Regents Point - Windcrest
Inspection history, citations, penalties and survey trends for this long-term care facility in Irvine, California.
- Location
- 19191 Harvard Avenue, Irvine, California 92612
- CMS Provider Number
- 555295
- Inspections on file
- 19
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regents Point - Windcrest during CMS and state inspections, most recent first.
Multiple residents were found with elevated bed side rails in use without required physician orders, informed consent, or proper assessments. Staff confirmed that necessary steps such as interdisciplinary evaluation, entrapment risk assessment, and documentation of alternatives were not consistently completed. Facility policy requiring these steps was not followed, and medical records for several residents showed missing or incomplete documentation related to bed rail use.
Cold beverages, including various juices, were served to all residents at temperatures above the facility's required standard of 41°F or below. The CDM confirmed that the measured temperatures ranged from 42.6°F to 43.8°F, which did not meet the policy for cold TCS food holding during meal service.
Surveyors found that the kitchen had significant sanitation failures, including a dirty stove hood, damaged and unclean utensils, heavily marred cutting boards, and improperly dried blenders. These issues were confirmed by dietary staff and affected all residents receiving food from the kitchen.
The facility did not fully assess all required bed entrapment zones for several residents using side rails, as documentation and staff interviews confirmed that only some zones were evaluated. Residents affected included those with cognitive impairment, physical limitations, and high fall risk, and the facility's own forms and procedures did not reflect complete assessments as required by policy.
The facility did not provide or document written information about advance healthcare directives for two residents, including one with severe cognitive impairment. Staff failed to complete required forms, document discussions, or provide resources as outlined in facility policy, and these omissions were confirmed by interviews with the case manager, DSD, SSD, and DON.
A resident with severe cognitive impairment and a high risk for falls did not have a physician-ordered floor mattress in place as a safety precaution. Despite care plan interventions and staff acknowledgment of the need for the mattress, it was observed leaned against the wall rather than at the bedside while the resident was in bed.
A resident with a PICC line did not have required measurements of external catheter length and arm circumference documented during dressing changes, as required by facility policy. Nursing staff confirmed these assessments were not performed or included in the care plan or physician's orders, and the DON verified the deficiency.
Multiple residents requiring respiratory support did not receive care in accordance with physician orders or facility policy. One resident's CPAP machine lacked a physician's order, care plan, and documented maintenance, with cleaning performed only by the resident and family. Another resident's oxygen cannula was found on the floor, and two residents received oxygen therapy that did not match physician orders or lacked required safety signage. Staff interviews and record reviews confirmed these failures in documentation, equipment care, and adherence to prescribed therapy.
A resident receiving enoxaparin injections did not have injection sites rotated as required, resulting in skin discoloration that was not assessed or reported. Additionally, oxycodone administration was documented on the controlled drug record but not on the MAR, leading to incomplete reconciliation of a controlled substance. Staff and leadership confirmed these deficiencies during interviews and record reviews.
Surveyors found that the medication error rate exceeded 5% after a nurse failed to administer metformin with a meal as ordered for a resident with diabetes, and another resident did not receive a calcium citrate supplement on time due to pharmacy delivery delays. These errors were confirmed through observation, interviews, and record review.
A facility's assessment did not include active participation from direct care staff, their representatives, residents, or family members, as required by updated CMS guidance. Additionally, the assessment lacked a contingency plan for staffing needs. These deficiencies were confirmed by the Administrator during document review and interview.
Multiple breaches in infection control were observed, including a CNA placing a urinal near beverages and failing to change gloves or perform hand hygiene, personal belongings stored with clean linen, and an LVN not following hand hygiene protocols during wound care for a resident with a sacrococcyx pressure injury. Staff and supervisors acknowledged these failures, which were not in accordance with facility policies.
A resident with mild cognitive impairment and an indwelling urinary catheter was repeatedly observed with an uncovered urinary catheter drainage bag, both in bed and in a wheelchair. Staff confirmed that the drainage bag was not covered with a privacy bag as required by facility policy, and the care plan lacked an intervention to ensure the bag was covered. Interviews with a CNA, LVN, and the DON verified the deficiency in maintaining the resident's dignity.
A resident with an indwelling urinary catheter had incomplete documentation of urine output in the medical record, despite physician orders and facility policy requiring intake and output to be recorded every shift. Nursing staff and the DON confirmed that several entries were missing from the Treatment Administration Record.
A facility failed to monitor a resident's psychosocial wellness after an alleged financial abuse incident. The care plan required monitoring by nursing and social services staff for three days, but notes were missing for two days, indicating non-compliance. The DSD confirmed the resident should have been monitored as per the care plan.
The facility failed to ensure accurate MDS assessments for two residents. One resident receiving hospice care was not marked as such in the MDS, and another resident with serious mental illness was incorrectly coded as not requiring a level II PASARR evaluation. Both the MDS Coordinator and the DON acknowledged these oversights.
The facility failed to complete a PASARR evaluation for a resident after a new diagnosis of schizophrenia and prescription of Risperdal. Staff interviews confirmed that a new PASARR should have been conducted to determine if the resident would benefit from additional services.
The facility failed to follow physician orders for a resident with diabetes and hypotension by not notifying the physician of elevated blood glucose levels and administering midodrine despite high SBP. Interviews confirmed these lapses, with staff acknowledging the failure to adhere to orders.
The facility failed to ensure proper infection control practices during catheter care and glucometer use. A CNA did not change gloves after catheter care, and an RN did not disinfect a glucometer after use on two residents. Both actions were against facility policies and confirmed by multiple staff members.
A resident with a history of pneumonitis, atrial fibrillation, and rheumatoid arthritis did not receive a follow-up pneumococcal vaccine despite consent being given. Facility staff were unaware of the oversight, and both the Administrator and DON confirmed the resident should have received the vaccine.
Failure to Obtain Orders, Consent, and Assessments for Bed Rail Use
Penalty
Summary
Surveyors identified that the facility failed to follow required protocols for the use of bed side rails for multiple residents. Observations revealed that several residents were found in bed with elevated bilateral side rails without evidence of a physician's order, informed consent, or proper assessments documented in their medical records. In several cases, residents had cognitive impairments or lacked capacity to make decisions, yet there was no documentation of family or representative involvement in the consent process. Staff interviews confirmed that the necessary steps, such as obtaining a physician's order, conducting entrapment and bed rail assessments, and securing informed consent, were not consistently completed prior to the application of side rails. Medical record reviews for the affected residents showed missing or incomplete documentation, including absent physician orders for side rail use, lack of informed consent forms, and incomplete interdisciplinary team (IDT) evaluations. In some instances, side rail evaluations indicated that side rails were not indicated for the resident, yet the rails were still in use. Additionally, some residents' records lacked documentation of the risks and benefits discussion or the rationale for side rail use, and in certain cases, the IDT meeting documentation was incomplete or missing required signatures from care team members such as the physician or social worker. The facility's own policies and procedures require that alternatives to bed rails be attempted first, and if unsuccessful, a comprehensive assessment, interdisciplinary evaluation, and informed consent must be completed before side rails are used. Despite these requirements, the facility failed to ensure compliance, resulting in the use of side rails without proper authorization or assessment for nine sampled residents and one non-sampled resident. These failures were confirmed through staff interviews and record reviews, and were found to be inconsistent with both facility policy and federal safety alerts regarding the risks of bed rail entrapment.
Cold Beverage Temperatures Exceed Safe Holding Standards
Penalty
Summary
The facility failed to ensure that cold beverages served to residents were maintained at the required appetizing and safe temperatures. During a tray line observation, the Certified Dietary Manager (CDM) measured the temperatures of various juices, including cranberry juice, orange juice, and a mixed juice, and found them to be between 42.6 and 43.8 degrees Fahrenheit. These temperatures exceeded the facility's policy requirement that cold Time/Temperature Control for Safety (TCS) foods be held at 41 degrees Fahrenheit or below. The CDM acknowledged that the beverages were not at the appropriate temperature prior to being served to residents, despite being placed in a bucket of ice for cooling. All 45 residents in the facility consumed food and beverages prepared in the kitchen, according to the Diet Type Report.
Widespread Kitchen Sanitation Failures and Unsafe Food Contact Surfaces
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations during a kitchen tour. The hood over the stove was found to have black, dirt residue, and the Dietary Aide confirmed this condition. Facility policy required the Maintenance Department to clean such equipment, but this was not done, resulting in unsanitary conditions above the food preparation area. Kitchen utensils and equipment were observed to be in poor condition, with several items cracked, chipped, melted, discolored, or otherwise damaged. These included blenders, serving spoons, spatulas, scoops, and cutting tools. The Dietary Aide verified that these items were in use and stored as clean, despite their compromised surfaces, which made them difficult or impossible to clean properly. Facility policies and USDA Food Code require utensils and food-contact surfaces to be smooth, cleanable, and in good repair, but these standards were not met. Additionally, many utensils and kitchenware items stored as clean were found to have visible food residue, watermarks, crusted debris, and fuzzy film. Cutting boards were heavily marred, discolored, and had deep grooves, making them unsanitary and difficult to clean. Heavy-duty blenders were stored while still wet, with water visible inside and on the lids, contrary to facility policy and food code requirements for air drying. All of these deficiencies were acknowledged by the Dietary Aide and the Director of Dining Services, and affected all residents consuming food prepared in the kitchen.
Failure to Complete Full Bed Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed systems were accurately completed for multiple residents. Specifically, the Bed System Measurement Device Test Results Worksheet used by the facility did not include or document assessments for Zones 6 and 7, which are critical areas identified by the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. This omission was confirmed through review of facility documentation and interviews with the Maintenance Supervisor, who acknowledged that these zones were not reflected or assessed on the forms for several residents. Observations revealed that numerous residents were found in beds with elevated bilateral side rails, and their medical records showed a range of cognitive and physical impairments, including severe cognitive impairment, fluctuating decision-making capacity, and physical limitations such as osteoporosis and high fall risk. Despite these vulnerabilities, the required entrapment assessments for all seven zones were not completed or documented for these residents. In several cases, staff interviews confirmed a lack of awareness or understanding of the entrapment assessment process, and the documentation consistently showed only Zones 1 to 4 were assessed. The facility's policy and procedure required that bed frames, mattresses, and bed rails be checked for compatibility and entrapment risk, and that maintenance staff routinely inspect all beds and related equipment. However, the actual practice did not align with these requirements, as evidenced by the incomplete assessments and lack of documentation for Zones 6 and 7. This deficiency was identified for nine sampled residents and one non-sampled resident, all of whom had beds with side rails in use, and was verified through direct observation, record review, and staff interviews.
Failure to Provide and Document Advance Directive Information for Residents
Penalty
Summary
The facility failed to provide written information regarding the right to formulate advance healthcare directives for two residents, as required by its own policies and procedures. For one resident, the medical record did not contain evidence that written information about advance directives was provided upon admission, despite documentation indicating the resident had executed an advance directive. The case manager, responsible for gathering advance directives, was unable to produce documentation of discussions or provision of information regarding advance directives for this resident, and the required staff signature was missing from the acknowledgment form. For another resident, who was readmitted with severe cognitive impairment as indicated by a BIMS score of zero, the medical record showed an incomplete POLST form and an acknowledgment that the resident wished to execute an advance directive. However, there was no documentation that resources or follow-up were provided to the resident's family member, and no advance directive was available in the medical record. The social services designee confirmed that the process and resources provided for executing an advance directive must be documented, and acknowledged that this was not done. Interviews with facility staff, including the case manager, director of staff development, social services designee, and DON, confirmed that the expected processes for providing information, documenting discussions, and assisting with advance directives were not followed or documented for these residents. The lack of documentation and incomplete forms were verified by staff during the survey.
Failure to Implement Physician-Ordered Fall Precaution for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls was free from accident hazards, as required by both physician order and facility policy. Specifically, the resident, who had severe cognitive impairment, Alzheimer's disease, dementia, and poor safety awareness, was supposed to have a floor mattress placed at the bedside as a fall precaution. Despite a care plan and a physician's order for the use of a floor mattress, observations revealed that the mattress was not in place while the resident was in bed; instead, it was found leaned against the wall. Medical record review confirmed the resident's high fall risk and the need for the floor mattress intervention. Staff interviews corroborated that the mattress should have been in place at all times when the resident was in bed, especially given the resident's history of attempting to get out of bed and a previous fall incident. The failure to implement this safety intervention as ordered constituted a deficiency in providing adequate supervision and accident hazard prevention.
Failure to Document PICC Line Measurements During Dressing Changes
Penalty
Summary
The facility failed to provide necessary care and services for the maintenance of a peripherally inserted central catheter (PICC) line for one resident. Specifically, the facility did not obtain or document the required measurements of the external catheter length and arm circumference during dressing changes, as outlined in their own policy and procedure for central venous catheter care. The resident's care plan and physician's orders also lacked directives to measure and record these parameters, and there was no evidence in the treatment administration records that these assessments were performed. Interviews with nursing staff confirmed that while they were aware of the need to monitor for infection and perform dressing changes, they did not include the required measurements in their assessments or documentation. The resident involved had a PICC line placed in the facility for IV antibiotic administration and was observed with the line in place and a dressing dated from a previous week. Both the licensed vocational nurse (LVN) and registered nurse (RN) acknowledged that the measurements were not taken or documented, and the director of nursing (DON) verified these findings. The absence of these documented assessments had the potential to delay the identification of PICC line-related complications for the resident.
Deficiencies in Respiratory Care and Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services for several residents requiring oxygen therapy and CPAP support. For one resident using a CPAP machine, there was no documented physician's order, no care plan, and no evidence of care or maintenance of the device in the medical record. The resident reported that she and her family were solely responsible for cleaning and maintaining the CPAP machine, with no involvement from facility staff. Observations and interviews confirmed that staff were aware of the device but did not ensure its care or proper documentation, and the device was not cleaned according to manufacturer guidelines. For another resident, the oxygen nasal cannula was found on the floor while the oxygen concentrator was running, indicating improper administration and storage of oxygen equipment. The facility's policy required that oxygen tubing not be placed on the floor and be kept in a bag when not in use, but this was not followed. Additionally, another resident was observed receiving oxygen at a higher flow rate than ordered by the physician, and staff were incorrectly documenting compliance with the physician's order in the system. There was also a failure to post required oxygen signage on the door for a resident receiving oxygen therapy, as required by facility policy. These deficiencies were identified through observations, interviews with staff and residents, and review of medical records and facility policies. The failures included lack of physician orders, care plans, proper documentation, adherence to prescribed oxygen flow rates, and compliance with infection control and safety protocols for respiratory equipment.
Failure to Rotate Injection Sites and Incomplete Controlled Substance Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not rotating injection sites for enoxaparin, an anticoagulant medication, as required by facility policy. Documentation showed that the medication was repeatedly administered to the same area of the resident's upper arms over several days, rather than rotating sites as directed. This resulted in the resident developing bluish to greenish discoloration on the right upper arm, which was observed during an interview and not previously assessed, monitored, or reported to the physician or family representative as required. Additionally, the facility did not ensure accurate reconciliation and documentation of a controlled substance, oxycodone HCl IR, for the same resident. The medication was documented as administered on the Controlled Drug Record but was not recorded on the electronic Medication Administration Record (MAR). Staff interviews confirmed that the medication was removed from the bubble pack and given to the resident, but the administration was not properly documented in the MAR immediately after, as required by facility policy. The resident involved had no capacity to exercise rights or sign necessary documents and was receiving enoxaparin for DVT prophylaxis and oxycodone for pain management. Facility staff, including LVN, RN, and DON, verified the findings during interviews and record reviews, confirming that both the failure to rotate injection sites and the failure to accurately document controlled medication administration occurred.
Medication Error Rate Exceeds 5% Due to Administration and Delivery Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During medication administration, one licensed nurse did not follow physician orders for a resident prescribed metformin for diabetes mellitus. The nurse administered the metformin tablet at 9:22 AM, while the resident had eaten breakfast at 8:00 AM, contrary to the order specifying the medication should be taken with meals. The nurse confirmed the medication was not given as directed with the meal. Additionally, another resident did not receive a prescribed calcium citrate supplement on time following admission because the medication had not yet been delivered by the pharmacy. The nurse stated that all medication orders are sent to the pharmacy upon admission and are usually delivered the same day, but in this instance, the supplement was not available for administration. These events were observed and verified through interviews and medical record reviews.
Facility Assessment Lacks Required Stakeholder Involvement and Staffing Contingency Plan
Penalty
Summary
The facility failed to ensure that its Facility Assessment included the active involvement of required individuals, such as direct care staff, direct care representatives, residents, residents' representatives, and family members, in its development. Review of the Facility Assessment dated 3/12/25 showed no evidence of participation from these groups. This omission was confirmed during an interview and document review with the Administrator, who acknowledged the lack of involvement from these stakeholders and was aware of the updated CMS guidance requiring such participation. Additionally, the Facility Assessment did not include a contingency plan for staffing needs, as required by the revised CMS guidance. The Administrator verified that the assessment lacked this component and had not been updated to reflect the latest requirements. The absence of both stakeholder involvement and a staffing contingency plan was identified through document review and staff interview, indicating noncompliance with current regulatory expectations.
Infection Control Breaches in Resident Care, Laundry, and Wound Treatment
Penalty
Summary
The facility failed to maintain its infection prevention and control program as evidenced by multiple observed breaches in infection control practices. In one instance, a certified nursing assistant (CNA) placed a resident's urinal containing urine on top of the overbed table near uncovered cups of water and juice. The CNA then removed the urinal, discarded its contents, rinsed it, and returned it to the same location, all while wearing the same gloves. The CNA continued to use the contaminated gloves to move the overbed table and put socks on the resident, without performing hand hygiene or changing gloves. Both the CNA and the infection preventionist (IP) acknowledged that the urinal should not have been placed on the overbed table and that proper hand hygiene was not performed. Another deficiency was observed in the facility's laundry area, where a laundry aide's personal belongings, including a black backpack and jacket, were stored with clean linen in the clean linen room. Both the laundry aide and the housekeeping supervisor confirmed that personal items should not be stored with clean linen, as per facility policy. The administrator also verified that the clean linen area must be kept clean and free of personal belongings. Additionally, a licensed vocational nurse (LVN) failed to perform appropriate hand hygiene during wound care for a resident with a sacrococcyx pressure injury. The LVN was observed touching the resident's thigh after handling a trash can with the same gloves, removing gloves and donning new ones without hand hygiene, and completing the wound care procedure without changing gloves or performing hand hygiene between steps. The LVN acknowledged that proper infection control practices, including handwashing after touching dirty surfaces, were not followed. The director of nursing (DON) confirmed that the facility's policy requires hand hygiene and glove changes during such procedures.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Drainage Bag
Penalty
Summary
Facility staff failed to maintain the dignity of a resident with an indwelling urinary catheter by not covering the urinary catheter drainage bag with a privacy bag. Multiple observations over several days showed the resident in bed and in a wheelchair with the drainage bag uncovered and visible at the side of the bed or under the wheelchair. The facility's policy on dignity requires staff to promote and protect resident privacy, including bodily privacy during personal care and treatment procedures. However, the resident's care plan did not include an intervention to cover the urinary catheter drainage bag with a privacy bag. The resident, who had mild cognitive impairment and required total assistance for urinary catheter care, had a physician's order for catheter care every shift and to change the catheter bag as needed. Staff interviews confirmed that the drainage bag was not covered and that it should have been, according to facility expectations. The Director of Nursing also verified that the expectation was for the drainage bag to be covered to maintain resident dignity.
Incomplete Documentation of Urine Output for Catheterized Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, specifically regarding the documentation of urine output for a resident with an indwelling urinary catheter. According to the facility's policy on Output Measuring and Recording, urine output should be recorded in milliliters in the resident's medical record every shift. However, a review of the resident's Treatment Administration Record (TAR) revealed missing documentation of urine output on several dates and shifts, despite physician orders requiring intake and output monitoring every shift and catheter care. During interviews, both a registered nurse and the Director of Nursing confirmed the presence of the indwelling catheter and acknowledged the incomplete documentation. They verified that the nurses were responsible for measuring and recording the urine output in the TAR, and confirmed the specific dates and shifts where documentation was missing. The administrator also verified these findings during a subsequent interview.
Failure to Monitor Resident's Psychosocial Wellness After Alleged Financial Abuse
Penalty
Summary
The facility failed to adequately monitor a resident's psychosocial wellness following an allegation of financial abuse. The care plan for the resident, who was admitted to the facility on an unspecified date, included specific interventions to address the alleged financial abuse. These interventions required monitoring by nursing staff and social services staff for three days, assisting the resident in developing a meaningful activity program, notifying relevant authorities and the resident's responsible party, and observing the resident for signs of depression or anxiety. However, the facility did not adhere to these interventions as required. Upon review, it was found that the psychosocial monitoring notes from the social services staff were missing for two days following the incident, and there was no nursing progress note for one of those days. This lack of documentation indicates that the resident was not monitored for the psychosocial effects of the alleged abuse as outlined in the care plan. The Director of Staff Development confirmed these findings, acknowledging that the resident should have been monitored for 72 hours by both nursing and social services staff.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for two residents. Resident #34 was admitted with multiple diagnoses, including chronic obstructive pulmonary disease and malignant neoplasm of the skin. Despite being admitted to hospice care as indicated by physician orders and the care plan, the MDS assessment did not reflect this status. Both the MDS Coordinator and the Director of Nursing acknowledged that hospice care should have been marked on the MDS assessment, but it was overlooked, resulting in an inaccurate MDS assessment for Resident #34. Resident #3, who was admitted with diagnoses including psychosis, major depressive disorder, and dementia with psychotic disturbance, was incorrectly coded in the MDS assessment as not being considered by the state level II PASARR process to have a serious mental illness. Documentation from the State of California-Health and Human Services Agency indicated that a level II mental health evaluation was required and specialized services were recommended. The MDS Coordinator and the Director of Nursing both confirmed that the MDS should accurately reflect the resident's mental health status, but it did not, leading to an inaccurate assessment for Resident #3.
Failure to Complete PASARR Evaluation for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for a resident after a newly evident serious medical illness diagnosis of schizophrenia. The resident, who was admitted with diagnoses including major depressive disorder and dementia, was later found to have schizophrenia and was prescribed Risperdal, an antipsychotic medication. Despite this significant change in the resident's medical condition, no PASARR evaluation was conducted to determine if the resident would benefit from additional services. Interviews with facility staff, including the MDS Coordinator, Director of Nursing, and the Administrator, confirmed that a new PASARR should have been completed when the resident was prescribed the antipsychotic medication. The staff acknowledged that the nurse who received the order should have notified the MDS Coordinator to submit a new PASARR. The failure to complete the PASARR evaluation was identified through a review of the resident's medical records, care plan, and physician's orders.
Failure to Follow Physician Orders for Blood Glucose and Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure staff followed the physician's orders for a resident with type 2 diabetes mellitus and hypotension. Specifically, the staff did not notify the physician when the resident's blood glucose level exceeded 300 mg/dL and did not hold a medication when the resident's systolic blood pressure (SBP) was greater than 140 mmHg. The resident had an order for midodrine to be held if the SBP was above 140 mmHg and an order for insulin lispro with instructions to notify the physician if the blood glucose level was above 300 mg/dL. Despite these orders, the resident received midodrine when the SBP was 148 mmHg, and the physician was not notified when the blood glucose level reached 347 mg/dL. Interviews with the Licensed Vocational Nurse (LVN) and the Medical Doctor (MD) confirmed these lapses in following the physician's orders. The LVN did not recall administering the midodrine outside the prescribed parameters and admitted to not notifying the physician about the elevated blood glucose level. The MD expressed concerns about the lack of notification regarding the elevated blood glucose level and emphasized the importance of following physician orders. The Director of Nursing and the Administrator also stated their expectations that nursing staff should adhere to physician orders.
Infection Control Deficiencies in Catheter Care and Glucometer Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the provision of catheter care and the use of a glucometer. Specifically, a Certified Nurse Assistant (CNA) did not change gloves after completing catheter care for a resident with severe sepsis and chronic kidney disease, and continued to perform other tasks such as placing a new incontinence brief and changing the resident's bed pad without changing gloves. This was acknowledged by the CNA, the Director of Nursing, the Administrator, and the Infection Preventionist, all of whom confirmed that gloves should be changed when moving from a dirty to a clean task. Additionally, a Registered Nurse (RN) failed to disinfect a glucometer after using it to check the blood glucose levels of two residents. The RN did not clean the glucometer after each use and placed it back on the medication cart. Interviews with the RN, the Director of Staff Development, the Director of Nursing, and the Administrator confirmed that the glucometer should be cleaned with germicidal wipes after each use to prevent cross-contamination. The RN was unaware of the proper cleaning procedure, believing it was the responsibility of the night shift nurse.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure a pneumococcal vaccine was administered to a resident after consent was received. The facility's policy, revised in March 2022, mandates that all residents are offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections. Resident #25, admitted on 05/02/2023, had a history of pneumonitis due to inhalation of food and vomit, permanent atrial fibrillation, and rheumatoid arthritis. The resident's immunization report indicated they received a pneumococcal vaccine on 07/18/2017, and consent for a follow-up vaccine was given on 10/16/2021. However, there was no record of the resident receiving the follow-up vaccine after consent was obtained. During interviews, both the Licensed Vocational Nurse (LVN) and the Director of Staff Development were unaware of why the resident did not receive the vaccine. The Administrator and the Director of Nursing confirmed that the resident should have received the pneumococcal vaccine once consent was received. The failure to administer the vaccine as per the facility's policy and the received consent constitutes the deficiency identified in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
