Citations in California
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in California.
Statistics for California (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in California
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A CNA did not wear the required gown and gloves while providing high-contact care to a resident with a central line, despite facility policy and a physician's order for enhanced barrier precautions. Signage outside the room did not indicate the need for these precautions for the resident, and staff interviews confirmed the oversight in both PPE use and updating of precaution signage.
A resident experienced low pulse rates and poor oral intake over several days, but nursing staff did not complete follow-up assessments, notify the physician, or document interventions as required by facility policy. The DON confirmed that abnormal vital signs and poor meal intake were not consistently treated as significant changes of condition, resulting in a lack of timely clinical response.
Two residents who used bilateral grab rails had their bed rail entrapment assessments inaccurately completed, with all seven zones marked as 'pass' instead of correctly identifying which zones were applicable. The maintenance supervisor used incorrect measurement methods, and both the DON and maintenance supervisor confirmed the assessments were not done according to policy or FDA guidance.
A resident with limited English proficiency, who primarily spoke Cantonese and Vietnamese, was not provided with effective communication accommodations. Despite facility policies, staff did not provide a communication board in the resident's room or utilize interpreter services, resulting in the resident relying on family members to communicate needs. Staff were unable to demonstrate knowledge or use of translation resources, and the absence of these accommodations had the potential to impact the resident's psychosocial well-being and delay care.
A resident admitted with a physician's order for apixaban to treat atrial fibrillation did not have a care plan developed to address the use of this anticoagulant medication. Multiple staff, including an RN, LVN, MRD, and MDS Coordinator, confirmed the absence of a care plan, despite facility policy requiring comprehensive, person-centered care plans for each resident. The lack of a care plan was verified through medical record review and staff interviews.
A resident with hypertension and congestive heart failure, who was cognitively intact, exhibited a sudden change in behavior by refusing care, screaming, laughing inappropriately, and kicking a staff member. Despite staff involvement and facility policy requiring physician notification for such changes, the physician was not informed of the incident.
A cracked floor in a hallway, observed by surveyors and reported as unsafe by several residents and staff, was not repaired or marked with warning signs. Residents with mobility impairments and fall risks were seen traversing the area, and facility records showed no maintenance reports or actions taken, despite the facility's policy requiring safe and well-maintained flooring.
Two residents did not receive their prescribed medications on time, and staff failed to notify the physician prior to administering the late doses. In both cases, medications scheduled for the morning were given several hours late without prior physician input, and documentation of physician notification or assessment for adverse effects was lacking. Nursing staff and the DON confirmed that the required process for physician notification was not followed.
A nurse failed to sign the treatment administration record for a resident's wound care and pleural catheter treatments, leaving uncertainty about whether care was provided. In a separate case, a nurse documented that a resident's morning medications were given before actual administration, which occurred later in the day after the resident initially refused. These actions resulted in incomplete and inaccurate medication and treatment records, as confirmed by staff interviews and policy review.
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to wear the appropriate personal protective equipment (PPE) while providing high-contact care to a resident with an indwelling medical device. The facility's policy required staff to don both gown and gloves during high-contact care activities for residents with indwelling devices, such as central lines, to prevent the transmission of multidrug-resistant organisms (MDROs). During an observation, the CNA was seen wearing only gloves while assisting the resident with morning care and transferring them to a wheelchair, despite the resident having a physician's order for enhanced barrier precautions (EBP) due to a central line for dialysis access. The signage outside the resident's room indicated that only the roommate was on EBP, and did not reflect that the observed resident also required these precautions. The registered nurse (RN) confirmed that the signage should have included the resident, as per the physician's order, and stated that the Director of Staff Development (DSD) was responsible for updating such signage. The infection prevention (IP) nurse also confirmed that staff must wear both gown and gloves for residents with EBP orders and that she was responsible for ensuring proper signage and PPE availability. Interviews with facility staff, including the CNA, RN, IP nurse, and Director of Nursing (DON), confirmed awareness of the EBP requirements and the importance of following them to prevent infection transmission. However, the failure to update signage and ensure staff compliance with PPE protocols resulted in a lapse in infection control practices for the resident with a central line. This deficiency was identified through observation, interviews, and review of facility policies and the resident's medical record.
Failure to Assess, Notify, and Document Changes in Resident Condition
Penalty
Summary
The facility failed to provide necessary care and services to ensure the highest practicable well-being for a resident, as required by professional standards and the facility's own policies. Specifically, the facility did not complete follow-up assessments, notify the physician, or document actions taken when the resident exhibited a low pulse rate and poor oral intake. The resident's medical records showed multiple instances of bradycardia, with pulse rates below 60 bpm, and there was no evidence that these abnormal findings were followed up with appropriate clinical interventions or physician notification, as outlined in the facility's policy for changes in a resident's condition. Additionally, the resident experienced a significant decline in meal intake over several days, with documented refusals and consumption of less than 25% of meals on multiple occasions. Despite this, there was no documentation of follow-up assessments, physician notification, or care plan adjustments in response to the resident's poor nutritional intake. Interviews with nursing staff confirmed that these changes were observed and reported to charge nurses, but the required documentation and clinical follow-up were not completed. The Director of Nursing (DON) indicated that abnormal vital signs alone were not considered a significant change of condition and did not expect licensed nurses to document follow-up entries after providing interventions. The DON also stated that a significant change of condition related to meal intake would only be recognized after three to four days of consecutive low intake with refusal. These practices were inconsistent with the facility's policy and contributed to the failure to ensure timely and appropriate care for the resident.
Inaccurate Bed Rail Entrapment Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed rails were accurately and completely performed for two residents who used bilateral grab rails. According to the FDA's guidance, there are seven zones in a bed system where entrapment can occur, and the facility's policy requires regular inspection and assessment of these zones to identify potential risks. However, the entrapment assessments for both residents were incorrectly completed, with some zones marked as 'pass' when they should have been marked as 'not applicable' based on the type of bed rails in use. For one resident, who had moderate cognitive impairment and used bilateral grab rails for mobility and transfers, the assessment marked all seven zones as 'pass' even though only certain zones were relevant for the type of rails installed. Similarly, for another resident who was cognitively intact and also used bilateral grab rails, the assessment again marked all zones as 'pass' instead of correctly identifying which zones applied. The maintenance supervisor, responsible for these assessments, was found to have used an incorrect method for measuring one of the zones and confirmed that the assessments were inaccurate. Observations and interviews with staff, including the Director of Nursing and the maintenance supervisor, verified that the entrapment assessments were not completed according to the facility's policy or the FDA guidance. The inaccurate assessments had the potential to negatively impact residents by failing to properly identify and mitigate entrapment risks associated with the use of bed rails.
Failure to Provide Communication Accommodations for LEP Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident with limited English proficiency (LEP) who primarily spoke Cantonese and Vietnamese. Despite facility policies requiring language assessments, notification of language access coordinators, and provision of communication aids such as interpreters and communication boards, the resident was not provided with effective means to communicate daily needs. Observations and interviews revealed that the resident could not effectively communicate with staff due to the absence of staff who spoke her language, lack of a communication board in her room, and no use of telephone translation services by staff. The resident's medical records indicated she was alert, oriented, and had moderate cognitive impairment, with a stated preference for communication in Cantonese and a need for an interpreter. During interviews, the resident reported having to wait for family members to communicate her needs, as staff did not use available translation resources. Staff members, including an LVN and CNA, were unable to locate a communication board in the resident's room and demonstrated a lack of knowledge regarding the use of language line services. The Director of Staff Development also failed to show that communication aids were available for the resident. Family members expressed concern about the resident's ability to have her needs met, especially during times when family was not present. They confirmed that staff had not used communication boards or translation services during the resident's stay. The facility's failure to provide these accommodations had the potential to negatively impact the resident's psychosocial well-being and could result in delayed provision of care, as the resident's needs may not have been effectively communicated or addressed.
Failure to Develop Care Plan for Anticoagulant Medication
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident who was prescribed an anticoagulant medication, apixaban, for atrial fibrillation. The resident was admitted with a physician's order for apixaban, and the medical record confirmed the resident had the capacity to understand and make decisions. Despite this, a review of the resident's medical record did not show any care plan addressing the use of the anticoagulant medication. Interviews with facility staff, including an RN, LVN, the Medical Records Director (MRD), the MDS Coordinator, and the Director of Nursing (DON), confirmed that no care plan was developed for the anticoagulant medication. The RN verified the existence of the physician's order but stated she was not responsible for developing care plans for anticoagulant use upon admission. The LVN emphasized the importance of having a care plan for anticoagulant medications to outline goals and interventions such as monitoring for side effects and reassessment of outcomes. Further interviews revealed that the MRD was responsible for auditing new admission charts for medication entries and baseline assessments, but the ADON and MDS Coordinator were responsible for reviewing and initiating care plans for medications. The MDS Coordinator confirmed that a care plan for anticoagulant use should have been initiated as soon as possible and acknowledged its absence in the resident's record. The DON was informed and acknowledged the findings.
Failure to Notify Physician of Resident's Sudden Behavioral Change
Penalty
Summary
The facility failed to notify the attending physician of a sudden and marked change in a patient's behavior, as required by regulation. Patient 4, who had diagnoses of hypertension and congestive heart failure and was cognitively intact, refused a shower and began screaming when staff attempted to change her soiled incontinence briefs. The situation escalated to the point where the patient was yelling, laughing inappropriately, and ultimately kicked a staff member. Multiple staff, including the Administrator and Director of Social Services, were present and attempted to address the situation, but the physician was not notified of this significant behavioral change. Interviews with staff, including the CNA, Administrator, Director of Staff Development, LVN, and Director of Nursing, confirmed that the physician should have been informed of the change in the patient's condition. The facility's own policy also required prompt notification of the physician and resident representative in the event of a change in the resident's medical or mental condition. The failure to report this incident represented a lapse in following both regulatory and facility policy requirements.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/7/2025, the RN supervisor assessed Patient 4 for any signs of adverse outcome regarding refusals to showers/bed bath. Upon explanation and discussing the importance of showers, Patient 4 was still not convinced to allow the CNA to continue with the hygienic and care procedure. CNA was relieved from her care and another CNA was assigned immediately with no further issues. Change of Condition was initiated and completed by the Charge Nurse to reflect Patient 4's behavior. MD and responsible party (RP) were made aware of patient 4's refusals. Patient 4's care plan was updated by the MDS nurse to signify her behavior change. Patient 4 will be monitored for 72-hours for any other changes. On 10/7/2025, the Director of Nursing Services (DON) and Director of Staff Development (DSD) completed an in-service to nursing staff on how to handle patient refusals of showers and notification requirements and processes for changes of condition. A policy and procedure titled, "CHANGE of CONDITION," was reviewed and discussed followed by question-and-answer evaluation. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, DSD interviewed all CNAs on shift to identify additional patients with episodes of care needs refusals, included them on a "Special Care Needs" list to ensure proper monitoring and appropriate interventions as individualized as possible. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025, DON held an in-service with all licensed nurses on P/P: Change of Condition, with an emphasis on MD/RP notification. On 10/29/2025, two additional systematic changes were implemented: 1. "Resident Special Care Needs" worksheet was modified to include patients with episodes of refusals of care needs. The list will be generally updated weekly and as changes occur by the Desk Nurse, to be shared on both nursing units. 2. "Huddle" every shift to review patients with special needs such as giving detailed attention to the patients who would tend to refuse care. Discussed with the team huddle the importance of reporting any incident of refusals to immediately implement interventions as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Weekly audits on refusals based on Change of Condition reports will be reviewed by the DON/Designee. The DON/Designee will present any findings to the QAPI/QAA Committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Failure to Repair Cracked Floor Creates Safety Hazard
Penalty
Summary
The facility failed to maintain the flooring in a safe and good repair, as evidenced by the presence of a cracked floor in the hallway from the entrance to nurse station 1, in front of the rehab service room and patio. Multiple residents, including those with mobility impairments and fall risks, were observed traversing this area. The cracked floor was directly observed by surveyors, and residents as well as staff acknowledged its unsafe condition, noting the potential for falls. Resident records reviewed showed that affected individuals had significant medical histories, including diabetes, COPD, osteoarthritis, cerebral infarction, hypertension, paraplegia, and rheumatoid arthritis. These residents required varying levels of assistance with mobility and activities of daily living, and their care plans specifically called for a safe, clutter-free environment to prevent falls. Despite these documented needs, the cracked floor remained unaddressed. Interviews with residents, a Licensed Vocational Nurse, the Maintenance Director, and the administrator confirmed that the cracked floor had not been reported or repaired. The Maintenance Log contained no entries regarding the issue, and no warning signs had been placed to alert residents or staff. The facility's own maintenance policy required regular upkeep of flooring to prevent injuries, but this was not followed in this instance.
Plan Of Correction
General Maintenance How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 10/09/25, the Maintenance Supervisor (MS) repaired the crack on the hallway floor near Station 1 and the Rehabilitation Room to eliminate any potential safety hazard for residents. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 10/21/25, the Safety Committee conducted a comprehensive walk through of the facility to identify any additional cracks or floor hazards throughout all resident and common areas. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/21/25 and 10/22/25, the Director of Staff Development (DSD) and Maintenance Supervisor (MS) provided in-service training to all staff regarding the use and importance of the Maintenance Log for timely reporting and follow-up on facility repairs. - Beginning 10/22/25, the Maintenance Supervisor will conduct floor inspections 2-3 times per week for three months to monitor for cracks or hazards and ensure prompt corrective action is taken as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Maintenance Supervisor (MS) will be reporting the results of the monitoring to the QA committee and safety committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Notify Physician of Late Medication Administration
Penalty
Summary
The facility failed to notify the attending physician when medications were not administered on a timely basis as prescribed for two patients. For one patient, who had diagnoses including muscle weakness, GERD, depression, and cerebral infarction, multiple scheduled morning medications were not administered at the prescribed time. The medications, which included pregabalin, duloxetine, famotidine, fenofibrate, and several supplements, were given three and a half hours late without prior notification to the physician. The patient confirmed not receiving the medications on time, and the nurse acknowledged that the physician was not notified of the missed doses or the late administration. The subsequent dose was administered only a few hours after the late dose, again without physician input, and there was no documentation of assessment for adverse reactions due to the close timing of doses. For the second patient, who had paraplegia and was cognitively intact, the morning medications were not administered at the scheduled time due to the patient's refusal, except for pain medication. The nurse waited for the patient to request the medications and eventually administered them several hours late. The physician was only notified about the late administration after the survey team inquired, and not before the medications were given. The nurse stated that the physician should be notified in such situations to avoid potential double dosing, especially for medications scheduled twice daily. The facility's policy required contacting the physician if a dose was believed to be inappropriate or excessive, but this was not followed prior to the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not have a specific policy for late medication administration, but acknowledged the importance of notifying the physician before giving late doses. The staff recognized that failing to notify the physician and document instructions could lead to inappropriate medication timing and potential adverse effects. The deficiency was identified through interviews, record reviews, and direct observation, showing a lack of timely physician notification and documentation when medications were not administered as ordered.
Plan Of Correction
C 0875 - NURSING SERVICE - GENERAL Medication Administration IMMEDIATE CORRECTIVE ACTION: 1. The RN supervisor assessed Patient 10 on any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP =124/74, P = 76, R = 19, O2 Sat = 96% and Pain level = 2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. 2. The RN supervisor assessed Patient 5 for any abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96% & Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. 3. A one-on-one in-service was initiated and completed with LVN 2 and LVN 4 respectively to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. Discussed also the potential of unwanted effects from medications being administered too close of the time of the next ordered dose to be given. Reiterated in the discussion on the importance for the patients' MD be notified of circumstances that may lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. An in-service was done by the DON on 10/28/2025 on all nursing staff on how to handle patients with medications that are delayed in administration. A policy and procedure titled, "Medication Administration" was reviewed and discussed. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: All alert/oriented patients are with the potential to have set ways of taking their medications, these identified patients must be properly assessed by the RN supervisor as to the need of time adjustments on their medications to be administered. Patients with special requests or needs must be communicated to their respective MDs for proper orders to ensure ultimate safety, health and well-being of identified patients. The Medical Records Department will continue to do daily audits on both eMARs and eTARs to ensure proper charting and documentation as required. Any deviations must be reported to the DON/Designee for immediate resolutions/corrections. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: The facility had implemented a Weekly Medication Pass Audit by the DON, ADON and DSD to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations must be corrected immediately, and continued mentoring with performance improvement must be done with the specific charge nurses. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report and discuss with the QAPI/QAA committee the outcomes of Weekly Medication Administration audits including issues observed during medication pass and immediate actions done to prevent deficient practice from occurring. This will be reviewed for 3 months. E) COMPLETION DATE: 10/31/2025
Failure to Document and Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure proper documentation and administration of medications and treatments for two patients, resulting in deficiencies related to medication and treatment records. For one patient with chronic respiratory failure, asthma, and pleural effusion, the treatment nurse did not sign the electronic Treatment Administration Record (eTAR) for three ordered treatments on a specific date. The treatments included care for a right thigh scab, a right Pleur X catheter, and a post-surgical spine site. The eTAR was left blank for these treatments, while other dates were properly signed, indicating a lapse in documentation and uncertainty about whether the treatments were administered as ordered. In another instance, a cognitively intact patient with paraplegia and multiple medication orders did not receive their scheduled morning medications at the prescribed time due to refusal. The nurse documented the medications as given before actually administering them, which did not occur until later in the afternoon. This premature documentation could have led to confusion for the oncoming shift and the risk of medications being administered too close together. The nurse acknowledged documenting before administration and recognized the potential for confusion and medication errors. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require that medications and treatments be documented immediately after administration. The facility's policies also emphasize the importance of accurate and timely documentation to ensure continuity of care and adherence to physician orders. The failure to follow these procedures resulted in incomplete records and the potential for missed or improperly timed treatments and medications.
Plan Of Correction
Completed patient 2's treatment on 10/04/2025, immediately completed late entry documentation. On 10/07/2025, the RN supervisor immediately assessed Patient 5 for any change of condition or abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96%, and Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. MD was notified. On 10/7/2025, the DON initiated and completed a one-on-one in-service with LVN 4 to discuss the policy and procedure (P/P) on charting and documentation and timely medication administration. The emphasis was on signing eTAR immediately upon completion of treatment. DON also discussed the potential of unwanted effects from medications being administered too close to the time of the next ordered dose to be given. DON reiterated the importance of notifying the patient's MD of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring period would be done to ensure patient safety, followed by accurate timely documentation. **B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE:** 1. On 10/7/2025, upon identification of deficient practice, DON, ADON, and Treatment Nurse immediately reviewed all eTARS for the last 30 days to ensure that no additional gaps in documentation were identified. No additional residents were affected by the deficient practice. 2. On 10/7/2025, DON, ADON, and RN Supervisor immediately interviewed all the licensed nurses on shift to identify any other delayed medication administration. No further residents were identified to be affected by the deficient practice. 3. The Medical Records Department will continue to do daily treatment audits to ensure that any potential deficient practice does not occur by notifying the DON/Designee immediately. Further, the DON has in-services scheduled for licensed nurses for continuous education and training. **C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR:** 1. On 10/28/2025, DON completed an in-service for all nursing staff on "Charting and Documentation" policies and procedures. The discussion was followed by a question-and-answer evaluation. On 10/30/2025, the facility implemented a weekly eTAR audit to be completed by the Medical Records Department to ensure accuracy and completion of treatment documentation. Audit findings will be provided to DON and/or Designee. 2. On 10/30/2025, the facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. **D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED:** The DON/Designee will report weekly findings for eTAR audits and medication pass audits to the QAPI/QAA committee monthly for three months for recommendations. **E) COMPLETION DATE:** 10/31/2025
Some of the Latest Corrective Actions taken by Facilities in California
- Provided facility-wide in-service training on medication-administration policies, emphasizing verification of resident and drug information, parameter-based holds, and physician notification (K - F0760 - CA)
- Delivered targeted one-on-one coaching to identified nurses on Epogen administration according to laboratory parameters (K - F0760 - CA)
- Created a dedicated Epogen injection log and instituted weekly audits of orders, MARs, and laboratory values to confirm parameter compliance (K - F0760 - CA)
- Launched a QAPI initiative to monitor Epogen practices and adjust measures for ongoing state and federal compliance (K - F0760 - CA)
- Conducted in-service education for all licensed staff on reconciling GACH discharge orders, resolving discrepancies, and monitoring anticoagulant side-effects (J - F0684 - CA)
- Assigned RN Supervisor to review clinical-alerts reports daily for continuity-of-care issues and bleeding indicators (J - F0684 - CA)
- Required DON/ADON or RN Supervisor to perform medication reconciliation against GACH discharge orders for every new admission (J - F0684 - CA)
- Implemented a QAPI Performance Improvement Project with daily audits of discharge-order compliance, anticoagulant use, and adverse-effect monitoring (J - F0684 - CA)
- Engaged Quality & Safety consultant to audit medication reconciliation and anticoagulant monitoring for newly admitted residents (J - F0684 - CA)
- Mandated monthly submission of audit results to the QAA committee for oversight until sustained compliance is achieved (J - F0684 - CA)
Significant Medication Errors: Epogen Administered Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that two residents were not administered Epoetin Alfa-epbx (Epogen) injections outside of the parameters specified in their physician orders. Both residents had orders to hold Epogen injections if their hemoglobin (Hgb) levels exceeded 10 g/dl. Despite these clear instructions, staff administered multiple doses of Epogen to both residents when their Hgb levels were above the prescribed threshold. One resident, with a history of end stage renal disease, dependence on dialysis, and anemia, received 19 unnecessary doses of Epogen over a period when their Hgb level was documented at 11.5 g/dl. The medication administration records and interviews with licensed vocational nurses revealed that the nurses did not check the most recent Hgb levels or review the physician's order before administering the medication. The nurses acknowledged that they failed to follow the order to hold the medication and recognized this as a medication error. Another resident, with a history of kidney transplant and anemia, received three unnecessary doses of Epogen when their Hgb levels were 12.3 g/dl and 12.9 g/dl. The nurse responsible admitted to not checking the latest Hgb level or reading the physician's order accurately before administration. The Director of Nursing confirmed that the facility did not follow the physician's orders and that licensed nurses were required to check current Hgb levels before administering Epogen. Facility policy required medications to be administered as prescribed, including adherence to any parameters set by the physician.
Removal Plan
- Notify the pharmacist regarding Resident 35 receiving extra doses of Epogen injections.
- Communicate with the Nephrologist to have the dialysis center administer Epogen injections based on lab work during dialysis treatments.
- Follow up with Resident 35's Primary Physician to clarify the order for Epogen to be given at the dialysis center.
- Assess Resident 35 for overall health condition and status.
- Notify Resident 89's Primary Physician regarding Resident 89 receiving extra doses of Epogen injections when Hgb was above the prescribed parameter.
- Continue the Epogen order for Resident 89 with the same parameter (hold Epogen injections when Hgb > 10 mg/dl), pending a complete blood count result.
- Notify the pharmacist regarding Resident 89 receiving Epogen injections when Hgb was above the prescribed parameter.
- Assess Resident 89 for overall health condition and status.
- Notify the Medical Director of the Immediate Jeopardy and develop a removal plan.
- Notify all licensed nurses of the Immediate Jeopardy findings and provide in-services regarding the Medication Administration policy and procedure, including checking/verifying resident and medication information, holding/discontinuing medication per parameters, and notifying physicians of medication-related issues.
- Notify the specific RN and LVNs responsible for the identified findings and provide one-on-one in-services regarding medication administration policy, focusing on Epogen injection administration based on parameters, following disciplinary action.
- Complete in-services regarding medication administration policy and procedure for all licensed nurses.
- Initiate a Quality Assurance and Performance Improvement (QAPI) plan to address the findings.
- Review all current residents with Epogen injection orders.
- Provide in-service regarding medication administration policy and procedure for all licensed nurses.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed to ensure compliance.
- Create an Epogen injection administration log including resident name, Epogen injection order, medication administration following parameter, and laboratory monitoring.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed, and document findings with corrective action on the monitoring log.
- Review the QAPI program and adjust measures to ensure effective and ongoing compliance with State and Federal regulations.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of nontraumatic intracerebral hemorrhage in the brain stem, severe cognitive impairment, and at risk for elopement was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident had previously been assessed as low risk for elopement, but on the day of the incident, was observed by a CNA packing belongings and expressing a desire to leave. Despite this, the resident was not immediately reassessed for elopement risk, and no detailed monitoring plan or interventions were implemented in accordance with the facility's elopement policy. Staff, including the DON and Social Services Assistant, were made aware of the resident's intent to leave and were instructed to monitor the resident and ensure the facility doors were supervised. However, the doors were not continuously monitored, as the receptionist responsible for this task was not present and no other staff were specifically assigned to this duty. As a result, the resident was able to exit the facility undetected, travel to a previous residence, and remain away from the facility for over six hours before being returned by an unidentified individual. Interviews and record reviews confirmed that staff failed to follow the facility's policy and procedure for elopement prevention, including reassessment of risk and implementation of appropriate interventions when a resident demonstrates behaviors such as packing belongings and verbalizing a desire to leave. The lack of immediate supervision and failure to monitor facility exits directly led to the resident's elopement.
Removal Plan
- Resident agreed to be transferred to the acute care hospital for further evaluation. The attending physician issued the order for transfer.
- Resident will remain on 1 to 1 (1:1) supervision for safety until transportation arrives for pickup. An order was obtained by the physician, and a log was used by the staff to document.
- The facility will implement 24-hour monitoring of the doors to strive and prevent harm to all our patients.
- Resident refused to be transferred to the General Acute Care Hospital (GACH) when transport arrived.
- Received orders from physician to apply a wander guard to Resident.
- Obtained informed consent from Resident's Responsible Party (RP).
- Resident continued to refuse the wander guard despite several attempts and education on safety. Physician and Resident's RP made aware.
- Resident will remain on 1:1 monitoring with a log for staff to document to ensure safety and continuous 24-hour monitoring of doors to prevent another incident reoccurring.
- Resident's elopement assessment was updated to reflect Resident being at high risk for elopement.
- Situation, Background, Assessment Recommendation (SBAR) documentation initiated for Resident and 72-hour SBAR documentation initiated.
- Resident's care plan was updated with interventions implemented to prevent a repeat event.
- Resident spoke with a psychiatrist via resident's telephone for evaluation for psychological support and emotional distress. The psychiatrist ordered a follow-up with social services for discharge. Resident was placed on psychological monitoring.
- Resident will be seen by a psychologist for evaluation for psychosocial distress related to the recent event of elopement.
- All residents have had an elopement risk evaluation assessment. All residents will be assessed upon admission, quarterly and in the event of a significant change with care plans updated.
- Residents who are at high risk for elopement will be added to the quarterly Quality Assurance and Performance Improvement (QAPI) committee to identify other residents who have the potential to be affected.
- Care plans will be updated for all residents who are at low, moderate or high risk for elopement and will include strategies and interventions to maintain the residents' safety.
- The facility has identified only one resident at high risk for elopement which is Resident.
- The facility will put a system in place for residents who are identified as low to moderate elopement risk for frequent visual monitoring.
- The facility has put into place 24-hour door monitoring to ensure the deficient practice does not reoccur.
- The Director of Nursing (DON) and Director of Staff Development (DSD) in-serviced staff members concerning the facility's policy to preserve and maintain resident safety by instituting measures to monitor and prevent resident from opportunities of wandering and eloping away from facility. DSD will in-service all licensed staff and before working assigned shift, staff will be in-serviced. As new hires come in, they will be educated and in-serviced on the elopement policy as well.
- The facility will place an elopement binder at each nursing station identifying which residents are at low, moderate, and high risk for elopement. Included in the binder will be policy and procedures related to elopement, face sheets with clear picture identifiers of residents at risk and protocols for the event of an elopement.
- The facility will implement a system that when an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner, get help from staff immediately in the vicinity, instruct the charge nurse and or DON that the resident is attempting to leave or has left the premises.
- The facility will implement a system that when a resident is missing, the facility will initiate the elopement/missing resident emergency procedure, initiate a search of the building and premises and notify the Administrator (ADM), the DON, the resident's responsible party, physician, law enforcement, ombudsman, and CDPH.
- The facility will implement a system for when the resident who eloped is found, the DON and or charge nurse will examine the resident for injuries, contact the physician, report findings and conditions of the resident, notify the resident's responsible party, notify local law enforcement that the resident has been located, and initiate 72-hour SBAR documentation.
Failure to Verify Discharge Orders and Monitor Anticoagulant Use Leads to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and services in accordance with professional standards of practice for a resident who had recently undergone lumbar decompression and fusion surgery. The facility did not ensure that the admitting RN reviewed and verified the hospital discharge records with the attending physician, specifically regarding the start date for Plavix, an antiplatelet medication. The hospital discharge orders clearly indicated that Plavix was to be started nine days after admission, but the facility's licensed nurses began administering the medication immediately upon admission, based on an incomplete faxed medication list that lacked start dates. The facility also failed to provide continuity of care by not following the neurosurgeon's specific order to delay the initiation of Plavix. The medication was administered for four days prior to the intended start date, and there was no evidence that the nurses clarified the discrepancy with the attending physician. Additionally, the facility did not assess, monitor, or document the resident for signs and symptoms of bleeding, hematoma, or hemorrhage, despite the resident's recent spinal surgery and use of an antiplatelet medication, both of which increased the risk for such complications. As a result of these failures, the resident experienced a change of condition, becoming unresponsive and requiring emergency transfer to a hospital, where imaging revealed multiple intracranial hemorrhages. The resident subsequently died, with the immediate cause of death listed as nontraumatic intracranial hemorrhage. Interviews with facility staff and physicians confirmed that the medication was given earlier than ordered and that appropriate monitoring and verification of orders did not occur.
Removal Plan
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding reviewing and verifying any discrepancies with the ordering physician by clarifying the faxed medication discharge order and the GACH discharge papers that were given to the resident. In addition, clarify medication orders that are missing the start and end dates.
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding monitoring the resident status post-surgery and the use of anticoagulant therapy for potential side effects such as signs/symptoms of bleeding.
- The DON and designee provided in-service to the licensed nurses regarding: Review and verify GACH discharge orders with facility's attending physician. Status post-surgery residents with anticoagulant use and signs/symptoms of bleeding. Following GACH discharge orders. Any licensed staff, who were not present, the DON will do in-service education upon returning to work.
- Residents on anticoagulants were assessed for any signs/symptoms of bleeding, potential side effects of anticoagulant use and black box warning monitoring.
- The Registered Nurse (RN) Supervisor will check clinical alerts report daily for any COC and any signs/symptoms of bleeding.
- DON, ADON or RN Supervisor/designee will conduct medication reconciliation with the residents GACH discharge orders and admitting orders carried out by licensed nurse.
- Newly admitted residents will have random audits following GACH discharge orders and completion of medication reconciliation. Three residents weekly for four weeks, then two residents weekly for two weeks, then two residents a month for two months. Inservice would be given to licensed nurses involved. Findings will be presented in the monthly QAA meeting.
- DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) for the following: Review and verify GACH discharge orders with attending physician. Use of anticoagulant and its side effects. Following GACH discharge orders. PIP resulted in DON/ADON doing daily audits in reviewing compliance for following GACH discharge orders, continuity of care, use of anticoagulant and identification of potential adverse side effect of the medication.
- The Quality and Safety (QS) RN/Consultant will complete audits on medication reconciliation, the use of anticoagulants, and its side effects for newly admitted residents.
- ADM, DON or Designee will submit audit findings to QAA committee monthly until compliance is met.
- The facility will develop a QAPI-PIP for the use of anticoagulant to be submitted in the next QAA committee meeting.
- ADM and DON are responsible for implementing, monitoring and evaluating the Plan of Correction (POC).
Failure to Provide Treatment and Monitoring for Resident with Mental Health Crisis
Penalty
Summary
A resident with diagnoses of depression, anxiety, and borderline personality disorder was identified as being a danger to self and others (DTSO) after verbalizing intentions to harm self and others. Despite a physician's order for transfer to a general acute care hospital (GACH) and recommendations for psychiatric and psychological consultations, the resident refused these interventions. The facility failed to implement 1:1 sitter observation, did not monitor or document the resident's behavior after being identified as DTSO, and did not develop or implement a care plan to address the resident's refusal of transfer or psychiatric consultation. There was no evidence in the medical record that the facility monitored the resident's behavior or provided additional interventions after the resident refused psychiatric consultation. Staff interviews confirmed that no hourly monitoring, documentation, or care planning was initiated following the resident's refusal of transfer and ongoing verbalizations of self-harm or harm to others. The interdisciplinary care team did not meet to address the situation, and there was no documentation of behavioral observations or safety interventions in the resident's chart during the period of risk. As a result of these failures, the resident was later found unresponsive in their room with opened prescription medication containers not dispensed by the facility. The resident was transferred to the hospital via emergency services, where toxicology confirmed an intentional overdose of tricyclic antidepressants. The resident required intubation and admission to the intensive care unit. The facility's lack of assessment, supervision, monitoring, and care planning for a resident identified as DTSO directly preceded this critical incident.
Removal Plan
- The charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist.
- If a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior, and refused to be transferred to the hospital licensed nurse will immediately notify MD.
- The Director of Social Services completed a Psychosocial Assessment of identified residents who has a diagnosis of depression, reviewed and updated Care Plan as necessary.
- Licensed staff were instructed to document behavioral observations in the monitoring log such as DTSO every hour and notify the nurse or RN supervisor and/or designee.
- The Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis.
- The Director of Social Services completed a psychosocial assessment of all residents with a diagnosis of depression to identify residents who may be DTSO and no other residents were identified at risk of harming themselves or others.
- Situation, Background, Assessment, and Recommendation (SBAR) / Change in Condition (COC) was implemented, and in-service was conducted by Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental condition and/or status.
- 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations.
- The care plan was reviewed and updated for identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer for resident's safety.
- The Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety.
- Crisis Intervention Plan included: Provide safe and clean environment; Visual check and document monitoring of resident behavior every hour for resident safety; Administer medication as ordered; Diet as ordered; Encourage to verbalize feelings; Always approach in calm and friendly manner and unhurriedly; To ensure all needs are met; Provide emotional support; Maintain comfort and dignity; To call doctor of medicine (M.D) for any noted change of condition.
- Social Services will re-evaluate and update initial psychosocial assessment of the resident when a resident refused for psychiatric consult and licensed nurse will inform MD.
- Social services will make daily visits to re-engage the resident and residents who are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in the progress notes and provide resident's education on the importance of psychiatric evaluation.
- Behavioral and Crisis intervention care plan will be implemented to reflect ongoing risk for harm to self and others. Interventions included: PRN and scheduled psychiatric medication management; Behavior tracking and psychiatric consultation follow-up; Staff re-education on management of residents with psychosocial adjustment difficulties; Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques.
- The ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition.
- Licensed staff in-services will continue until compliance is met.
- All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant regarding the existing policies and procedures: Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others; Requesting, Refusing and/or Discontinuing Care or Treatment; Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy.
- The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x 4 weeks, then monthly x 3 months.
- All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician.
- Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Secure Rehab Equipment Leads to Resident-to-Resident Assaults
Penalty
Summary
The facility failed to ensure that the rehabilitation (Rehab) room and its equipment were secured and supervised at all times, resulting in unauthorized access by residents. Specifically, a resident with a history of anxiety disorder, cognitive decline following a stroke, and intact cognition according to the Minimum Data Set (MDS), was able to enter the Rehab room without staff knowledge and obtain a dowel, a piece of equipment used for physical therapy. The Rehab room door was routinely closed but not locked when staff were not present, and weighted dowels and free weights were left unsecured and accessible on the wall. This lack of supervision and security allowed the resident to use the dowel to physically assault two other residents on separate occasions. In one incident, a resident was struck on the left arm, and in another, a resident was hit on the right arm, right shoulder, and face, then pushed to the floor, resulting in a non-displaced fracture of the mid sacrum. Staff interviews and progress notes confirmed that the dowel used in the assaults was taken from the Rehab room, and that staff were unaware of the resident's access to the equipment until after the incidents occurred. Observations conducted nearly three weeks after the second incident revealed that the Rehab room equipment remained unsecured. The facility's policy required individualized safety assessments and targeted interventions to reduce accident hazards, including appropriate supervision based on residents' needs and environmental risks. However, the interdisciplinary care team did not identify or address the risk of residents accessing Rehab equipment unsupervised, nor did they implement interventions to prevent such access. The failure to secure the Rehab room and its equipment, combined with insufficient supervision and lack of timely care plan updates, directly led to the incidents of resident-to-resident physical aggression and injury.
Removal Plan
- Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation completed and submitted. Resident 1 and Resident 3 were immediately separated from each other.
- Resident 3 was transferred to another room in a different wing with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital for assessment and returned the same day. Resident 3's care plan was updated to include a resident-to-resident altercation.
- Resident 1's care plan for behaviors was reviewed and updated to include physical aggressive behavior. Resident 1 was referred to a psychiatric mental health Nurse Practitioner but refused. The IDT met with Resident 1 and her family to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent to GACH for in-patient psychiatric evaluation and returned with a UTI diagnosis and antibiotics. Resident 1's care plan and IDT note was updated to address Resident 1's use of a dowel during the episode of aggressive behavior.
- A tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process.
- The Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created to document and verify daily compliance with this security measure.
- The Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside.
- The IDT was in-serviced by the Senior Nurse Executive to review how to conduct an IDT meeting when reviewing resident to resident incidents.
- An ad hoc QAPI Committee meeting was scheduled to conduct a root cause analysis to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions.
- The Executive Director will oversee corrective actions initiated and monthly thereafter during QAPI meetings, based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits and safety equipment monitoring of rehab equipment random audits, will be reviewed and revised with the QAPI Committee.
- Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
- Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse will perform specific roles in monitoring, oversight, education, compliance, and corrective action implementation.
- All residents were identified as potentially affected by the deficient practice.
- The Interdisciplinary Team (IDT) in-service by the Senior Nurse Executive to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents.
- A log was created to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. The Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- The Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- Inservice training for staff license nurses was started on updating comprehensive care plans for residents that have been identified with physical aggression. The facility will continue training until all staff nurses have attended.
- Inservice training for IDT was started on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. Training will continue until all IDT members have attended.
- Inservice training for rehab staff was started on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on how to track and sign equipment in and out, noting its location and assigned user. Training will continue until all Rehab staff have attended.
Failure to Notify Physician of Change in Condition Results in Resident Death
Penalty
Summary
The facility failed to promptly notify a resident's physician of significant changes in the resident's condition, despite clear symptoms and facility policies requiring such notification. The resident, who had a history of constipation and was at risk due to medication use and decreased mobility, experienced abdominal distension, firmness, and pain, and had not had a bowel movement for two days. Although the nursing staff assessed the resident and noted these symptoms, they did not communicate the full extent of the findings—including abdominal distension, firmness, and pain—to the physician. Instead, only the complaint of constipation was relayed, and the physician ordered magnesium citrate. After administration of magnesium citrate, the resident's symptoms did not improve. The resident continued to experience abdominal distension, firmness, and developed shortness of breath requiring increased supplemental oxygen. The resident also reported severe abdominal pain rated 8 out of 10. Despite these worsening symptoms and the lack of response to treatment, the nursing staff did not notify the physician of the resident's deteriorating condition. Instead, communication remained within the nursing team, and the physician was not informed of the new or worsening symptoms, nor was the resident transferred for higher-level care. Ultimately, the resident was found unresponsive with coffee ground emesis, was not breathing, and had no pulse. Emergency services were called, and resuscitation efforts were unsuccessful. The physician later confirmed that, had they been notified of the full clinical picture, additional interventions such as diagnostic imaging or hospital transfer would have been considered. The failure to notify the physician of the resident's change in condition was identified as a deficiency by the survey agency, as it prevented timely medical intervention and contributed to the resident's rapid decline and death.
Removal Plan
- An in-service was initiated by the DON and the Assistant DON to all licensed nursing staff (all RNs and LVNs) on contacting the physician as soon as possible for any resident's COCs specifically for residents with constipation, abdominal pain, abdominal distention, and abdominal firmness; contacting the resident's physician as soon as possible when there is a delay in medication and when a resident's symptoms do not improve or worsen during a COC; ensuring accurate, complete, and timely documentation; completing an accurate assessment of the residents' overall condition and thorough documentation.
- The DON provided an in-service to direct care staff including nursing assistants in recognizing subtle but significant changes in the resident condition and how to communicate these changes to the LNs. CNAs were re-educated and encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the residents' condition.
- The medical records team conducted an audit of change in a resident's condition or status with emphasis on timely physician notification. The audit results showed residents were identified as not having a BM for three days.
- The facility identified residents who had no BM for three days, the residents were assessed by assigned LNs and the steps stated below were followed. The audit results are reviewed by the RN Supervisor to ensure: any changes to the residents' condition are communicated to the primary physician for any recommendations and for new orders; the nursing team has documented in the residents' medical record relative to changes in the residents' medical/mental condition or status; the residents' CP is updated to reflect the residents' COCs; the licensed nursing staff documents in the residents' clinical record for the COC reported or assessed by licensed nursing staff; the RN Supervisor has validated the completion of the SBAR by LNs.
- The DON and Regional Clinical Consultant initiated Competency Skill Checks for all RNs on COCs, notification of physicians, changes/worsening conditions, specific system assessment with emphasis on bowel management, Point Click Care clinical alert and hand-off communication. Competency Skill Checks will be completed for any RN currently on medical leave or vacation before providing patient care. In-services will be continued by the DON until all licensed staff are re-educated.
- The facility has created a bowel management tool for significant COCs identifying the need to notify the physician. LNs are responsible for identifying significant COCs on bowel management: License nurses will identify Residents who have not had BMs for 72 hours, with new or worsening symptoms, and other associated abnormal changes but not limited to frequency and consistency of bowel, abdominal pain, abdominal distension, decreased peristalsis, and signs of GI bleeding; upon identification LNs will utilize the tool and document the notification of the physician; LNs will continue documenting the COCs through the SBAR in the clinical health records; LNs will obtain recommendations from the physicians and will carry the recommendations out; the tool will be completed daily during each shift by the charge nurses, the tool will be collected by medical record staff and retained for review.
- The medical records team also conducted an audit of the alert system in PCC. The PCC alert notifies the nursing team when a resident does not have BMs for 24 hours or more.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when a facility failed to ensure a safe and appropriate discharge for a resident with a complex medical and psychiatric history, including epilepsy, encephalopathy, anxiety disorder, and schizophrenia. The resident had fluctuating capacity to make medical decisions, was at risk for falls, and required assistance with ambulation, medication management, and activities of daily living. Despite these needs, the resident was discharged to an unlicensed board and care (B&C) facility that could not provide the necessary level of care, including ambulation assistance, epilepsy management, or medication administration and storage. The facility did not follow its own discharge and transfer policy and procedures, as the interdisciplinary team (IDT) did not conduct a discharge planning meeting prior to the resident's transfer. Key departments, including nursing, activities, and rehabilitation, were not notified or involved in the discharge planning process. The resident's care plan, which required coordination with rehabilitative therapies and community resources, was not implemented, and the discharge planning review form was incomplete. The facility also failed to verify the B&C's license, assess the appropriateness of the discharge location, or provide a hand-off report to the receiving facility regarding the resident's medical conditions and care needs. As a result of these failures, the resident experienced a series of adverse events after discharge, including a fall with head injury at the B&C, subsequent hospitalization, transfer between multiple facilities, and an episode of elopement that led to police intervention and further hospitalization. Interviews with facility staff and external providers confirmed that the resident's needs exceeded the capabilities of the B&C, and that critical steps in the discharge process, such as medication reconciliation, communication with the receiving facility, and post-discharge follow-up, were not performed.
Removal Plan
- The Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility's Director of Nursing (DON)/Director of Staff Development (DSD)/Designee including the new processes implementation related to identified concerns to all active license nurses and IDT members.
- The facility has 30 licensed nurses and 24 have been provided with in-service and education. Facility does not have a licensed staff on vacation, leave nor FMLA (Family and Medical Leave Act).
- The Social Services consultant worked 1:1 with the Social Services Director (SSD). The SSD completed the Discharge Planning Review form, sections 1 (Discharge Goals/ General Information) A (Discharge Goals/ General Information) & B (Caregiver Responsibilities), 2 (Self Care Evaluation and Equipment) Q (equipment and supplies), Contacts and Sign and Date of the Discharge Summary, for training purposes.
- The facility DON and Medical Records initiated an audit to residents who have been discharged to a lower level of care in the past 30 days to ensure proper discharge planning was conducted prior to discharge with resident/responsible party, an IDT meeting was conducted prior to discharge, an endorsement of the resident's medical history and medication reconciliation was provided to receiving facility. No similar issues were identified.
- For those residents who lack capacity or with fluctuating capacity, the Office of Public Representative (OPR) will be contacted by the facility's SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness.
- For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness.
- Discharge planning will begin on the residents' admission to the facility.
- The Attending Physician and the IDT will review the residents' progress and determine a possible discharge date and document in resident's health record.
- The facility Admin notified Resident 1's attending physician, by phone of the concerns related to the resident's transfer to the Board and Care, the fall sustained and readmission to the hospital.
- The facility Admin notified facility Medical Director by phone of the Immediate Jeopardy that was issued, deficient practice and plan to correct.
- The facility Admin initiated a QAPI (Quality Assurance and Performance Improvement) regarding the Transfer and Discharge of residents.
- The facility staff will assist the physician and the resident to obtain medications after discharge from the facility. When discharged, remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge if the medications were specifically ordered to be sent home with the resident.
- The Licensed Nurse will assure that the medication orders are reviewed with the resident and/ responsible party and explanation of all discharge medication orders occur at the time of discharge and documented on the resident's health record.
- The facility will ensure that the resident receives adequate follow-up including the ability to have a physician's prescription available to procure drug supply immediately after discharged from the facility and conduct a proper endorsement of resident's ordered medications and discharge instructions to the receiving facility and documented on the resident's health record.
- The facility's SSD and Admin located Resident 1. Resident 1 resided in Skilled Nursing Facility (SNF) 2 and was doing well.
- The facility's SSD/Designee will conduct a post discharge follow up call within 72 hours to ensure that the resident has transitioned adequately to the new facility/location moving forward.
- Newly hired licensed nurses/IDT will be educated by the facility's DON/DSD on facility's P&P pertaining to Discharge and Transfer of residents during their orientation and as needed.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident, who was assessed as being at risk for elopement, was able to leave the facility's secured unit unsupervised. The resident's care plan required staff to conduct visual checks every 15 minutes and to follow specific protocols to prevent elopement. On the day of the incident, a CNA exited the secured unit without ensuring the door was closed and locked behind them, and did not confirm that no residents were following. Surveillance footage showed the resident holding the door open after the CNA exited, then proceeding through the lobby and out the facility's main entrance, which was neither locked nor alarmed at the time. No staff were present in the lobby to monitor the exit. The resident's whereabouts were not documented in the 15-minute monitoring log for several hours, and the assigned CNA later stated that it was unrealistic to monitor and document all assigned residents every 15 minutes due to workload. The facility's receptionist was not present at the front desk during the time of the elopement, and the main entrance door was not secured or alarmed, allowing the resident to exit undetected. The resident was not discovered missing until later in the evening, after which a search was initiated. The resident had a history of exit-seeking behaviors, including wandering, expressing a desire to leave, and packing belongings. Medical records indicated diagnoses such as paranoid schizophrenia, anxiety disorder, epilepsy, and diabetes mellitus, and the resident required regular medication and supervision. The facility's policies required regular checks and supervision for residents at risk of wandering or elopement, but these protocols were not followed, resulting in the resident's unsupervised exit from the secured unit and the facility.
Removal Plan
- The DON provided a verbal one-on-one in-service via phone regarding the elopement policy to CNA 6, following a disciplinary Performance Correction.
- The Registered Nurse Supervisor contacted nearby hospitals and the local police department to locate Resident 3. The ADM contacted private investigators who were also utilized to find Resident 3. A flyer of the missing resident was also provided by the PI.
- The local police found Resident 3 and dropped Resident 3 off at Clinic 1. The DON communicated with Clinic 1's Nurse who confirmed Resident 3 was currently in Clinic 1 with stable vital signs. The DON notified Resident 3's Primary Physician/Medical Doctor who instructed to transfer Resident 3 back to the facility.
- Two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility.
- The Registered Nurse Supervisor conducted a comprehensive assessment of Resident 3 upon Resident 3's return to the facility. Resident 3's vital signs were stable, no signs or symptoms of major injury were noted. The Medical Doctor ordered to transfer Resident 3 to a General Acute Care Hospital for further evaluation. Facility staff notified Resident 3's conservator regarding Resident 3 was found.
- The DON posted a virtual alert sign at secured unit exit areas, reminding staff to keep doors closed before walking away from all secured exit areas, as ongoing safety education.
- The facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility.
- The DON and the Director of Staff Development provided in-services to staff members regarding the elopement policy, covering the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or existing the secured unit, staff members must check/confirm that no resident is existing from the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes in the secured unit and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- Elopement Trainings: RNs, LVNs, CNAs, department managers and assistants, activity assistants, housekeeping and laundry employees, and dietary service staff received the in-service training for elopement. Staff need to complete the in-service regarding elopement upon returning to work and prior to providing resident/resident care. Staff not working due to medical, emergency leaves, vacation, and leave of absence will complete their in-services upon their return.
- The ADM notified the Medical Director of the IJ findings in the IJ template. The Medical Director assisted in developing the IJ removal plan.
- The facility also installed a new door keypad for safety in the front lobby.
- There were residents residing in the secured unit.
- The ADM, the DON, and the DSD made rounds, observed staff members entering/exiting the secured unit. No issues were identified.
- The maintenance supervisor inspected all exit doors, gate, and door/gate alarms. No issues were noted.
- The DON would repeat the in-service regarding Elopement policy to staff members every month, for 3 months. The in-services would cover the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or exiting the secured unit, staff members must check/confirm that no residents are exiting the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- The DON developed an Elopement Monitoring Log, which included supervision and redirection, precautions for entering/exiting the secured unit, and monitoring of the front gate alarm to prevent elopement.
- The facility would conduct a head count at every shift on the secured unit station for 3 months, using the current day's census to enhance supervision.
- The DON, the DSD or the Registered Nurse Supervisor would conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the monitoring findings/actions in the monitoring log.
- The ADM and the DON developed a Quality Assurance and Performance Improvement for elopement to address the deficient practice in the IJ findings.
Failure to Prevent Elopement and Provide Supervision Results in Resident Injury
Penalty
Summary
A facility failed to provide adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease and dementia and was assessed as lacking capacity for decision-making, had a documented history of wandering and previous attempts to leave the facility without informing staff. The resident's care plan specifically identified the risk for elopement and included interventions such as anticipating needs, encouraging activity participation, and frequent visual checks for safety. Despite these documented risks and interventions, the resident was left unsupervised in a wheelchair in the hallway after being assisted to the restroom, and staff did not maintain the required level of monitoring. On the day of the incident, the resident was observed propelling herself down the hallway and was later seen in the front lobby. The facility's front exit door was left wide open and unmonitored when the receptionist left her post unattended to use the restroom. No staff were present to observe or redirect the resident, and the door alarm was not responded to in a timely manner. The resident exited the facility unsupervised, traveled to an adjacent property, and fell from her wheelchair onto the street. The incident was not immediately noticed by staff, and the resident was found by a passerby who called emergency services. As a result of the elopement and fall, the resident sustained multiple injuries, including fractures to the nose, jaw, and ribs, a laceration to the lip, a hematoma, and damage to dental implants. Interviews with staff and review of records confirmed that the facility did not follow its own policies and procedures regarding supervision, elopement prevention, and door monitoring. The lack of supervision and failure to ensure the function and monitoring of exit doors directly led to the resident's elopement and subsequent injuries.
Removal Plan
- Resident 1 was placed on 1:1 supervision with staff educated on supervision until a safe plan is determined by the IDT.
- In-service education was provided to the weekend and evening receptionist regarding not leaving their post unattended.
- In-service education regarding monitoring/supervision, wandering, and elopement policy was provided to the receptionist and facility staff on shift, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel.
- Facility doors were checked for appropriate function by the Maintenance Director.
- A head count of all in-house residents was initiated and all residents were accounted for.
- Elopement assessments were completed on all residents by the DON/designee.
- Two residents identified at risk for elopement were reviewed by the DON/designee for appropriate care plan interventions.
- In-service education regarding wandering and elopement was provided to facility staff, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel. Staff on leave or PRN will be in-serviced on their next scheduled shift.
- An IDT meeting was conducted for the two residents identified as at risk for elopement.
- The DON or designee will audit new admissions with elopement risks and ensure appropriate interventions are in place.
- The SSD or designee will review all new admissions to ensure an elopement risk assessment has been completed, and those residents identified at risk are updated in the Elopement binder. Audits will be conducted until substantial compliance is achieved.
- New hires will receive education on wandering, elopement, and resident safety by the DON, SSD, or designee(s) upon hire and annually thereafter. Ongoing in-service trainings regarding wandering, elopement, resident safety, and resident monitoring/supervision will be performed.
- Elopement risk binders were reviewed and updated by the DON and Administrator. Binders are available at each nursing station and reception area, updated by the SSD with oversight by the DON.
- Elopement code drills were initiated on all shifts and will continue by Administrator/DON and/or DSD.
- A check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. Frequency increased.
- A check of facility doors and alarms will be performed by the Maintenance Department until substantial compliance is achieved. Any findings will be corrected immediately and trends reported to the QA/QAPI Committee.
- The QAPI Committee will review and discuss elopement and supervision for all residents during QAPI meetings to determine effectiveness and provide feedback and program modification until compliance is maintained.
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