's recommendation for a resident's medication monitoring. The resident, with a history of hemiplegia and cerebral infarction, was on atorvastatin and clopidogrel. The pharmacist recommended monitoring specific lab tests, but the RN Supervisor confirmed no orders were made. Interviews with staff revealed the facility's process for implementing pharmacy recommendations was not followed, resulting in the deficiency.
A medication error rate of 7.41% was identified when an LVN administered the wrong medication to a resident with anemia. The resident was prescribed ferrous fumarate but received ferrous sulfate instead. The error was confirmed by the Consultant Pharmacist and acknowledged by the LVN, who failed to notice or report the discrepancy. The facility's policy requires medications to be administered as prescribed, and this failure led to the deficiency.
A resident with a history of hallucinations was slapped by another resident with severe cognitive impairment, despite having a care plan to reduce noise levels to prevent aggressive behavior. The incident was witnessed by a CNA and reported to CDPH, but there was a delay in reporting, violating the facility's policy on immediate abuse reporting.
A CNA witnessed a resident slap another resident, but the incident was not reported to the State Survey Agency within the required two-hour timeframe. The resident who was slapped had a history of hallucinations, while the resident who slapped had severe cognitive impairment. Despite staff awareness of the incident, the report was delayed, violating federal reporting requirements.
The facility failed to maintain functional door locks for three residents, as observed during a complaint investigation. The Maintenance Supervisor confirmed the sliding and screen door locks were broken, and makeshift locks were ineffective. The Administrator was unable to locate missing parts for the makeshift locks, contradicting the facility's policy on providing a safe environment.
A resident with cognitive impairments eloped from a facility due to an unsecured gate in the courtyard, which was not alarmed or equipped with an auto-closure mechanism. The staff, including the Maintenance Director and nursing personnel, were unaware of the resident's whereabouts and the functionality of security devices. The facility lacked effective implementation of safety policies, and environmental safety rounds were not conducted as claimed.
A resident with chronic pain did not receive scheduled doses of Hydromorphone due to pharmacy delivery failures and inadequate facility processes. The resident experienced severe pain and withdrawal symptoms, and the physician was not informed of the issues. Staff reported ongoing problems with medication delivery and accessing the emergency medication supply.
The facility failed to prevent the worsening of a resident's pressure ulcer by not obtaining a doctor's order for wound treatment, not documenting the wound's status, and not conducting a comprehensive nutritional assessment. This led to the development of necrotic tissue and an increase in the wound's size.
The facility failed to provide adequate supervision for a resident who required extensive one-person physical assistance with transfers and ambulation. The resident, who had severe cognitive impairment and multiple diagnoses, was found lying in the hallway, resulting in a right femoral fracture and significant functional decline. Staff confirmed the resident's need for extensive assistance, which was not provided, leading to the incident.
The facility failed to ensure regular care plan conferences for two residents, resulting in their inability to participate in their person-centered plans of care. One resident's representative was not consistently invited, and another resident did not have quarterly meetings as required.
The facility failed to update care plans for a resident's decline in functional status, leading to inadequate care and supervision. The resident, with conditions including Diabetes Mellitus and Neurocognitive Disorder, experienced a fall and developed a pressure ulcer. Despite needing extensive assistance, the care plans inaccurately indicated the resident could ambulate and reposition independently.
A resident's sacral wound was treated with Medihoney by an LPN without a documented physician's order, contrary to facility policy. The DON confirmed that nurses must obtain a doctor's order before administering any treatment, following the five rights of medication administration.
The facility failed to provide timely rehabilitation screening and follow-up on a STAT X-ray request for a resident who fell and complained of hip pain. The resident did not receive a rehabilitation screening until 20 days after the fall, and the X-ray, which revealed a femoral neck fracture, was delayed by eight days. Additionally, the facility waited another eight days to obtain a weight-bearing precaution order, during which the resident was allowed to perform sit-to-stand activities.
Unassessed Medication Self-Administration and Misplaced Medication Cup
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to professional standards and facility policy when a resident was effectively left to self-administer medications without a required assessment. The resident, admitted in 1/2019 with hemiplegia, hemiparesis, and dysphagia, had an admission/readmission data tool dated 8/14/24 indicating he did not want to self-administer medications. A BIMS completed on 2/6/26 showed intact cognition with a score of 14. On 3/4/26 at 8:53 a.m., surveyors observed a medicine cup labeled for bed 18B containing three pills on top of the overbed table of the resident in bed 18C. The resident confirmed he occupied bed 18C, stated he was not sure if the medications were his, and reported that no nursing staff had assessed whether it was safe for him to take medications without supervision. The resident reported he had not requested to self-administer medications or to have medications left at his bedside and that he did not take the medications because he had difficulty taking them without assistance. During interviews, LN A verified the medicine cup labeled 18B with three pills was on the overbed table of the resident in 18C and acknowledged uncertainty about what the medications were. LN B stated she was not sure if the resident was safe to self-administer medications and confirmed that facility policy did not allow medications to be left at bedside or residents to self-administer without an assessment by the IDT. The interim DON verified that the admission/readmission data tool indicated the resident did not want to self-administer medications and that there was no assessment indicating it was safe for the resident to do so. The interim DON stated that, in the absence of such an assessment, staff should not allow the resident to self-administer medications and that allowing this could result in accidents such as choking. Facility policies on administering medications and self-administration required that residents may self-administer only if the attending physician and IDT determined it was clinically appropriate and safe.
Unsecured Bedside Medications Left Unattended
Penalty
Summary
Surveyors identified a deficiency in medication security and administration when a resident’s medications were left unattended at the bedside. The resident, admitted in 1/2019 with diagnoses including hemiplegia, hemiparesis, and dysphagia, was observed with a medicine cup labeled "18B" containing three pills on top of the overbed table. During the observation, the resident stated they were not sure if the medications were for them and did not know when the medications had been left there. The resident further reported that staff left medications on the overbed table all the time and that they had not requested staff to leave medications at the bedside. A concurrent observation with a licensed nurse confirmed the presence of the medicine cup with three pills on the resident’s overbed table. The nurse stated that staff should not leave medications at residents’ bedsides and acknowledged that medications should be administered under staff observation. Another licensed nurse similarly stated that medications should not be left at the bedside because staff were supposed to watch residents take their medications and that leaving them was a safety risk. The Interim DON stated that staff should not leave medications at the bedside and that this practice was not allowed per facility policy. Review of the facility’s policies on administering medications and self-administration of medications showed requirements that medications be administered safely and stored in a safe, secured place not accessible by other residents, and that any medications found at bedside and not authorized for self-administration be given to the charge nurse.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to the deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Improper Commode Bucket Covering Breaches Infection Control
Penalty
Summary
A deficiency was identified when a resident's commode bucket was found covered with a blanket instead of a proper lid. The resident, who had been admitted with pain in the right knee and difficulty walking, reported that staff had not provided a commode with a lid and instead used a blanket to cover the bucket. This was confirmed during observation and interviews with both the resident and unlicensed staff, who acknowledged that using a blanket in this manner was unsanitary and not in line with infection control practices. Further interviews with the Infection Preventionist and the Minimum Data Set coordinator confirmed that covering the commode bucket with a blanket was not acceptable, as it could lead to cross contamination and infection. The facility's infection control policy, which aims to maintain a safe and sanitary environment, was not followed in this instance. The blanket used to cover the commode was considered contaminated and posed a risk for the spread of bacteria.
Failure to Monitor and Report UTI Symptoms Resulting in Delayed Diagnosis
Penalty
Summary
Nursing staff failed to provide care consistent with professional standards and the resident's individualized care plan for a resident with a history of urinary tract infections and urinary incontinence. Over approximately one month, the resident experienced symptoms consistent with a urinary tract infection, including bladder pain and blood-tinged urine. Despite these symptoms being documented in the medical record, nursing staff did not ensure that the resident's provider was notified, a urinalysis was obtained, or that the hematuria was monitored as required by the care plan and facility policy. The resident's care plan specifically directed staff to monitor and document signs and symptoms of UTI, such as pain and blood-tinged urine, to minimize the risk of septicemia. On one occasion, nursing staff documented blood-tinged urine and blood in the vaginal area, and the nurse practitioner on call ordered continued monitoring and a gynecology consult. However, there was no evidence that a urinalysis was performed or that the hematuria was further monitored. The nurse practitioner later stated he was not informed of the hematuria or bladder pain, and would have ordered a urinalysis if he had been made aware. The resident continued to experience symptoms, including increasing pain, nausea, vomiting, and dizziness, until she was eventually sent to the hospital, where she was diagnosed with a UTI caused by E. coli. Interviews with facility staff confirmed that the required assessments and notifications were not completed, and facility policies requiring identification, documentation, and reporting of UTI symptoms were not followed.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident squeezed her left arm, resulting in bruising and pain. Resident 1, who has severe cognitive impairment due to radiculopathy and unspecified psychosis, was found crying with a bruise and scratch on her left forearm after the incident. The incident was witnessed by a CNA who reported that Resident 2, also with severe cognitive impairment due to unspecified dementia, was the aggressor. The CNA intervened and brought Resident 1 to a nurse for evaluation. Interviews with staff and another resident confirmed that Resident 2 had a history of aggressive behavior and had to be physically separated from Resident 1 during the incident. The facility's abuse prevention policy, which states that residents have the right to be free from abuse, was not effectively implemented in this case. The administrator confirmed that the abuse allegation was investigated and substantiated, indicating a failure to ensure the safety and well-being of Resident 1.
Failure to Implement Pharmacy Recommendations for Resident's Medication Monitoring
Penalty
Summary
The facility failed to act upon pharmacy recommendations for a resident reviewed for unnecessary medications, psychotropic medication, and medication regimen review. The facility's policy required that a consultant pharmacist perform a comprehensive medication regimen review at least monthly, with recommendations to be acted upon and documented by facility staff or the prescriber. However, for one resident, the facility did not implement the pharmacist's recommendation to monitor specific laboratory tests, despite the recommendation being signed by the physician. The resident in question had a medical history of hemiplegia and hemiparesis following a cerebral infarction, among other conditions, and was taking atorvastatin and clopidogrel. The consultant pharmacist recommended monitoring a lipid panel, comprehensive metabolic panel, and complete blood count, but the RN Supervisor confirmed that no orders for these laboratory tests were made. Interviews with facility staff, including the RN Supervisor, Senior Director of Clinical Operations, and the Administrator, revealed that the facility's process for ensuring the implementation of pharmacy recommendations was not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 7.41% error rate during a medication administration observation. This deficiency was identified when a Licensed Vocational Nurse (LVN) administered the wrong medication to a resident. The resident, who had a medical history including iron deficiency anemia and osteoarthritis, was prescribed ferrous fumarate for anemia. However, the LVN mistakenly gave the resident ferrous sulfate instead, which, although containing iron, is a different salt compound than what was ordered by the physician. The error was confirmed during an interview with the Consultant Pharmacist, who stated that any medication not given as ordered is considered a medication error. The LVN acknowledged the mistake upon reviewing the medication orders and admitted to not noticing the discrepancy or reporting it. The Senior Director of Clinical Operations and the Administrator both confirmed that the LVN did not follow the physician's orders, which constituted a medication error. The facility's policy requires medications to be administered as prescribed, and the LVN's failure to adhere to this policy led to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident 1, from physical abuse by another resident, identified as Resident 2. Resident 1, who had a history of yelling and screaming due to hallucinations, was slapped on the left side of her face by Resident 2. Resident 2 had a care plan intervention to modify her environment by reducing noise levels due to a potential for aggressive behavior. Despite this intervention, Resident 2 entered Resident 1's room and slapped her, resulting in visible redness and scattered petechiae on Resident 1's left cheek. The incident was witnessed by Certified Nursing Assistant C, who reported seeing Resident 2 intentionally slap Resident 1. The report indicates that Resident 2 had severe cognitive impairment, as evidenced by a BIMS score of 3, and had a history of physical behaviors related to dementia. The facility's policy requires that allegations of abuse be reported immediately or within two hours, but there was a delay in reporting the incident to the California Department of Public Health (CDPH). The facility's Administrator confirmed that the abuse allegation was substantiated and that the incident was reported to CDPH. However, there was a discrepancy in the timing of the report, as the facility was unable to provide fax confirmation that the SOC 341 form was sent within the required timeframe. The facility's policy emphasizes the residents' right to be free from abuse, neglect, and exploitation, but this incident highlights a failure to adhere to these standards.
Delayed Reporting of Resident Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving two residents to the State Survey Agency within the required timeframe. On the afternoon of August 25, 2024, a Certified Nursing Assistant (CNA) witnessed one resident slap another resident on the left side of her face. The incident was reported to a Licensed Nurse, who then delayed reporting the incident to the State Survey Agency until later that evening, more than five hours after the event occurred. This delay in reporting did not comply with the federal requirement to report such incidents immediately, or within two hours if they involve abuse. The residents involved in the incident had specific behavioral and cognitive challenges. The resident who was slapped had a care plan indicating she experienced hallucinations that caused her to yell and scream due to fear. The resident who committed the act of slapping had a care plan noting a potential for physical behaviors related to dementia, with a BIMS score indicating severe cognitive impairment. Despite these documented issues, the facility did not take immediate action to report the incident, which could have prevented further escalation or recurrence of abuse. Interviews with facility staff revealed that the CNA reported the incident to two Licensed Nurses during a shift change. However, the Licensed Nurse responsible for reporting the incident to the State Survey Agency did not do so until several hours later. The facility's policy requires that allegations of abuse be reported immediately or within two hours, but this protocol was not followed. The facility's Administrator confirmed the delay in reporting and acknowledged the failure to meet the required reporting timeframe.
Broken Door Locks Compromise Resident Safety
Penalty
Summary
The facility failed to ensure a safe and functional environment for three of seven sampled residents in a specific room, as the sliding door and screen door locking mechanisms were broken. This issue was identified during a complaint investigation by the California Department of Public Health. The Maintenance Supervisor, during an observation and interview, confirmed that the sliding door locks were broken and could not be locked. Additionally, the screen door was bent and unable to lock, posing a potential risk to the residents' safety. The Maintenance Supervisor was unaware of the issue until the surveyor's visit. Further observations with the facility Administrator revealed that makeshift locking systems were in place for the sliding doors in the affected rooms. However, one of these makeshift locks was missing a part, rendering it ineffective. The Administrator attempted to locate the missing part but was unsuccessful. The facility's policy on providing a safe and homelike environment was reviewed, which emphasized the importance of safety and comfort for residents, but the current state of the door locks contradicted this policy.
Resident Elopement Due to Unsecured Facility Gate
Penalty
Summary
The facility failed to ensure the safety of a resident who eloped from the premises and was found by the police 0.4 miles away. The facility is located on a hill with a steep incline and moderate traffic, and the courtyard area had an unsecured gate that allowed unsupervised passage to the street. The Maintenance Director acknowledged that the gate was not alarmed and could be easily opened by a resident, and the door leading to the courtyard was not equipped with an alarm system. The Maintenance Director also admitted to not knowing if the resident had a security device on the day of the elopement and was unaware of the manufacturer's instructions for the security alarms. The nursing staff demonstrated a lack of awareness regarding the resident's whereabouts and the functionality of the security devices. Licensed Nurse B was unaware of any safety concerns for the resident and did not check the security device, while Licensed Nurse A stated that the resident usually walked around independently and was not assigned a 1:1 observation. The Social Services Director confirmed that the resident had lowered cognition and liked to walk around the building, but did not think the resident had a security device alarm at the time of the elopement. The Director of Nursing stated that the facility did not conduct a Root Cause Analysis for the elopement and admitted that the resident was not wearing a security device at the time. The facility's policies and procedures for resident safety and supervision were not effectively implemented. The Administrator stated that the staff followed facility policies and procedures when the resident eloped, but there was no facility policy for resident safety. The environmental safety rounds were not conducted daily as claimed, and there was no timeline in place to address the identified elopement and safety risks. The facility's documentation indicated that the environment and assistive equipment were not checked for potential issues that could have contributed to the event, and the gate remained unsecured 12 days after the elopement.
Pharmacy Delivery Failures Lead to Missed Pain Medication
Penalty
Summary
The facility's pharmacy failed to provide timely pharmaceutical services to a resident, resulting in missed doses of Hydromorphone, a pain medication. The resident, who had a history of diabetes, paraplegia, amputation, phantom limb syndrome with pain, and chronic pain syndrome, was prescribed Hydromorphone to manage his chronic pain. However, the medication was not administered as scheduled on multiple occasions, including a 24-hour period where six doses were missed. The reasons documented for the missed doses included waiting for supplies and awaiting delivery, indicating a failure in the pharmacy's delivery system and the facility's medication management process. The resident experienced increased pain, symptoms of narcotic withdrawal, and emotional distress due to the missed doses. The resident reported feeling suicidal, hopeless, and out of control, and his pain levels were documented as severe during the periods when the medication was not administered. Despite these issues, there was no documentation of a nursing care plan for pain management in the resident's medical record, and the physician was not informed of the ongoing medication delivery and administration problems. Interviews with facility staff and the consulting pharmacist revealed that medication delivery issues were an ongoing problem, with nursing staff having to make multiple calls to the pharmacy to request medications. The facility's emergency medication supply (e-kit) was not utilized effectively due to discrepancies in prescription dosages and a lack of communication with the physician for one-time orders. The Director of Nursing confirmed the lack of documentation and escalation of the issue, indicating a breakdown in the facility's processes for ensuring timely medication administration and communication with healthcare providers.
Failure to Prevent Worsening of Pressure Ulcer
Penalty
Summary
The facility failed to assess and provide necessary services to prevent the worsening of a facility-acquired pressure ulcer for a resident. The resident was found to have an open wound on her sacrum and coccyx, but the facility did not obtain a doctor's order for routine wound treatment when the wound was identified. Additionally, the facility did not assess and document the status of the wound perimeter, wound bed, and healing progress as part of the pressure ulcer care plan. This led to the worsening of the resident's sacral wound, which developed thick adherent devitalized necrotic tissue and increased in size. The facility's progress notes indicated that the resident's sacral wound was treated with Medihoney without a written doctor's order. The Director of Nursing confirmed that nurses are expected to obtain a doctor's order before administering any medication or treatment. The treatment nurse also failed to document any changes in the wound's condition, and there were no notes indicating that the physician was notified of the wound's worsening condition prior to the wound doctor's visit. Furthermore, the facility did not conduct a comprehensive nutritional assessment for the resident after the identification of the sacral pressure ulcer. The Registered Dietician confirmed that the resident was not included in the list of residents being monitored for pressure ulcers and that there was no comprehensive nutritional assessment conducted for the resident in November. The facility's policy on the prevention of pressure injuries and nutritional assessment requires a comprehensive nutritional assessment for residents at risk of pressure injuries or with existing pressure injuries.
Failure to Provide Adequate Supervision for Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who required extensive one-person physical assistance with transfers and ambulation. The resident, who had diagnoses including Diabetes Mellitus, Hypertension, and Neurocognitive Disorder, was found lying in the hallway after being last observed in bed. This incident resulted in the resident sustaining a right femoral fracture and a significant decline in physical function. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for extensive assistance with transfers and ambulation. Interviews with staff confirmed that the resident required extensive assistance with transfers and ambulation prior to the fall. After the fall, the resident became dependent on staff for transfers and did not ambulate. The Physical Therapy evaluation noted a significant functional decline due to the right hip fracture, and the resident was placed on non-weight bearing status. The facility's policy on Activities of Daily Living (ADL) indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, but this was not adhered to in this case.
Failure to Conduct Regular Care Plan Conferences
Penalty
Summary
The facility failed to ensure care plan conferences were conducted for two sampled residents, resulting in their inability to participate in the development and implementation of their person-centered plans of care. Resident 1, who had severe cognitive impairment due to dementia, was not represented by his designated representative in most care plan meetings. The representative, Witness C, stated he was not invited to participate in most of the care plan meetings and that these meetings were not multidisciplinary. The Social Service Director (SSD) confirmed that care conferences are held quarterly and as needed, but could not explain why Resident 1 did not have a care conference every three months as required. The SSD also verified that Resident 1 had care conferences on specific dates but did not know why the representative was not consistently invited. Resident 2, who was cognitively intact with a BIMS score of 15 out of 15, also did not have regular care plan conferences. The SSD verified that Resident 2 had care conferences on two specific dates but did not provide a reason for the lack of quarterly meetings. The facility's policy requires that residents and their representatives be informed of their right to participate in care planning and that any impracticality in their participation be documented. However, this policy was not followed, leading to a deficiency in ensuring that residents and their representatives could participate in care planning, thereby affecting their quality of care and quality of life.
Failure to Update Care Plans for Resident's Decline in Functional Status
Penalty
Summary
The facility failed to implement timely revisions to the ADL Self Care Performance Deficit Care Plan for a resident when it did not update the care plan to reflect the resident's decline in functional status. The resident, who was admitted with diagnoses including Diabetes Mellitus, Hypertension, and Neurocognitive Disorder, experienced a fall and developed a pressure ulcer. Despite these changes, the care plan continued to indicate that the resident could ambulate without assistance and move freely in bed, which was inconsistent with the resident's actual need for extensive one-person physical assistance with transfers, bed mobility, and ambulation as noted in the MDS assessment. Additionally, the Pressure Ulcer Care Plan for the resident was not updated to reflect the resident's inability to reposition herself due to requiring extensive assistance with bed mobility. The care plan intervention to encourage the resident to reposition herself was not feasible given her condition. Both the MDS Coordinator and the DON confirmed that the care plans did not accurately reflect the resident's current needs and that the care plans should have been updated to ensure appropriate care and supervision.
Unauthorized Wound Treatment Without Physician's Order
Penalty
Summary
The facility failed to meet nursing professional standards for one resident when a licensed staff member provided wound treatment without a physician's order. Specifically, Resident 1 had a sacral wound treated with Medihoney by Licensed Staff B, who claimed to have received a verbal order from the physician but failed to document it. Upon review, both Licensed Staff B and the Director of Nursing (DON) confirmed that there was no written order for the treatment on the date in question. The DON emphasized that nurses are expected to obtain a doctor's order before administering any medication or treatment, following the five rights of medication administration. Licensed Staff F explained that new skin issues are identified during routine care and that any new wounds should be documented in the resident's medical record, with the physician being notified to obtain a treatment order. The facility's policy on administering medications, revised in April 2019, states that medications should be administered safely, timely, and as prescribed. The failure to follow this policy resulted in a potential risk for Resident 1 of an adverse drug reaction due to the unauthorized use of Medihoney.
Failure to Provide Timely Rehabilitation Screening and X-ray Follow-up
Penalty
Summary
The facility failed to provide necessary services for a resident after a fall incident. The resident, who had diagnoses including diabetes mellitus, hypertension, and neurocognitive disorder, was found lying in the hallway. Despite a recommendation for a rehabilitation screening post-fall, the facility did not perform the screening until 20 days later. The delay was due to the rehabilitation staff not receiving a referral from the nursing staff, and the Director of Rehabilitation, who participated in the post-fall review, did not pass the information to the rehabilitation staff. This resulted in the resident not receiving timely skilled therapy services. Additionally, the facility delayed performing a right hip X-ray for the resident who complained of right hip pain. The request for a STAT X-ray was sent to the primary care physician, but there was no follow-up from the nursing staff until six days later. The X-ray provider did not find the request form, and the X-ray was eventually performed eight days after the initial complaint. The X-ray revealed a right femoral neck fracture, but the facility waited another eight days to obtain an order for weight-bearing precautions. During this period, the resident was allowed to perform sit-to-stand activities multiple times, potentially exacerbating the injury. Interviews with the occupational therapist, physical therapist, and MDS coordinator confirmed the lack of timely rehabilitation screening and follow-up on the X-ray request. The Director of Nursing acknowledged that the nurses should have followed up on the X-ray request and obtained the weight-bearing precaution order sooner. The facility's policy indicated that residents with significant changes should be screened by therapy, but this was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Rafael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Ridge Care Center | 0 mi | ★★★★★ | 27 | 0 |
| Northgate Postacute Care | 0 mi | ★★★★★ | 34 | 0 |
| Smith Ranch Skilled Nursing & Rehabilitation Cente | 0.8 mi | ★★★★★ | 17 | 0 |
| Villa Marin | 0.8 mi | ★★★★★ | 11 | 0 |
| Marin Post Acute | 1.2 mi | ★★★★★ | 25 | 0 |
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