San Bruno Skilled Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in San Bruno, California.
- Location
- 890 El Camino Real, San Bruno, California 94066
- CMS Provider Number
- 555276
- Inspections on file
- 19
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at San Bruno Skilled Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was discharged to an emergency department solely after Medicare benefits were exhausted, despite no documented change in condition and no medical necessity for an ED transfer. The discharge care plan lacked specific problems, goals, interventions, and a documented destination preference, and it was not updated with the resident’s or representative’s wishes. Provider documentation conflicted, with orders for discharge home with home health services while social services arranged transport to a VA ED to check benefits and assign a social worker. The resident’s representative reported not being informed about applying for Medi-Cal or paying privately, and VA staff confirmed there was no scheduled benefits appointment, that the resident was brought directly to the ED without medical need, and that no Medicaid application had been filed. Facility records showed poor care coordination, conflicting discharge documentation, and failure to follow internal policies requiring appropriate notice, documentation, and financial assistance counseling at discharge.
A resident did not receive consistent range of motion (ROM) exercises to the left lower extremity, leading to the development of contractures. Initial therapy assessments showed normal ROM, but subsequent documentation revealed a decline in knee extension and mobility that was not properly addressed or reflected in the care plan. Upon hospital transfer, the resident had contractures, multiple wounds, and poor circulation in the affected leg.
The facility failed to provide sufficient space for group activities and communal dining, conducting activities in the hallway and serving meals in residents' rooms. This arrangement disturbed residents near the activity area and limited communal dining options. The Activities Director and Administrator confirmed the lack of designated spaces, with activities held in hallways and meals served in rooms since the pandemic.
A facility failed to maintain the privacy of a resident's care instructions, which were posted on the resident's bedroom wall, exposing their medical condition to others. The resident, with cognitive impairment and multiple diagnoses, had their care instructions posted by a family member. The DON acknowledged the issue but noted the family's involvement. This action violated the facility's policy on treating residents with dignity and respect.
A facility failed to assess and educate a resident on the self-administration of doxycycline, an antibiotic, as required by policy. The resident was observed with doxycycline on their bedside table and stated they were taking it for a bacterial infection. The RN and ADON were unaware of a care plan for the medication, and the resident's care plan only included five other medications for self-administration. The care plan was updated after the issue was identified, but the medication orders did not reflect the resident's use of doxycycline.
A resident's POLST form was found incomplete, lacking clear signatures and the identity of the individual with whom it was discussed. The DON confirmed the absence of necessary information, which could impact honoring the resident's end-of-life choices.
A facility failed to provide a resident with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) while receiving Medicare Part A services. The resident, who had multiple diagnoses and was responsible for his own decisions, did not receive the SNF ABN due to being out for dialysis on the day it was supposed to be issued. Although a Notification of Medicare Non-Coverage (NOMNC) was provided, the absence of the SNF ABN meant the resident was not informed about potential financial liability and the right to appeal.
A resident with multiple health issues, including moderate cognitive impairment, reported hip pain later diagnosed as a pathological fracture. Despite no falls or activities explaining the pain, the facility failed to report the injury of unknown origin to the California Department of Public Health, as confirmed by the DON and Director of Staff Development. Facility policies require such injuries to be reported and investigated, but this was not done.
The facility failed to complete MDS assessments for four residents within the required timeframe. Admission and annual assessments were not completed within 14 days of admission or the ARD, as required by the RAI User Manual. The MDS Coordinator confirmed the delays, which could result in delayed identification of residents' needs.
A resident admitted to hospice care with serious health conditions did not have a Significant Change in Status Assessment (SCSA) completed within the required 14-day period. The assessment was completed 16 days after hospice admission, potentially delaying appropriate treatment and services.
The facility failed to complete MDS quarterly assessments within the required timeframe for three residents. The assessments were not completed within 92 days following the previous OBRA assessment, as required. The MDS Coordinator acknowledged the delay, which could result in delayed identification of residents' needs.
The facility failed to implement person-centered care plans for three residents, leading to deficiencies in care. A resident with respiratory issues received incorrect oxygen levels, another resident with COPD was given more oxygen than prescribed, and a resident requiring a two-person assist for transfers was handled by one staff member, contrary to their care plan.
A facility failed to update a resident's care plan after an IDT assessment found their weight loss acceptable due to CHF. The care plan aimed to maintain the resident's weight within 5% of 195 lbs, but the resident's weight dropped to 182.8 lbs. The RD acknowledged the need to update the care plan to align with the IDT's findings, suggesting a BMI-based goal.
The facility did not follow physician's orders for oxygen administration for two residents. One resident with respiratory failure was observed with an incorrect oxygen delivery setup, while another resident with COPD received a higher oxygen flow than prescribed. These actions were inconsistent with the facility's policy and the residents' care plans.
A resident with hemiplegia and other conditions was transferred by a single RNA using a sit-to-stand lift, despite the care plan requiring two-person assistance. The sling used was frayed and missing a buckle. Staff interviews revealed a lack of recent training and inconsistencies in understanding transfer requirements.
A medication error rate of 11% was observed in an LTC facility due to improper administration practices. A nurse failed to verify a resident's identity and did not ensure full consumption of MiraLAX, while another nurse improperly administered Flonase by not following recommended guidelines.
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation. The Certified Dietary Manager (CDM) and another staff member were seen preparing food while wearing the bracelets, which they later removed. The facility's policy specifies minimal jewelry and requires hand jewelry to be covered with gloves.
The facility's QAPI program failed to prevent medication errors, resulting in an 11% error rate during a medication pass. Errors included improper resident identification and incorrect administration of medications. The Quality Committee had only met once in the past year and lacked a project to address these errors.
The facility failed to maintain its infection control program for two residents on transmission-based precautions. A resident with MRSA had no PPE available outside their room, contrary to facility policy. Another resident on enhanced barrier precautions had their PPE cart misplaced, and an LVN handled their Foley bag without PPE. These actions were against CDC guidelines and facility policies, potentially increasing infection spread risk.
Improper Discharge to Emergency Department After Medicare Exhaustion Without Adequate Planning or Counseling
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective discharge planning process and to ensure an orderly, appropriate discharge for one of three sampled residents. The resident was admitted with multiple chronic conditions, including COPD with acute exacerbation, centrilobular emphysema, gait and mobility abnormalities, unsteadiness, dysphagia, CKD, and urinary retention. A discharge care plan was initiated but left the discharge destination preference blank and did not identify specific discharge problems, goals, or interventions. The care plan was not revised or updated to reflect any discharge preferences of the resident or the resident’s representative. As the resident’s Medicare Part A coverage approached exhaustion, the facility issued a Notice of Medicare Non-Coverage indicating the end date of coverage. Provider documentation around this time was inconsistent: a practitioner note stated the resident was medically stabilized but not strong enough to return home and that discharge planning was pending therapy progress, while a physician discharge summary documented a planned discharge home with home health services and a stable condition. A physician order later specified discharge home with RN, PT, OT, HHA, and SW services. However, the Notice of Proposed Transfer/Discharge and the facility’s Discharge Summary and Post-Care Instructions instead identified a plan to send the resident to a VA location to check benefits eligibility and assign a social worker for placement under a VA program, with transportation by a friend. On the actual day of discharge, the social worker documented that the resident would be brought to the VA emergency room so that a social worker, VA PCP, and benefits eligibility could be arranged, citing exhaustion of Medicare days at the current and previous SNFs. Nursing documentation recorded that the resident left via a transportation company but did not document the discharge destination or home health information as ordered by the physician. Interviews with the DON and ADON confirmed there was no significant change in the resident’s condition and that the resident was stable on the day of discharge, indicating no medical necessity for an emergency transfer. The social worker and VA staff confirmed that the resident was taken directly to the VA emergency department without an appointment and without an apparent medical reason, and VA staff reported telling the social worker that the resident could not be brought in “for no reason.” The resident’s representative reported not being informed about the option to apply for Medi-Cal or to pay privately to remain at the facility and described the discharge as rushed, with nothing prepared in advance, despite the social worker’s knowledge that the resident had no place to stay because his prior apartment had been demolished. VA staff further stated that no Medi-Cal application had been filed for the resident and characterized the discharge as occurring after the resident ran out of 100 Medicare days. Review of the clinical record showed a lack of documented care coordination and discharge planning discussions with the interdisciplinary team, the resident, and the representative, and the discharge documentation from medical provider, social services, and nursing contained conflicting information. These actions and omissions were inconsistent with the facility’s own transfer/discharge policies, which require that residents not be transferred unless necessary for their welfare, that appropriate notice and documentation be provided, that residents receive assistance with third-party payment applications, and that residents who continue to need LTC services be offered the option to remain privately or with Medicaid assistance.
Failure to Provide Consistent ROM Interventions Resulting in Contractures
Penalty
Summary
A facility failed to provide consistent range of motion (ROM) exercises to a resident's left lower extremity (LLE) from admission until hospital transfer, resulting in the development of contractures. Initial assessments and therapy evaluations indicated that the resident had normal ROM in both lower extremities, with no contractures present. However, subsequent therapy notes and evaluations documented a progressive decline in the resident's left knee extension, with increasing difficulty in straightening the knee and performing transfers. Despite these changes, there was no documented change-of-condition evaluation or timely revision of the resident's care plan to address the decline in mobility. Therapy documentation showed that while some improvement in left knee extension was recorded over a short period, there were also periods with no improvement or worsening of the condition. The care plan addressing physical therapy and restorative nursing ROM was not updated to reflect the resident's declining ROM in the LLE, and there was a lack of documentation indicating that lower extremity ROM exercises were consistently provided. Interviews with facility staff confirmed that changes in the resident's mobility were not properly assessed or documented, and that contractures were not initially recognized or addressed in a timely manner. Upon hospital admission, the resident was found to have contractures in the LLE, along with multiple serious wounds, poor blood flow, and signs of infection and tissue death in the affected leg. The hospital team noted that the resident's poor nutrition, tight leg muscles, and compromised circulation would make wound healing difficult. The failure to provide consistent ROM interventions and to update care plans in response to the resident's declining mobility directly contributed to the development of contractures and associated complications.
Inadequate Space for Activities and Dining
Penalty
Summary
The facility failed to provide adequate space for group activities and communal dining for its 43 residents, as observed during a survey. The facility, licensed for 45 beds, conducted activities in the hallway due to the absence of a designated activity or dining room. This arrangement caused inconvenience to residents whose rooms were near the activity area, as they were disturbed by the noise. Resident 32 expressed discomfort with the noise from activities such as music and karaoke held in the hallway outside his room. The Activities Director confirmed that activities were held in the hallway, and residents in nearby rooms often closed their doors to minimize the noise. Additionally, the facility did not have a designated dining room, resulting in residents eating meals in their rooms. The Certified Dietary Manager stated that all meals were served in residents' rooms since the pandemic, and the previous dining room was repurposed as a rehab room. Resident 20 mentioned a preference for eating in a dining room rather than in his room, highlighting the lack of communal dining space. The Administrator acknowledged that activities and dining were conducted in the therapy room, hallway, or patio, depending on the weather, but noted that residents preferred eating in their rooms or the hallway.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the privacy of a resident's unique care instructions, which were posted in two places on the resident's bedroom wall. This action exposed the resident's medical condition to other residents and visitors. The resident, admitted to the skilled nursing facility with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Major Depressive Disorder, was found to have a cognitive impairment with a BIMS score of 8. During interviews, a CNA mentioned that the resident's daughter posted the care instructions, and the DON acknowledged the posting but suggested that the resident's name should not be included. The facility's policy on Resident's Rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Assess and Educate Resident on Self-Administration of Doxycycline
Penalty
Summary
The facility failed to ensure that a resident could safely self-administer doxycycline, an antibiotic, as there was no assessment or education provided to the resident regarding its self-administration. The facility's policy requires the interdisciplinary team to assess a resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. However, this was not done for the resident in question, who was observed with a bottle of doxycycline on their bedside table and stated they were taking it for a bacterial infection. The registered nurse was unaware of a care plan for the doxycycline, and the case manager confirmed that a self-medication assessment and care plan should be in place for residents self-administering medications. Further investigation revealed that the resident's care plan, dated several months prior, only included five other medications for self-administration, none of which were doxycycline. The assistant director of nursing was also unaware of the resident taking doxycycline and expressed concern about the risk of overdose. The care plan was updated to include doxycycline only after the issue was identified, but the medication orders still did not reflect that the resident was taking doxycycline. This oversight could lead to potential risks such as overdose, drug interactions, or unrecognized side effects.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to maintain a valid Physician Orders for Life-Sustaining Treatment (POLST) for one of the residents, identified as Resident 47. The POLST, which is a critical document for guiding medical treatment decisions during end-of-life care, was found to be incomplete. Specifically, the POLST lacked a clear signature or identity of the individual with whom the POLST was discussed, which is a requirement for its validity. This deficiency was identified during a review of Resident 47's records, which showed that the POLST form did not have the necessary signatures or printed names of either the patient or a legally recognized decision maker. During an interview and record review with the Director of Nursing (DON), it was confirmed that the section of the POLST indicating whether the information was discussed with the patient or a legally recognized decision maker was left blank. The DON acknowledged the absence of a clear signature and printed name, stating that the form was incomplete. Resident 47, who was admitted in April 2024, had a cognitive status indicating intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. The lack of a valid POLST form has the potential to result in the resident's end-of-life choices not being honored.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN, Form CMS-10055) to a resident receiving Medicare Part A services. This notice is essential to inform residents of potential financial liability for non-covered stays and their right to appeal. The deficiency was identified for a resident who was admitted with multiple diagnoses, including orthopedic aftercare following surgical amputation, a non-pressure wound, type 2 diabetes mellitus, and end-stage kidney disease. The resident was responsible for his own decisions and was receiving Medicare Part A skilled services, which started on May 12, 2024, and the last covered day was May 31, 2024. The case manager stated that the resident had reached his maximum potential and was saving the remaining Part A days for an upcoming surgery. Although a Notification of Medicare Non-Coverage (NOMNC) was provided to the resident before the last covered day, the SNF ABN was not issued because the resident was out for dialysis on the day it was supposed to be given. The previous Social Services Director confirmed that the SNF ABN was not issued due to the resident's absence for dialysis. The facility's failure to provide the SNF ABN meant the resident was not informed about the potential financial liability and the right to appeal the termination of Medicare Part A services.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframes for a resident who reported hip pain, which was later diagnosed as a pathological fracture. The resident, who had multiple diagnoses including end-stage renal disease, anemia, and muscle wasting and atrophy, was admitted in January 2024. The resident had a Brief Interview for Mental Status score indicating moderate cognitive impairment. On a specific date, the Director of Nursing (DON) noted the resident's complaint of right hip pain and an X-ray revealed a right distal femoral fracture. Despite the absence of any reported falls or activities that could explain the pain, the incident was not reported to the California Department of Public Health as required. Interviews with the DON and the Director of Staff Development confirmed that the injury should have been reported as an injury of unknown origin. The facility's policies on investigating resident injuries and recognizing signs of abuse/neglect indicate that such injuries should be reported and investigated according to established guidelines. However, the interdisciplinary team deemed the injury as likely a spontaneous pathological fracture, and no report was made to the authorities. This oversight in reporting the injury of unknown origin could lead to delayed identification and investigation of possible harm from abuse.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for four residents within the required timeframe, as mandated by the Resident Assessment Instrument (RAI) User Manual. Specifically, the admission and annual MDS assessments for Residents 29, 16, 17, and 8 were not completed within 14 days of admission or the Assessment Reference Date (ARD). For Resident 29, the admission MDS assessment was completed 16 days after admission. Resident 16's annual MDS assessment was completed 16 days after the ARD, while Resident 17's annual MDS assessment was completed 17 days after the ARD. Resident 8's admission MDS assessment was completed 29 days after admission. The MDS Coordinator confirmed during interviews that the assessments were completed late and acknowledged the requirement for the admission MDS assessment to be completed by the 14th day of admission and the annual MDS assessment to be completed 14 days after the ARD. The facility's policy and procedure on comprehensive assessments, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, were reviewed and indicated the necessity for timely completion of these assessments to assist in developing person-centered care plans. The failure to adhere to these timelines could result in delayed identification of residents' needs and significant issues affecting their well-being.
Failure to Timely Complete SCSA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care. The resident, who had diagnoses including stroke, respiratory failure, pulmonary fibrosis, and lung involvement in systemic lupus erythematosus, was admitted to hospice on November 11, 2023. According to the facility's records, the SCSA was completed on November 26, 2023, which was 16 days after the resident's admission to hospice care, exceeding the required 14-day timeframe. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) and the MDS Coordinator were aware of the resident's hospice admission. The MDS Coordinator confirmed that the SCSA should have been completed within 14 days of the hospice admission. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that an SCSA is required when a terminally ill resident enrolls in a hospice program, and the assessment must be completed within the specified timeframe. The delay in completing the SCSA could potentially delay the provision of appropriate treatment and services for the resident.
Failure to Complete MDS Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessments were completed within the required timeframe for three residents. Specifically, the assessments were not completed within 92 days following the previous OBRA assessment, as mandated by regulations. For Resident 20, the quarterly MDS with an Assessment Reference Date (ARD) of May 9, 2024, was completed 26 days after the ARD, instead of the required 14 days. Similarly, Resident 3's quarterly MDS with an ARD of May 14, 2024, was completed 21 days after the ARD, and Resident 17's quarterly MDS with an ARD of May 16, 2024, was completed 17 days after the ARD. The MDS Coordinator acknowledged during interviews that the assessments were not completed within the required timeframe. The facility's policy and procedure, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, require that the MDS completion date must be no later than 14 days after the ARD. The failure to adhere to these timelines could result in delayed identification of needs and significant issues affecting the residents' well-being.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement a person-centered care plan for three residents, leading to deficiencies in their care. Resident 3, who was readmitted with diagnoses including stroke and respiratory failure, was observed with an ill-fitting non-rebreather mask on top of a nasal cannula. The Licensed Vocational Nurse (LVN) noted that Resident 3 was receiving oxygen at 2 liters per minute (LPM) via nasal cannula, contrary to the active order which required 5 LPM. This discrepancy in oxygen administration was not aligned with the resident's care plan, which specified the need for continuous oxygen at 3-5 LPM. Resident 29, admitted with conditions such as heart failure and chronic obstructive pulmonary disease (COPD), was found to be receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The LVN confirmed the error upon reviewing the active orders and adjusted the oxygen flow accordingly. The care plan for Resident 29 indicated the necessity for continuous oxygen at 2 LPM, highlighting a failure to adhere to the prescribed oxygen settings. Resident 16, who has hemiplegia and vascular dementia, required a two-person assist for transfers using a standing lift. However, during an observation, a Restorative Nursing Assistant (RNA) attempted to transfer the resident alone, stating familiarity with the resident's needs. This was contrary to the care plan, which mandated a two-person assist to ensure safety during transfers. The discrepancy between the care plan and the actual practice posed a risk of falls or injury to the resident.
Failure to Update Care Plan After IDT Assessment
Penalty
Summary
The facility failed to update a care plan following an interdisciplinary team (IDT) assessment for a resident whose body weight was beyond the recommended range specified in their care plan. The care plan, initiated on May 14, 2024, aimed to maintain the resident's body weight within 5% of 195 pounds. However, a review on June 4, 2024, showed the resident's weight had dropped to 182.8 pounds, which was below the 5% threshold. Despite this significant weight loss, the care plan was not updated to reflect the IDT's assessment, which considered the weight loss acceptable due to the resident's diagnosis of congestive heart failure (CHF). During interviews and record reviews, both the Director of Nursing (DON) and the Consultant Registered Dietician (RD) acknowledged the discrepancy between the care plan's weight goals and the IDT's assessment. The RD noted that the care plan should have been updated to align with the IDT's findings, suggesting that a goal based on body mass index (BMI) might be more appropriate for the resident. This oversight in updating the care plan could lead to clinical staff not recognizing significant changes in the resident's weight, potentially impacting their care.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to professional standards of care by not following the physician's orders for oxygen administration for two residents. Resident 3, who was readmitted with conditions including stroke, respiratory failure, and pulmonary fibrosis, was observed wearing an ill-fitting non-rebreather mask over a nasal cannula, contrary to the physician's order of 5 LPM via nasal cannula. The care plan indicated the need for continuous oxygen due to acute respiratory failure, but the observed practice did not align with the prescribed treatment. Similarly, Resident 29, admitted with diagnoses such as heart failure and COPD, was found receiving oxygen at 3 LPM instead of the ordered 2 LPM via nasal cannula. The active orders specified continuous oxygen at 2 LPM, with adjustments only if oxygen saturation fell below 92% or if there was shortness of breath. The facility's policy on oxygen administration emphasized verifying physician orders and ensuring the correct flow of oxygen, which was not followed in these instances.
Inadequate Supervision and Unsafe Transfer Technique
Penalty
Summary
The facility failed to provide adequate supervision and safe transfer techniques for a resident, identified as Resident 16, who required assistance due to medical conditions including hemiplegia, hemiparesis, aphasia, and vascular dementia. The resident's care plan specified the need for two-person assistance during transfers using a sit-to-stand lift. However, a Restorative Nursing Assistant (RNA) conducted the transfer alone, contrary to the care plan instructions. The RNA justified her actions by stating familiarity with the resident, despite acknowledging the requirement for two-person assistance. Additionally, the equipment used for the transfer was found to be in poor condition. The sling used was frayed, torn, and had a missing buckle, which the RNA admitted needed replacement. Interviews with other staff, including a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON), revealed inconsistencies in understanding the transfer requirements and a lack of recent training on the use of mechanical lifts. The facility's policy and user manuals clearly stated the need for two-person assistance and the importance of using equipment in good condition, which was not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 11% during a medication pass. This was due to three medication errors out of twenty-six opportunities involving two residents. One incident involved a registered nurse who administered medication to a resident without verifying their identity, as the resident did not speak English and no photo identification was available. Additionally, the nurse did not ensure the resident consumed the entire dose of MiraLAX, leaving half of the mixture at the bedside, contrary to the manufacturer's instructions. Another error involved a licensed vocational nurse who improperly administered Flonase to a resident. The resident did not blow their nose before administration, and both nostrils were sprayed simultaneously without closing one nostril as recommended. The nurse did not instruct the resident to exhale through their mouth after administration, failing to adhere to the proper technique for optimal delivery and absorption of the medication.
Unsafe Food Handling Practices Due to Jewelry
Penalty
Summary
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation and handling. This was noted during an initial tour of the kitchen, where the Certified Dietary Manager (CDM) and another kitchen staff member were seen preparing food for lunch while wearing the bracelets. During an interview, the CDM acknowledged the oversight and mentioned that the bracelets had been removed. The staff explained that wearing bracelets is a cultural practice for Indians, signifying marriage. The facility's policy on food preparation and service, dated November 2022, specifies that jewelry should be worn minimally, and hand jewelry should be covered with gloves.
Ineffective QAPI Program Leads to High Medication Error Rate
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) program was found to be ineffective in preventing medication administration errors, as evidenced by a medication pass observation revealing an 11% error rate, which exceeds the acceptable threshold of 5%. During the observation, three errors were identified out of twenty-six medication administration opportunities involving two residents. The first error involved a failure to properly identify a resident before administering medication, as the nurse did not verify the resident's identity due to a language barrier and did not follow the facility's policy for identification. The second error occurred when the same nurse administered MiraLAX to the same resident, who did not consume the entire dose, leaving the medication to settle on the bedside table. The third error involved the improper administration of Flonase to another resident, where the nurse did not follow the correct procedure, resulting in the resident inhaling the medication incorrectly. An interview with the Quality Committee members revealed that they had only attended one meeting in the past year and could not recall any discussions on medication errors. They also lacked an ongoing performance improvement project specifically aimed at reducing medication errors, acknowledging the need for improvements in the medication administration process.
Inadequate Implementation of Infection Control Protocols
Penalty
Summary
The facility failed to implement and maintain its infection control program for two residents on transmission-based precautions. Resident 32, who was admitted with multiple diagnoses including an infection of an amputation stump and MRSA, was supposed to be under contact single room isolation precautions. However, during multiple observations, there was no personal protective equipment (PPE) available outside of Resident 32's room, which was necessary for staff and visitors to wear before entering. Licensed Vocational Nurses (LVNs) confirmed the absence of PPE and expressed uncertainty about its removal, which was against the facility's policy requiring PPE to be available directly outside the room. For Resident 34, who was on enhanced barrier precautions due to a Foley catheter, the facility also failed to adhere to infection control protocols. The PPE cart intended for Resident 34 was incorrectly placed next to his roommate's area instead of his care area. Additionally, during an observation, LVN 1 handled Resident 34's Foley bag without wearing the required PPE, which included a gown, gloves, and mask. The Infection Preventionist confirmed that these precautions were necessary during direct contact with the resident, including touching the Foley bag. The facility's policy and procedure, as well as guidelines from the Centers for Disease Control and Prevention (CDC), emphasize the importance of using PPE during high-contact resident care activities to prevent the spread of multidrug-resistant organisms. Despite these guidelines, the facility did not ensure the proper placement and use of PPE for residents on transmission-based and enhanced barrier precautions, potentially increasing the risk of infection spread among staff and residents.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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