View Park Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3737 Don Felipe Drive, Los Angeles, California 90008
- CMS Provider Number
- 555065
- Inspections on file
- 40
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at View Park Convalescent Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a history of anxiety experienced acute agitation and refused medication and hospital transfer. A nurse practitioner ordered a one-time dose of Ativan to manage the resident's behavioral distress and facilitate transport, but there was no documentation or recollection that informed consent was obtained prior to administration, contrary to facility policy requiring prescriber-obtained consent for psychotropic medications.
A resident with a history of falls, impaired cognition, and mobility issues experienced a fall resulting in a hip fracture after the facility failed to complete a thorough fall risk assessment and did not implement or document individualized fall prevention interventions such as tab alarms or regular rounding, despite facility policy and staff awareness of the resident's high fall risk.
A resident with complex medical and mobility needs missed multiple doctor's appointments and blood work because the facility arranged transportation that did not accommodate requirements for a bariatric van or gurney. Staff and documentation confirmed that the resident was dependent for transfers and that inappropriate vehicles were repeatedly sent, leading to appointment cancellations.
Kitchen staff did not label cilantro, lettuce, and carrots with delivery or use-by dates, and some vegetables were stored while brown and wilted. Additionally, a dietary staff member failed to wash hands after donning a hairnet and before handling food, contrary to facility policy.
Two residents with limited English proficiency and cognitive capacity were not treated with dignity and respect by a medication nurse, who failed to communicate in a language they could understand and responded dismissively when another resident attempted to assist. The DON acknowledged that miscommunication could cause frustration and that staff should facilitate interpretation, as required by facility policy.
Two residents with documented language preferences other than English were not provided communication in their preferred language, despite being cognitively intact and having these needs identified in their assessments. One resident reported difficulty communicating with medication nurses and was not offered interpretation or alternative communication methods. The DON confirmed that interventions such as obtaining staff to interpret should be used, but these were not implemented, resulting in unmet communication needs.
A resident with multiple chronic conditions and a language preference other than English did not receive ordered as-needed pain medication and was not educated about his pain medications in an understandable language. Despite active orders for both ibuprofen and Percocet, only ibuprofen was administered, and the resident was left confused about his pain management regimen.
Surveyors found that the facility did not maintain a clean and safe environment for all residents, as evidenced by a leaking pipe in one medication room and a cockroach infestation in another. The issues were not reported or addressed by staff or the Maintenance Supervisor, and pest control records showed no treatment for the affected area, despite facility policies requiring regular maintenance and pest control.
A cook did not follow the standardized recipe for Szechwan pork by adding salt, pepper, and garlic powder, which were not included in the approved recipe. This action was observed and confirmed by interviews with the cook, the RD, and the DON, all of whom stated that recipes must be followed to meet therapeutic dietary needs, especially for residents with hypertension.
A container of jelly with an open date beyond the allowed 30-day period was found in a refrigerator, and both the RD and DON confirmed it should have been discarded according to their understanding of safe food handling practices. Facility policy on storage duration conflicted with staff statements, but the outdated jelly remained in the refrigerator, indicating a lapse in proper food storage procedures.
Surveyors found a resident bathroom with three soiled towels, a used coffee cup, and a water pitcher and cup left above the sink, in violation of infection control protocols. Staff interviews confirmed these items should not have been present due to infection control concerns, and facility policy requires all staff to follow procedures to prevent the spread of communicable diseases.
Twenty resident rooms were found to be below the federally required minimum square footage for multiple occupancy, with each room housing three residents in less than 240 sq. ft. Despite residents reporting adequate space and observations showing sufficient room for movement and care, the facility did not meet the regulatory standard for room size.
A resident with diabetes, congestive heart failure, and hypertension was inaccurately documented as receiving insulin on the MDS assessment, even though the insulin order had been discontinued prior to the assessment period. This error was identified through record review and staff interviews, revealing that the MDS did not accurately reflect the resident's medication status.
A resident with multiple medical conditions and no natural teeth was not assisted in obtaining replacement dentures after her original set went missing. Despite documented care plans, a dental consult indicating interest in dentures, and staff awareness of the issue, the facility did not make a timely dental referral or provide adequate follow-up, resulting in ongoing difficulty with eating and poor meal intake.
A CNA failed to don the required PPE when entering an isolation room during an influenza outbreak, despite facility policies and training. The resident had severe cognitive impairment and was on droplet precautions due to RSV exposure. This lapse in protocol increased the risk of infection spread.
A facility failed to ensure a resident with a gastrostomy tube and NPO order had appropriate orders for blood sugar checks every six hours. The resident, with severe cognitive impairment and multiple diagnoses including diabetes, was dependent on staff for daily activities. Despite the care plan indicating the need for Accu-checks, there were no specific orders for NPO status or separate blood glucose checks. Interviews confirmed the absence of necessary orders, potentially leading to inaccurate monitoring.
A resident at an LTC facility fell and fractured their femur after Maintenance Worker 1 mopped the floor without notifying the resident or placing a wet floor sign. The resident, who had a history of falls and required assistance with mobility, slipped on the wet floor while attempting to go to the bathroom. The facility's policies on fall prevention were not followed, leading to the incident.
A facility failed to report an alleged abuse incident to CDPH within the required two-hour timeframe. The incident involved a resident with dementia hitting another resident. Although the incident was reported internally, it was not communicated to CDPH promptly, as confirmed by staff interviews and facility policy.
The facility failed to ensure kitchen staff were properly trained and evaluated for competency, leading to incorrect sanitizing procedures and inconsistent adherence to the policy on residents bringing food from home. This could result in ineffective sanitization and increased risk of foodborne illnesses for residents.
The facility failed to ensure safe and sanitary food storage and preparation practices, including improper food labeling, poor air circulation in freezers, and unclean equipment. Observations revealed unlabeled, undated, and expired food, dirty storage areas, and cracked resident trays. Staff interviews confirmed the importance of proper food handling to prevent illness, but the facility did not adhere to its policies, resulting in multiple deficiencies.
The facility failed to properly dispose of garbage and refuse, with one black dumpster and one blue dumpster left uncovered and overflowing. The trash area was not maintained, with soiled gloves and debris scattered around. The Maintenance Supervisor confirmed the bins were not closed properly, potentially attracting pests and leading to cross-contamination.
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of cockroaches in the kitchen. Observations and interviews with Registered Dietitians confirmed the presence of pests, and a review of pest control service reports indicated multiple cockroach findings and recommended intensive treatment. The facility's policy on pest control was not effectively implemented, posing a risk of food contamination and potential foodborne illnesses for the residents.
A resident with dementia and adult failure to thrive was given Aspirin without a specified dosage due to an incomplete physician's order. The LVN administered 81 mg by default, and the DON confirmed that the pharmacist did not complete the Medication Regimen Review. The facility failed to clarify the correct dosage with the physician until later, violating their medication labeling policy.
The facility failed to meet professional standards of quality for a resident with dementia and hypertension by not specifying the dosage in a physician's order for Aspirin. Staff administered 81 mg by default, which could lead to incorrect dosing. Both LVN 1 and the DON confirmed that the order should have included the dosage.
The facility failed to properly store and dispose of medications according to their policies. An LVN was unable to identify unlabelled pills in a disposal container, and 34 multi-use medication containers lacked open dates. Both the LVN and DON were unaware of the facility's policies regarding medication disposal and labeling.
A resident with severe cognitive impairment was found with unauthorized medications at their bedside. The resident had not been assessed for self-administration of medications, and facility staff were unaware of the medications' presence. This failure posed a risk of harm due to potential drug interactions and allergic reactions.
The facility failed to provide advanced healthcare directive information to the responsible parties of two residents, violating their rights. Both residents lacked the capacity to make medical decisions, and the facility did not ensure that their healthcare wishes were documented, potentially leading to situations where their wishes might not be honored.
The facility failed to provide a safe environment for a resident with dementia by not securing or covering multiple exposed sheathed wires and connectors on the bed side rail. The Maintenance Supervisor confirmed the danger, and the Director of Nursing acknowledged the issue, stating that CNAs should report such hazards. The facility's policy on avoiding environmental hazards was not followed in this case.
A resident with an anxiety disorder and moderately intact cognition was found with elevated bed side rails used as physical restraints without proper assessment, consent, or a care plan. Staff confirmed the absence of an order for restraints, and the Director of Nursing acknowledged the potential harm and rights violation.
A facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident with Type 2 Diabetes, mobility issues, and muscle weakness. The resident, who lacked decision-making capacity, was observed on a LALM without a corresponding order. Both an LVN and the DON confirmed that this practice could lead to inappropriate treatments and interventions, potentially worsening the resident's condition.
The facility failed to develop and implement care plans for a resident's low air loss mattress and another resident's full bed length side rails. Both the LVN and DON confirmed the absence of these care plans, which hindered the ability to monitor the effectiveness of the interventions.
The facility failed to provide adequate assistance with ADLs for two residents, resulting in missed showers and feelings of anger and uncleanliness. Despite requests, staff were too busy to assist, leading to multiple missed hygiene care days.
The facility failed to ensure that the settings for a Low Air Loss Mattress (LALM) were correct and appropriate to the weight of a resident. The resident, who required assistance for daily activities and was at risk for pressure sores, had their LALM set to 280 pounds while their documented weight was 184 pounds. This discrepancy was confirmed by the RNS and DON, who acknowledged that incorrect settings could lead to the development or worsening of pressure sores.
The facility failed to change the tube feeding formula for a resident within the 48-hour timeframe as required by both the manufacturer's instructions and the facility's policy. This oversight was confirmed by both an LVN and the DON, and it posed potential health risks for the resident, who had multiple medical conditions and was dependent on staff for daily care.
The facility failed to ensure that five staff members were assessed for competency upon hire and annually. Interviews and record reviews revealed that several staff members, including a Treatment Nurse and a Registered Nurse Supervisor, had not completed annual skills competency training. The facility's policy requires annual competency assessments, but this was not adhered to, potentially leading to inadequate or delayed resident care.
The facility failed to label 34 multi-use open medication containers in Medication Cart B, #2, with an open-for-use date as required by policy. Both an LVN and the DON were unaware of the labeling policy.
The facility failed to provide at least 80 square feet per resident in 52 of 84 resident rooms, as required by federal regulations. Despite the deficiency, resident interviews indicated no concerns, and observations showed ample space for movement and care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not impede resident care or safety.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering a one-time dose of Ativan, an anti-anxiety medication, to a resident. The resident, an elderly female with multiple diagnoses including diabetes, COPD, hypertension, and a history of anxiety, experienced a change in condition characterized by agitation, refusal of medication and hospital transfer, and vital sign abnormalities. The nurse practitioner ordered Ativan to manage the resident's acute behavioral distress and facilitate safe transport to the hospital. However, there was no documentation or recollection by the LVN that informed consent was obtained before administering the medication, despite the resident being described as self-responsible and able to make her own decisions. Facility policy requires that informed consent be obtained by the prescriber prior to the initiation of any psychotropic medication, including anxiolytics such as Ativan. The DON confirmed that consent is required before administering such medications. The lack of documented informed consent prior to giving Ativan constituted a failure to ensure the resident's right to make an informed decision about her care, as required by facility policy and applicable regulations.
Failure to Develop Comprehensive Fall Prevention Plan and Complete Accurate Fall Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan and complete an accurate initial Fall Risk Evaluation for a resident identified as high risk for falls. The resident, who had a history of falling, hypertension, depression, impaired cognition, and required substantial assistance with activities of daily living, was admitted and readmitted to the facility. The Fall Risk Evaluation form for this resident was incomplete, with several key assessment questions left blank, resulting in an inaccurate fall risk score. The care plan noted the resident was at high risk for falls but only included a general intervention for staff to observe the resident frequently, without specifying detailed or individualized interventions to prevent repeated falls. Staff interviews revealed that the resident was confused, incontinent, had an unsteady gait, and was known to attempt to get up independently despite being unsafe to do so. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that the resident was a fall risk and described facility practices such as using tab alarms and rounding every two hours for fall prevention. However, the resident did not have a tab alarm in place, and there was no documented evidence that two-hourly rounds or other specific interventions were consistently performed for this resident. The facility's own policies required monitoring and documentation of interventions for fall risk residents, but these were not followed or documented in this case. As a result of these deficiencies, the resident was found on the floor in pain after a fall, which led to a right hip fracture requiring hospitalization and surgery. The incomplete assessment and lack of individualized, documented interventions contributed to the failure to prevent the fall and subsequent injury. Facility leadership, including the MDS Nurse and DON, confirmed that the assessment was incomplete and that missing information could lead to inaccurate care planning and potential harm.
Failure to Arrange Appropriate Transportation Resulting in Missed Medical Appointments
Penalty
Summary
The facility failed to ensure proper transportation arrangements for a resident with significant mobility and medical needs, resulting in missed doctor's appointments and blood work. The resident, who had diagnoses including acute embolism and thrombosis, peripheral vascular disease, schizophrenia, and HIV, required either a bariatric van, gurney, or geriatric chair for safe transport. Documentation showed that the resident was dependent on staff for transfers and required maximal assistance for mobility. On multiple occasions, the facility arranged transportation that did not meet the resident's needs, such as sending a non-bariatric van or a non-gurney vehicle, leading to the cancellation of scheduled medical appointments. Interviews with the resident and multiple staff members, including an LVN, Social Services director, Director of Staffing Development, and DON, confirmed that the resident missed at least two doctor's appointments and associated blood work due to inappropriate transportation being provided. Staff acknowledged awareness of the resident's specific transport requirements and the repeated issue of the transportation company sending vehicles that could not accommodate these needs. The facility's policy indicated that social services would assist residents in obtaining transportation, but this was not effectively implemented for this resident, resulting in the deficiency.
Failure to Ensure Proper Food Labeling and Hand Hygiene in Dietary Department
Penalty
Summary
Kitchen staff failed to follow proper food labeling and handling procedures, as observed during a survey. Cilantro, lettuce, and carrots stored in the refrigerator were not labeled with delivery or use-by dates, and some vegetables were found to be brown and wilted. The Dietary Supervisor confirmed that the produce had not been labeled upon receipt and acknowledged that spoiled items needed to be discarded. Additionally, a bin containing various vegetables lacked any labeling, and some items inside were visibly spoiled. During the same observation, one out of three dietary staff members did not wash their hands upon entering the kitchen, after donning a hairnet, and before handling food in the refrigerator. The Dietary Supervisor admitted that handwashing should have occurred before entering the kitchen and touching the refrigerator. Review of facility policies confirmed that all food items should be properly covered, dated, and labeled, and that staff are required to follow safe food handling practices to prevent foodborne illness.
Failure to Ensure Dignity and Respect in Resident Communication
Penalty
Summary
Two residents with cognitive capacity and language preferences other than English were not treated with dignity and respect by a medication nurse during communication. One resident, who required substantial assistance with activities of daily living and had a history of hypertension, diabetes, arthritis, and above-the-knee amputation, reported being spoken to disrespectfully and with an attitude by the evening medication nurse. The resident also stated that the nurse did not attempt to communicate in a language the resident could understand or take steps to facilitate effective communication. Another resident, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis, hypertension, and hyperlipidemia, witnessed the same nurse arguing with the first resident and attempted to assist with communication due to his partial understanding of English. His efforts were dismissed by the nurse, who told him to mind his own business. The Director of Nursing acknowledged that miscommunications could lead to frustration and suggested that an intervention would be to obtain another staff member to interpret for the residents. The facility's policy requires employees to treat all residents with kindness, respect, and dignity, which was not followed in these instances.
Failure to Communicate with Residents in Preferred Language
Penalty
Summary
The facility failed to ensure that two residents were communicated with in their preferred language, as required by their care needs and facility policy. Both residents were cognitively intact and had documented language preferences other than English in their Minimum Data Set (MDS) assessments. Despite this, interviews revealed that one resident experienced ongoing difficulty communicating with medication nurses, and no alternative communication methods or interpretation services were offered to assist him in understanding his care. The other resident also had a language preference documented but there was no evidence that this need was accommodated. The Director of Nursing acknowledged during an interview that lack of communication in a resident's preferred language could lead to frustration and that an appropriate intervention would be to obtain another staff member to interpret. The facility's policy on accommodating communication deficits stated that communication needs would be identified and appropriate interventions, including care planning, would be developed to meet those needs. However, the facility did not implement these interventions for the two residents, resulting in their communication needs not being met.
Failure to Provide and Communicate Ordered Pain Management
Penalty
Summary
A resident with a history of hypertension, type 2 diabetes, arthritis, and an above-the-knee amputation was admitted to the facility and was cognitively intact, with a language preference other than English. The resident was prescribed ibuprofen for mild pain and Percocet for moderate to severe pain, as needed. However, the resident reported not receiving the previously ordered pain medications and was only receiving Tylenol for pain. The resident expressed confusion about which pain medications were currently ordered and stated that information about pain medications was not communicated in a language he could understand. Record review showed that the resident had not received Percocet after a certain date, despite the orders still being active and available for administration if pain was present. The Medication Administration Record confirmed that only ibuprofen had been administered in recent days. The Director of Nursing verified that the Percocet orders were still active and could have been given. The facility's policy required prompt response to reports of pain and effective communication, but these were not followed, resulting in the resident not receiving appropriate pain management or education about his medications.
Failure to Maintain Clean, Safe, and Functional Environment Due to Leaking Pipes and Cockroach Infestation
Penalty
Summary
The facility failed to maintain a clean, safe, and functional environment for all 92 residents, as evidenced by multiple observations and interviews. In Medication Room A, a leaking pipe was found under the sink cabinet, with a grey wash basin placed to catch the water. The Registered Nurse Supervisor (RNS) was unaware of the leak, and no staff or the Maintenance Supervisor (MS) had reported it. The RNS acknowledged that unrepaired leaks could lead to mold, which could make residents and staff ill. In Medication Room B, multiple dead cockroaches were observed under the sink cabinet. The RNS, as well as the Director of Nursing (DON) and Administrator, confirmed that this infestation had not been reported to them. The Administrator stated that the MS is responsible for cleaning under sink cabinets and fixing leaks, and that pest control should be notified immediately in the event of an infestation. Pest control service records showed no indication that Medication Room B had been treated for cockroaches, despite the facility's policy of bi-monthly pest control visits. Interviews with the MS revealed that maintenance issues are to be logged at the nurses' stations and that he checks these logs daily. The MS stated he had last cleaned under the sink in station B two weeks prior and had not received any reports about cockroaches. He also confirmed he had no professional plumbing training and had not repaired the leaking pipe in Medication Room A. Facility policies reviewed indicated that the MS is responsible for maintaining plumbing and ensuring a clean, pest-free environment, but these responsibilities were not fulfilled as required.
Failure to Follow Standardized Recipe for Therapeutic Diets
Penalty
Summary
A deficiency occurred when a cook (CK) failed to follow the standardized recipe for Szechwan pork during lunch preparation. The recipe, as reviewed, did not include the addition of salt, pepper, or extra garlic powder. However, during observation, the CK admitted to adding these ingredients, specifically stating that salt was added to enhance the flavor of the pork. The CK acknowledged that the facility recipe should be followed and recognized that adding salt could negatively impact residents, particularly those with hypertension. Interviews with the registered dietician (RD) and the director of nursing (DON) confirmed that recipes are designed to meet therapeutic dietary needs and should be strictly followed, especially for residents with specific medical conditions such as hypertension. The facility's policy also requires that menus be prepared as written using standardized recipes, and that dietary staff are responsible for adhering to these guidelines to ensure nutritional adequacy and compliance with physician orders.
Failure to Discard Outdated Jelly in Refrigerator
Penalty
Summary
Surveyors observed that a container of jelly in one of the facility's refrigerators was labeled with an open date of 4/11/2024, which was beyond the 30-day period allowed for opened food items according to the registered dietician. The registered dietician confirmed during the observation that food items opened and stored in the refrigerator should be discarded after 30 days, and the jelly should not have remained in the refrigerator past this timeframe. The Director of Nursing also stated in an interview that food with a label date of 4/11/2024, whether open or closed, should not be present in the refrigerator due to potential harm. Facility policies reviewed indicated that food and supplies must be stored properly and safely, and that opened jellies, when refrigerated, are allowed for up to 6 months, which conflicted with the staff's statements. The presence of the outdated jelly in the refrigerator demonstrated a failure to follow safe food handling practices as observed and confirmed by staff.
Failure to Maintain Sanitary Environment in Resident Bathroom
Penalty
Summary
The facility failed to maintain a sanitary environment in one of its resident bathrooms by not adhering to established infection control measures. During a facility tour, surveyors observed three visibly soiled towels hanging on the towel rack, as well as a used coffee cup with residue and a water pitcher and cup placed on a shelf above the bathroom sink. These items were not supposed to be present in the bathroom according to infection control protocols. Certified Nurse Assistant (CNA) 1 confirmed that the dirty towels, coffee cup, and water pitcher should not be in the bathroom due to infection control concerns, but was unaware of who left them there. Further interviews with the infection prevention nurse (IPN) and the Director of Nursing (DON) confirmed that the presence of dirty towels, cups, and water pitchers in the bathroom constitutes an infection control issue, as it can expose residents to disease-causing microorganisms. A review of the facility's infection prevention and control policy indicated that the program is designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. The policy applies to all staff, who are trained on these procedures upon hire and periodically thereafter.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in 20 out of 40 resident rooms, as mandated by federal regulations. Specifically, the rooms in question were designed for three residents each but measured less than the required 240 square feet, with individual room sizes ranging from approximately 201 to 236 square feet. This deficiency was identified through a review of facility records, including a waiver request letter submitted by the Administrator, which acknowledged the shortfall in room sizes. The federal regulation requires at least 80 square feet per resident in multiple occupancy rooms, and the rooms listed did not meet this standard. During observations conducted over several days, residents were seen to have sufficient space to move about, and there was adequate room for necessary furniture and care equipment. Additionally, during a resident council meeting, several residents expressed that their room sizes were adequate. Despite these observations and resident statements, the facility's failure to meet the minimum square footage requirement constitutes a deficiency as per federal standards.
Inaccurate MDS Assessment of Insulin Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment entries accurately reflected a resident's insulin status. Specifically, the MDS for a resident, completed on 2/19/2025, indicated that the resident received one injection of insulin during the seven-day look-back period. However, a review of the resident's medical chart and interview with the MDS Coordinator revealed that the insulin order had been discontinued on 2/6/2025, prior to the look-back period. This resulted in inaccurate documentation on the MDS regarding the resident's insulin administration. The resident involved had a medical history including congestive heart failure, hypertension, and diabetes mellitus, and was dependent on staff for several activities of daily living. Both the MDS Coordinator and the Director of Nursing confirmed that the MDS is used to guide care planning and that inaccurate entries could lead to an incorrect care plan. The facility's policy required comprehensive assessments to be conducted according to established criteria and timeframes, but this was not followed in this instance.
Failure to Assist Resident in Obtaining Dentures After Loss
Penalty
Summary
The facility failed to assist a resident in obtaining dentures after the resident's dentures went missing. The resident, who had a history of diabetes mellitus, muscle wasting, atrophy, and anemia, was admitted and later readmitted to the facility. Documentation showed the resident was edentulous and at risk for poor oral intake, with care plans indicating the need for dental assessment and referral as well as good oral hygiene. Despite a dental consult noting the resident's interest in dentures and an order for dental consult and treatment as needed, the resident reported that her request for dentures had not been addressed and that her dentures had been missing for a long time. Staff interviews confirmed the resident no longer had dentures and had difficulty eating certain foods, rarely finishing her meals. The facility's policy required referral for dental services within three days if dentures were lost, or documentation of actions taken and reasons for delay. However, there was no evidence that the facility made a timely referral or provided adequate follow-up to ensure the resident could eat and drink adequately while awaiting dental services. The Social Services Director acknowledged the resident's request for dentures and the potential for weight loss due to the lack of dentures. The DON confirmed that staff are responsible for following up on such requests and recognized the impact of not having dentures on chewing and weight maintenance.
Inadequate PPE Use During Influenza Outbreak
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program during an influenza outbreak. Specifically, a certified nursing assistant (CNA) entered an isolation room without donning the required personal protective equipment (PPE), which included a gown, mask, and face shield. The CNA only wore gloves when entering the room of a resident who was on droplet precautions due to exposure to respiratory syncytial virus (RSV). The CNA admitted to forgetting to put on the full PPE because he was only assisting the resident with water and the resident was not his assigned responsibility. The resident in question had a severely impaired cognitive function and was unable to communicate needs or make decisions regarding care. The facility's policy required staff to don and doff PPE properly before entering and exiting isolation rooms, as reiterated by the RN Supervisor, Director of Staff Development, and Infection Preventionist during interviews. Despite the facility's policy and training efforts, the CNA's failure to adhere to the protocol represented a break in infection control, potentially increasing the risk of spreading influenza within the facility.
Failure to Ensure Proper Blood Sugar Monitoring for NPO Resident
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube feeding and an NPO order had appropriate medical orders for fingerstick blood sugar checks every six hours. The resident, who was admitted with diagnoses including type two diabetes, hypertension, heart failure, gastrostomy, dysphagia, and muscle weakness, was dependent on staff for various activities of daily living due to severely impaired cognition. Despite the resident's condition and care plan indicating the need for Accu-checks as ordered, there was no specific order for NPO status or separate fingerstick blood glucose checks apart from insulin orders. During interviews and record reviews, it was confirmed by both an LVN and an RN Supervisor that the necessary orders were not present in the resident's chart. The RN Supervisor acknowledged that blood sugar checks should occur every six hours for an NPO resident, yet the existing orders only specified checks before meals and at bedtime. This oversight had the potential to result in inaccurate blood sugar monitoring for the resident, impacting the care and services provided.
Failure to Prevent Fall Due to Wet Floor
Penalty
Summary
The facility failed to provide a safe environment to prevent falls for a resident, identified as Resident 1, who slipped and fell due to a wet floor in their room. Maintenance Worker 1 (MW 1) mopped the floor in Resident 1's room but did not notify the resident or their roommate that the floor was wet. Additionally, MW 1 failed to place a wet floor sign to alert the residents of the hazard. As a result, Resident 1, who was attempting to go to the bathroom, slipped on the wet floor and fell, suffering severe pain in the left knee. Resident 1 had a history of falls and was at risk for falls due to general weakness, a history of left ankle fracture, osteopenia, and muscle weakness. The resident was admitted to the facility for physical and occupational therapy and required assistance with mobility, using a walker for support. At the time of the incident, Resident 1 was alert and oriented but had impaired vision and required assistance with daily activities. The fall resulted in a left femur fracture, and the resident was transferred to a hospital for treatment, where they underwent surgery for the fracture. Interviews with staff and the resident's roommate confirmed that MW 1 did not inform them of the wet floor, nor was a wet floor sign placed. The facility's policy and procedures require staff to identify and mitigate fall risks, including wet floors, but these protocols were not followed. The Director of Rehabilitation and other staff acknowledged that a wet floor is a fall risk, and the failure to notify residents and place a warning sign contributed to the incident.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe. This deficiency involved an incident between two residents, where one resident, diagnosed with dementia and lacking decision-making capacity, allegedly hit another resident on the arm after attempting to unplug their television. The resident who was hit did not require pain medication and expressed no fear of remaining in the facility, acknowledging the other resident's mental state. The incident was reported internally within the facility, with the Certified Nursing Assistant informing the Administrator, who then informed the Director of Staff Development. However, the Administrator did not report the incident to CDPH within the mandated two-hour period. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed the understanding that such incidents should be reported promptly to CDPH. The facility's policy, revised in March 2023, also stipulates that allegations involving abuse or serious bodily injury must be reported within two hours.
Inadequate Training and Policy Adherence in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills. One dietary aide did not follow the manufacturer's guidelines when checking the concentration of the QUAT sanitizing solution. The aide dipped the test strip for only eight seconds instead of the required ten seconds and did not check the water temperature, which is necessary for accurate testing. The aide admitted to not being trained to test the water temperature and was unaware of the correct procedure. This failure to follow guidelines could result in ineffective sanitization of kitchen surfaces and dishes, potentially leading to foodborne illnesses for the residents. Additionally, staff members were not able to consistently verbalize the facility's policy regarding residents bringing food from home. Interviews with various staff members, including a Licensed Vocational Nurse, Activities Assistant, Activities Supervisor, and Director of Staff Development, revealed discrepancies in their understanding of how long food from outside sources could be stored. The staff provided conflicting information, ranging from one to three days, and some were unsure of the exact policy. This inconsistency in following the food storage policy could lead to residents consuming spoiled food, increasing the risk of foodborne illnesses. The facility's policy and procedures on food from outside sources were reviewed, indicating that while outside food is discouraged, it is allowed under certain conditions. The policy requires that the charge nurse be notified and that the food be checked to ensure it aligns with the resident's prescribed diet. However, the staff's lack of consistent knowledge and adherence to this policy highlights a significant gap in training and communication, which could compromise the safety and well-being of the residents.
Facility Fails to Ensure Safe and Sanitary Food Storage and Preparation
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. Observations revealed improper storage of food, including unlabeled, undated pasta, ranch dressing, and expired cheese. Additionally, bacon slices were found uncovered, unlabeled, and undated. The resident's refrigerator contained unlabeled, undated, and expired food, along with staff's parmesan cheese, drink, and Italian dressing. Interviews with staff confirmed the importance of labeling and dating food to prevent residents from consuming expired food, which could lead to illness. The facility also exhibited poor air circulation in Freezers 3 and 4, which were observed to be full of food. The Registered Dietitian acknowledged the overcrowding and the need for proper air circulation to maintain food safety. Furthermore, equipment cleanliness was compromised, with dirt and debris found in Freezer 3, dust buildup in Refrigerator 2's vent, and black dirt debris in Refrigerator 1. The dry storage area also had dust buildup, dirty cans, and food debris on the floor. The ice machine, located outside, had significant dirt buildup on both internal and external parts, raising concerns about cross-contamination and infection. Additionally, two dented cans were stored with undented cans in the dry storage area, and seventeen cracked and chipped resident trays were found in use. Staff interviews highlighted the potential risks of using dented cans and damaged trays, which could lead to bacterial growth and cross-contamination. The facility's policies and procedures were reviewed, indicating the need for proper labeling, dating, and cleanliness of food storage areas and equipment. However, the facility failed to adhere to these guidelines, resulting in multiple deficiencies that could potentially harm the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly, as observed during a survey. One of two black dumpsters and one blue dumpster were not covered for an unknown amount of time. The blue dumpster was overflowing with cardboard boxes. The trash area was not maintained, with soiled gloves and other debris scattered around. The Maintenance Supervisor confirmed that the trash bins were not closed properly and that the area was not clean, which could attract pests and lead to cross-contamination and potential illness among residents. The facility's policies and procedures for waste control and disposal, as well as pest control, were not followed. The policies required that trash bins be covered at all times, outside garbage bins be kept closed, and surrounding areas be kept clean. Additionally, cardboard boxes were to be broken down and disposed of timely. The Food Code 2017 also mandates that waste handling units for refuse be kept covered with tight-fitting lids or doors if kept outside the food establishment. These lapses in following established protocols contributed to the deficiency observed by the surveyors.
Sanitary Conditions in Food Services Department Not Maintained
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of cockroaches in the kitchen. During an observation and interview with the Registered Dietitian (RD 1), a dead cockroach and a live baby cockroach were found on the floor underneath the dishwashing sink. RD 1 acknowledged the presence of the insects and stated that the kitchen should be free of pests for food safety. Another observation and interview with Registered Dietitian (RD 2) confirmed the presence of pests, and RD 2 mentioned that a pest control service had recently treated the facility, but no cockroaches were found during their inspection. However, a review of the pest control service report from 3/28/2024 indicated that 12 cockroaches were found in the kitchen, and intensive roach treatment was recommended to prevent a kitchen shutdown. The report also recommended improving sanitation and keeping doors closed to prevent pest entry. Further inspection revealed a half-inch gap in the screen door leading to the trash area, which could allow pests to enter. The Administrator (ADM) reviewed a video clip of a cockroach in the dishwashing area and confirmed the presence of pests. ADM stated that the pest control service would return to inspect and treat the kitchen. A subsequent pest control service report from 4/3/2024 indicated that 30 German cockroaches were found in the kitchen, and intensive treatment was performed. The facility's policy on pest control, revised on 2/20/2024, stated that the facility should maintain an effective pest control program to keep the building free of insects and rodents. Despite these measures, the presence of cockroaches in the kitchen posed a risk of food contamination and potential foodborne illnesses for the residents.
Failure to Ensure Complete Medication Order for Resident
Penalty
Summary
The facility failed to ensure that Resident 3 was free from significant medication errors. Resident 3, who had diagnoses including adult failure to thrive and dementia, was readmitted to the facility with a physician's order for chewable Aspirin to be administered via G-tube once daily for cardiac prophylaxis. However, the order did not specify the dosage. During a medication administration observation, LVN 1 revealed that the computer system only indicated 'chewable aspirin' without a dosage, leading them to administer 81 mg by default. LVN 1 acknowledged that a complete medication order should include the name, dosage, and route of administration, and that an incomplete order could result in ineffective medication therapy or an overdose, which could be fatal to the resident. The Director of Nursing (DON) confirmed that the pharmacist did not complete the Medication Regimen Review (MRR) for the Aspirin, and the facility failed to clarify the correct dosage with Resident 3's physician until the day of the interview. The facility's policy on medication labeling, revised recently, mandates that all medications be properly labeled according to state and federal guidelines. The failure to ensure a complete medication order for Resident 3's Aspirin had the potential to lead to significant medication errors, including overdose or underdose, which could be fatal.
Failure to Specify Dosage in Medication Order
Penalty
Summary
The facility failed to meet professional standards of quality for Resident 3, who was admitted with medical diagnoses including adult failure to thrive, dementia, and hypertension. The deficiency was identified when it was observed that the physician's order for Aspirin, dated 12/29/2023, did not specify the dosage. During an interview, LVN 1 admitted that the computer system only indicated 'chewable aspirin' without a dosage, leading staff to administer 81 mg by default. LVN 1 acknowledged that a complete medication order should include the name of the medication, dosage, and route of administration. The Director of Nursing (DON) confirmed that the aspirin order should have included the dosage and that the absence of this information could result in incorrect dosing. The review of Resident 3's Minimum Data Set (MDS) indicated that the resident had impaired cognition and was dependent on staff for various activities, including feeding and personal hygiene. The facility's Medication Pass Tips, revised on 2/20/2024, emphasized the importance of the 'ten rights' of medication administration, including the right dose. The failure to include the correct dosage in the medication order had the potential to cause underdosing, overdosing, and hospitalization, as confirmed by both LVN 1 and the DON during their interviews.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and disposed of according to their policies and procedures. During an observation of Medication Cart B, an undated clear plastic container labeled 'Disposal Medication All Refusal' was found to contain 22 unidentifiable pills inside and four unidentifiable pills outside the container. The Licensed Vocational Nurse (LVN) could not identify the pills or determine if they were controlled substances. The Director of Nursing (DON) confirmed that refused medications should be discarded immediately in a locked storage room with a solution called a drug buster, but was unable to explain the consequences of not doing so. The facility's policy requires controlled medications to be destroyed in the presence of two licensed nurses and documented accordingly, which was not followed in this instance. Additionally, 34 out of 36 multi-use medication containers in Medication Cart B were found to be in use without an open date, contrary to the facility's policy. The LVN was unaware of the policy for labeling multi-use medication containers, despite being employed at the facility since July 2023. The DON also did not know that multi-use open medication containers needed to have an open date and was unfamiliar with the facility's policy on labeling open medications. The facility's policy mandates that the open date be labeled on medication containers once they are opened, which was not adhered to in this case.
Failure to Prevent Unauthorized Medication Access
Penalty
Summary
The facility failed to ensure that medications were not left with a resident who was not capable of self-administering them. Resident 77, who had severe cognitive impairment and required assistance with daily activities, was found with three pills on their bedside drawer. The resident stated that a friend had brought the medications because the facility staff were not responding to requests for headache medication. The resident's medication administration record indicated an order for Norco, but there was no documented evidence that the resident was assessed to self-administer medication. During interviews, the Licensed Vocational Nurse and the Director of Nursing confirmed that Resident 77 did not have an order to self-administer medications and should not have had any medications at bedside. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications, which had not been conducted for Resident 77. The Director of Nursing acknowledged that the presence of non-prescribed medications posed a risk for potential harm, including drug interactions and allergic reactions.
Failure to Provide Advanced Healthcare Directive Information
Penalty
Summary
The facility failed to ensure that advanced healthcare directive information was provided to the responsible parties (RPs) of two residents, resulting in a violation of their rights. Resident 1, who was diagnosed with Alzheimer's disease, schizophrenia, and hypertension, did not have the capacity to make medical decisions. Despite this, the facility did not contact Resident 1's power of attorney to complete the advanced directive acknowledgment (ADA) form. The Social Services Director (SSD) admitted that the ADA form was not completed and only sent an email regarding it on the day of the interview. This oversight meant that Resident 1's healthcare wishes were not documented in the chart, potentially leading to life-threatening situations where the resident's wishes might not be honored. Similarly, Resident 3, who was diagnosed with adult failure to thrive, dementia, and hypertension, also did not have the capacity to make medical decisions. The SSD confirmed that Resident 3's ADA form was not completed by the RP, which could result in the resident's healthcare wishes not being followed. The Director of Nursing (DON) emphasized the importance of completing the ADA form upon admission to ensure that the facility is aware of and can honor the residents' healthcare wishes. The facility's policy and procedures require compliance with healthcare decisions made by authorized persons, but this was not adhered to in these cases.
Failure to Secure Exposed Wires on Bed Side Rail
Penalty
Summary
The facility failed to provide a safe environment for Resident 29 by not securing or covering multiple exposed sheathed wires and connectors on the bed side rail. Resident 29, who was admitted with diagnoses including unspecified dementia, psychotic disturbance, and anxiety, did not have the capacity to understand and make decisions. The resident required assistance from staff for daily activities and exhibited behavioral symptoms of dementia such as anxiety and restlessness. During an observation, it was noted that the bed side rail had multiple exposed wires, which posed a risk of injury or harm to the resident. The Maintenance Supervisor confirmed that there was no request order for Resident 29's bed and acknowledged the danger posed by the exposed wires. The Director of Nursing stated that CNAs are responsible for reporting bed malfunctions to the maintenance supervisor and agreed that it was unacceptable for a resident to be on a bed with exposed wires. The facility's policy on avoiding environmental hazards indicated that items posing harm to residents should be removed, and direct caregivers should check the resident's unit to identify and remove such items. However, this policy was not followed in the case of Resident 29.
Inappropriate Use of Physical Restraints on Resident
Penalty
Summary
The facility failed to ensure that Resident 288 was free from physical restraints. Resident 288, who was admitted with an anxiety disorder and had moderately intact cognition, was observed with bilateral full-size bed side rails elevated. Certified Nursing Attendant 1 confirmed that the side rails were used to prevent the resident from falling, despite acknowledging the risk of the resident getting tangled in the rails. Licensed Vocational Nurse 2 and Licensed Vocational Nurse 3 both confirmed that there was no order for restraints in the resident's chart, and that the use of side rails without proper assessment, consent, or a care plan could potentially harm the resident. The Director of Nursing also confirmed that the side rails were elevated without an order or consent, emphasizing that this practice could disrespect the resident's rights and potentially cause harm. A review of the facility's policy on physical restraints indicated that any use of mechanical devices restricting freedom of movement requires an order from the attending physician, informed consent, and a detailed plan of care. The facility's failure to adhere to these policies resulted in the inappropriate use of physical restraints on Resident 288.
Failure to Obtain Physician's Order for Low Air Loss Mattress
Penalty
Summary
The facility failed to obtain a physician's order for a low air loss mattress (LALM) for a resident who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness. The resident, who lacked the capacity to understand and make decisions, was observed in bed on a LALM without a corresponding physician's order. This was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the absence of a physician's order could lead to inappropriate treatments and interventions, potentially worsening the resident's skin condition. The Director of Nursing (DON) confirmed that an order is required for the use of an air mattress and that it is not professional nursing practice to implement treatments without a physician's order. The facility's policy and procedures, dated 2/20/2024, also indicated that physician's orders must be obtained prior to the initiation of any medication or treatment. This deficiency had the potential to harm the resident by not providing appropriate treatment and interventions.
Failure to Develop and Implement Care Plans for Specialized Equipment
Penalty
Summary
The facility failed to develop and implement a care plan for Resident 9's low air loss mattress (LALM) and Resident 288's full bed length side rails. Resident 9, who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness, did not have a care plan for the LALM despite requiring assistance for daily activities and lacking the capacity to make decisions. During an observation, Resident 9 was found lying on a LALM set to 280 pounds, and both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed the absence of a care plan for the LALM, which hindered the ability to monitor the effectiveness of the intervention. Similarly, Resident 288, admitted with an anxiety disorder and requiring assistance for daily activities, did not have a care plan for the full bed length side rails observed in their room. The DON confirmed that no care plan for restraints was found in Resident 288's chart or electronic records. The facility's policy and procedures indicated that care plans should be reassessed and updated to reflect the current status of residents, but this was not adhered to in these cases.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, resulting in feelings of anger and potential health risks. Resident 54, who has muscle weakness and Type 2 diabetes, was observed with unshaven facial hair and reported not receiving assistance with shaving or showers as scheduled. Despite requesting showers, Resident 54 was told by staff that they did not have time, leading to multiple missed showers and bed baths in March 2024. The resident expressed feelings of anger and uncleanliness due to the lack of proper hygiene care. Resident 6, diagnosed with morbid obesity and muscle weakness, also did not receive scheduled showers. The resident reported not having showered in about two weeks and stated that staff were too busy to assist with showers. Observations confirmed that Resident 6 was not provided with showers on multiple scheduled days in March 2024. The resident expressed frustration and anger over not feeling clean and not preferring bed baths. Interviews with staff, including the Director of Staff Development (DSD), Certified Nurse Assistants (CNAs), and Licensed Vocational Nurses (LVNs), revealed inconsistencies in reporting and providing showers. The facility's policy requires residents to receive showers twice a week unless they refuse or are sick. However, staff failed to adhere to this policy, leading to the identified deficiencies in resident care.
Incorrect LALM Settings for Resident
Penalty
Summary
The facility failed to ensure that the settings for a Low Air Loss Mattress (LALM) were correct and appropriate to the weight of Resident 9. Resident 9, who was admitted with diagnoses including Type 2 Diabetes, abnormalities of mobility, and muscle weakness, did not have the capacity to understand and make decisions. The resident's Minimum Data Set (MDS) indicated that they required assistance from facility staff for eating, hygiene, and toileting. Despite being at risk for developing pressure sores, as indicated in the care plan, there was no specific care plan for the LALM. During an observation, it was found that the LALM was set to 280 pounds, while the resident's documented weight was 184 pounds. This discrepancy was confirmed by the Registered Nurse Supervisor (RNS 1) and the Director of Nursing (DON), who both acknowledged that incorrect settings could lead to the development or worsening of pressure sores. The facility's policy and procedures for pressure-reducing mattresses indicated that the mattress should be set according to the patient's weight or a healthcare professional's suggestion. However, this was not followed in the case of Resident 9. The LALM was not set at the correct weight, which could potentially harm the resident by not providing the correct amount of airflow needed to prevent or treat pressure injuries. The failure to adhere to the correct settings for the LALM and the absence of a specific care plan for its use contributed to the deficiency observed by the surveyors.
Failure to Change Tube Feeding Formula in a Timely Manner
Penalty
Summary
The facility failed to ensure that the tube feeding product/formula was not hanged for more than 48 hours per manufacturer's instructions and facility's policy and procedures for one of the sampled residents. Specifically, Resident 3 had a bottle of Glucerna connected to their gastrostomy tube that was dated 3/26/2024 and had not been changed for 6 days. This was confirmed during an observation and interview with LVN 5, who acknowledged that the feeding bottle should have been changed to prevent infection and potential adverse effects such as an upset stomach. The Director of Nursing also confirmed that tube feeding bottles should be changed every 24 to 48 hours to prevent bacterial growth and associated complications like abdominal pain and loose bowel movements. Resident 3 was admitted to the facility with medical diagnoses including adult failure to thrive, dementia, and hypertension. The resident was dependent on facility staff for feeding, toilet use, oral hygiene, and personal hygiene. The facility's policy and procedures, as well as the manufacturer's instructions for Glucerna, both indicated that the maximum hang time for sterile formula in a closed system is 48 hours. The failure to adhere to these guidelines resulted in the potential for significant health risks for Resident 3.
Failure to Assess Staff Competency
Penalty
Summary
The facility failed to ensure that five out of five staff members were assessed for competency upon hire and annually. This deficiency was identified through interviews and record reviews. The Treatment Nurse, who had been employed for seven years, could not recall the last time they completed an annual skills competency training. Similarly, the Registered Nurse Supervisor, who had worked at the facility only twice, had never completed a competency checklist. The Laundry Aid, who had been employed for several years, also confirmed never having completed an annual skills competency evaluation. The Certified Nurse Assistant 2 was the only staff member who had recently completed an annual skills competency training. The Director of Staff Development and the Director of Nursing confirmed that the facility does not keep employee files for registry nurses and relies on a registry app to verify credentials and competencies, which they could not identify by name. A review of employee files for the Licensed Vocational Nurse/Treatment Nurse, Certified Nurse Assistant 2, Certified Nurse Assistant 3, and the Laundry Aid revealed that none contained a skills competency checklist or a completed staff competency assessment. The facility's policy and procedures, revised in February 2024, indicated that employees should be assessed for competency upon hire and annually. However, the facility failed to adhere to this policy, leading to a potential knowledge, training, and certification deficit among staff, which could result in inadequate or delayed resident care.
Failure to Label Multi-Use Medication Containers
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not adhering to its policy for labeling multi-use medication containers. During a record review and interview, it was found that 34 multi-use open medication containers in Medication Cart B, #2, were in use without an open-for-use date as required by the facility's policy. Licensed Vocational Nurse 4 (LVN 4) and the Director of Nursing (DON) both admitted to not knowing the facility's policy for labeling these medications. The facility's policy, revised on February 20, 2024, mandates that medications stored in a bottle or container must be labeled with the open date once the container is opened.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 52 of 84 resident rooms, as required by federal regulations. Specifically, rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 116, 118, 120, 121, 122, 134, 137, 138, 141, and 142 were found to be deficient in this regard. The rooms in question had varying sizes but did not meet the minimum square footage requirements for the number of residents they housed. For example, rooms with three beds should have at least 240 square feet, but many of these rooms were significantly smaller. This deficiency was identified through observation, interviews, and record reviews during a recertification survey conducted from April 1 to April 4, 2024. Despite the deficiency, resident interviews indicated no concerns regarding the size of the rooms, and observations showed that residents had ample space to move freely and that there was sufficient space for nursing staff to provide care. The facility had submitted a Request for Room Size Waiver, arguing that the room sizes did not impede resident care or safety. During an interview, the administrator confirmed that a written request for the continued room waiver had been submitted. Measurements taken by the Maintenance Supervisor confirmed the room sizes, and it was noted that the measurements did not include any protrusions from the walls. The report recommends the continuation of the room size waiver.
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.
