Berkeley Pines Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berkeley, California.
- Location
- 2223 Ashby Avenue, Berkeley, California 94705
- CMS Provider Number
- 055892
- Inspections on file
- 12
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Berkeley Pines Skilled Nursing Center during CMS and state inspections, most recent first.
The facility did not participate in or document a full-scale community-based emergency preparedness exercise as required, and failed to provide records or after action reports for the only exercise certificate presented, affecting all residents.
Surveyors found that the facility did not perform the required four-hour load test on its emergency generator, as only two-hour load tests were documented. This deficiency affected all residents and both smoke compartments, as the facility could not demonstrate compliance with NFPA standards for emergency power system testing.
An exit sign with a battery backup near the kitchen corridor failed to illuminate when tested, as observed during a facility tour and confirmed by the Environmental Supervisor. This deficiency affected 15 residents and one smoke compartment, indicating the exit sign was not maintained in accordance with NFPA 101 requirements.
The facility failed to have an RN on duty for eight hours a day, seven days a week, resulting in no RN coverage for 149 days from October 2022 through December 2023. Interviews and record reviews confirmed the absence of RN coverage on weekends, and the facility lacked policies and job descriptions for RN and LVN duties.
The facility failed to employ a full-time dietitian or a qualified dietetic supervisor, resulting in inadequate supervision and training of food and nutrition staff. The Registered Dietitian did not provide sufficient consultation, leading to multiple issues in kitchen operations, including staff competency, menu adherence, and food safety.
The facility failed to ensure proper kitchen staff competency for testing sanitizer strength, checking dish machine temperature, and using the 2-compartment ware washing sink. Incorrect procedures and lack of adherence to policies placed residents at risk for illness due to potential cross-contamination and improper sanitation practices.
The facility failed to provide a vegetarian menu for a resident with a prescribed vegetarian diet and did not follow the lunch menu as planned for other residents. Items such as broccoli salad, tropical fruit mold, oven-roasted potatoes, and green beans with red peppers were either not prepared or not served as specified, leading to potential decreased nutrient intake for the residents.
The facility failed to ensure food was palatable and at a safe temperature, leading to potential decreased food consumption for 35 residents. Observations revealed that food temperatures were not consistently measured, and sampled food was below required temperatures. The Registered Dietitian admitted to not regularly monitoring food temperatures.
The facility failed to ensure food safety and sanitation, with issues including improper temperature control, unsanitized and uncalibrated thermometers, unsafe thawing of fish, and unclean kitchen surfaces and equipment. These deficiencies placed residents at potential risk for foodborne illnesses.
The facility failed to safely store food brought in by family and visitors for residents, leading to potential foodborne illness and decreased food intake. Observations revealed improperly labeled and stored food in the kitchen and staff refrigerator, with staff showing inconsistencies in handling and storage practices.
The facility failed to securely store controlled medications, ensure proper documentation during shift changes, and maintain a secure chain of custody for discontinued medications. An unlocked medication refrigerator and IV e-kit, missing signatures on controlled drug sign-in/sign-out sheets, and discrepancies between the MAR and CDR for a resident prescribed lorazepam were observed.
The facility had a 10.34% medication error rate during a medication pass, including errors in administering insulin, lactulose, and acetaminophen. The LVN failed to mix insulin properly, did not ensure a full dose of lactulose was given, and administered an incorrect dosage of acetaminophen.
The facility failed to monitor and log medication refrigerator temperatures, store food separately from medications, timely dispose of unused medications, remove expired insulin, lock medication carts when unattended, and store discontinued controlled substances in a permanently affixed storage space. These deficiencies were identified through observations, interviews, and record reviews.
The facility failed to prepare pureed food in a form appropriate for a pureed diet, risking aspiration in four residents. Pureed diets were placed on divided plates without indication, and the texture of the pureed green beans was thin and runny. Staff confirmed that pureed food should be firm, hold its shape, and be served on regular plates unless otherwise ordered.
The facility failed to ensure that 12 residents received physician-prescribed fortified diets, which are designed to increase calorie density for residents who cannot consume adequate amounts of calories and/or protein. During an observation, it was noted that the dietary aide did not communicate the need for fortified diets to the cook, resulting in these residents not receiving the additional calories required.
The facility failed to maintain an effective pest control program when ants were observed in the residents' dining/activity room over several days. Staff confirmed the presence of ants, which posed a risk to residents by potentially contaminating their food and causing negative feelings. The facility's pest control policy was not effectively implemented.
The facility failed to maintain essential equipment by not having stopper/plugs available for the two-compartment sink, which prevented its use for dishwashing when the dish machine was out of order. A cook confirmed the absence of stoppers, which are required by the facility's manual dishwashing procedures.
Failure to Conduct and Document Required Emergency Preparedness Exercise
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing plan as required by federal regulations. Specifically, the facility did not participate in a full-scale community-based emergency exercise within the last 12 months. During the annual Life Safety Code recertification survey, the surveyors requested documentation of such participation, but the facility was unable to provide any records indicating compliance with this requirement. The only documentation provided by the facility was a certificate for participation in the 2024 Great California ShakeOut. However, the facility did not supply an after action report or any record of staff participation related to this exercise. This lack of documentation meant that the surveyors could not verify whether the exercise met the regulatory requirements for a full-scale community-based emergency preparedness drill. During an interview, the Administrator acknowledged that the exercise was overlooked. As a result, the facility was found to be out of compliance with the emergency preparedness testing requirements, which affected all 35 residents in the facility at the time of the survey. No specific details about individual residents' medical histories or conditions were provided in relation to this deficiency.
Plan Of Correction
E 039 E 039 E 039 --- 1. Corrective Action: An after action participation report that will show actual involvement and activity in the community based exercise of the staff will be created on future community based exercise. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: Emergency Preparedness Communication plans will be reviewed and updated annually. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of correction: 06/13/2025
Failure to Conduct Required Four-Hour Generator Load Test
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 and NFPA 110 requirements for emergency power systems by not conducting the required four-hour load test on its 15-kilowatt propane generator. During a facility tour, surveyors requested and reviewed generator testing records and found that there was no documentation of a four-hour load test, as required to be performed at least once every 36 months. Instead, only records of two-hour load tests were available for review. The Environmental Supervisor confirmed during an interview that the vendor had only conducted two-hour load tests for the generator. This deficiency affected all 35 residents in the facility and both smoke compartments, as the generator is responsible for supplying essential electrical service in the event of a power outage. The lack of a four-hour load test could result in the malfunction of the emergency generator, as the facility could not demonstrate that the generator would operate under load for the required duration. No specific medical history or condition of the residents was mentioned in the report.
Plan Of Correction
Corrective Action: The facility conducted the 4-hour load test for the 15-kilowatt propane generator on 06/12/2025. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: The four-hour load test for the 15-kilowatt propane generator will be done every 3 years by the facility. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of Correction: 06/12/2025
Exit Sign with Battery Backup Failed to Illuminate During Test
Penalty
Summary
During a facility tour and interview with the Environmental Supervisor, it was observed that an exit sign with a battery backup located in the corridor near the exit to the Back Walkway by the kitchen failed to illuminate when tested. The deficiency was identified on 6/10/25 at 8:46 a.m. when the exit sign did not function as required during a test. The Environmental Supervisor confirmed that the exit sign had been tested the week prior to the survey. This failure affected 15 of 35 residents and one of two smoke compartments. The report cites that exit and directional signs must be displayed and continuously illuminated in accordance with NFPA 101, Life Safety Code, 2012 Edition, and that battery-powered exit signs must be tested and maintained as specified. The facility did not maintain the exit sign in accordance with these requirements, as evidenced by the failed test and the lack of continuous illumination.
Plan Of Correction
1. Corrective Action: The battery powered exit sign located in the corridor near the exit to the Back Walkway near the kitchen is now illuminating when tested. A new battery was installed on 06/11/2025. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: Battery powered exit signs will be checked monthly by the Maintenance Supervisor. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of Correction: 06/11/2025
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for eight hours a day, seven days a week, resulting in no RN coverage for 149 days from October 2022 through December 2023. This deficiency was identified through interviews and record reviews, revealing that there were no RNs on duty on weekends. The absence of RN coverage was confirmed by the licensed vocational nurse (LVN), the Administrator (ADM), and the Director of Nursing (DON), who all acknowledged the importance of having an RN for initial and emergency resident assessments and to oversee staff. The facility's Payroll Based Journal (PBJ) Staffing Data Reports corroborated the lack of RN coverage on numerous specific dates across the reviewed periods. During interviews, the ADM and DON admitted that the facility did not have a policy and procedure for RN coverage, nor did they have job duty descriptions for LVNs or RNs. The ADM was unable to refute the PBJ Staffing Data Reports that indicated the absence of RN coverage on the specified dates. This failure had the potential to place all 36 residents at risk during emergencies when RNs were not available to provide necessary assessments and licensed nursing services.
Failure to Employ Full-Time Dietitian and Provide Adequate Consultation
Penalty
Summary
The facility failed to comply with Federal regulations related to the oversight of food service operations by not employing a full-time dietitian or a qualified dietetic supervisor. The lack of a full-time supervisor resulted in inadequate supervision, training, and knowledge among the food and nutrition staff, which compromised the safety and sanitation of food services. Observations and interviews revealed that the kitchen had been without a full-time supervisor since August 31, and the current supervisor only visited the facility part-time, which was insufficient to manage the workload and ensure compliance with standards. Additionally, the Registered Dietitian (RD) did not provide sufficient consultation to the Food and Nutrition Services department. The RD's contract stipulated that she should conduct monthly food safety and sanitation audits and provide in-service education programs for food service personnel. However, the RD only completed two sanitation checklists in the past year and did not conduct any in-service training for the kitchen staff. The RD's reports mainly focused on labeling and dating food items, and there was a lack of detailed feedback on other critical areas of kitchen operations. During the re-certification survey, multiple issues were identified, including staff competency, failure to follow the planned menu, unpalatable food, inappropriate texture of pureed food, and non-compliance with physician's diet orders. The RD's limited presence and insufficient consultation contributed to these deficiencies, as the kitchen staff did not receive adequate guidance and oversight. The facility's administrator acknowledged the need for a full-time kitchen supervisor but had not yet taken steps to address the issue, citing budget constraints.
Deficiency in Kitchen Staff Competency and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper kitchen staff competency for testing sanitizer strength, checking the dish machine temperature, and using the 2-compartment ware washing sink. During an observation and interview, Cook 1 demonstrated incorrect procedures for testing the strength of the quaternary ammonia sanitizer solution. Cook 1 misinterpreted the color chart for the sanitizer test strip, leading to incorrect conclusions about the sanitizer's strength. Additionally, Diet Aide 1 did not follow appropriate procedures for filling the sanitizer bucket and testing its strength, resulting in a solution with no detectable sanitizer strength. The manufacturer's instructions and facility policies were not adhered to, indicating a lack of proper training and competency among the kitchen staff. Further observations revealed that Diet Aide 1 did not correctly determine the dish machine's operating temperature or log the dish machine's sanitizer strength and temperature. DA1 was unaware of the correct temperature requirements and did not use the dial on the dish machine to check the temperature. The logbook for documenting the dish machine's values was found to be incomplete, showing a lack of adherence to the facility's policies and procedures. The facility's policy required the FNS Director to instruct employees on the fundamentals of sanitation and the correct use of equipment, which was evidently not followed. Additionally, Cook 1 demonstrated a lack of knowledge regarding the proper use of the 2-compartment sink for manual dishwashing. Cook 1 was unaware of the required immersion time for items in the sanitizer solution, and the posted guidelines did not provide this information. The facility's policy for manual dishwashing procedures was incomplete, missing critical information about the immersion time. This deficiency in staff training and competency placed residents at risk for illness due to potential cross-contamination and improper sanitation practices in the kitchen.
Failure to Provide Appropriate Vegetarian Menu and Follow Lunch Menu
Penalty
Summary
The facility failed to ensure that a vegetarian menu was available for a resident with a prescribed vegetarian diet. Despite the resident's diet order being clearly documented in her records, including her physician's orders and nutrition care plan, the facility did not provide appropriate vegetarian meals. The resident frequently received meals she did not like, such as refried beans, mashed potatoes, and grilled cheese sandwiches, leading her to rely on food she ordered herself or kept at her bedside. The Registered Dietitian (RD) and Food and Nutrition Services Director (FNSD) were unaware of the resident's dietary needs and preferences, and no vegetarian menu was available at the facility. Additionally, the facility did not follow the lunch menu as planned for other residents. The menu included items such as broccoli salad, tropical fruit mold, oven-roasted potatoes, and green beans with red peppers, but these items were either not prepared or not served as specified. For example, broccoli salad was not made, and no substitute was provided. Tropical fruit mold was not prepared, and canned fruit was served instead. Oven-roasted potatoes were not available for residents on pureed, mechanical soft, or regular vegetarian diets, who received instant mashed potatoes instead. Green beans were served without the red peppers as specified in the recipe. The deficiencies in meal preparation and service were confirmed through observations, interviews, and record reviews. The FNSD acknowledged the issues, stating that the necessary ingredients were available but not used, and that inventory and ordering processes were not properly managed. The RD confirmed that the menu was not followed according to the dietary requirements and recipes. These failures had the potential to result in decreased nutrient intake and negatively impact the health of the residents.
Failure to Ensure Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure food was palatable in regard to taste and temperature, which had the potential to result in decreased food consumption for 35 residents. Resident 5 reported that breakfasts especially come cold, and Resident 10 stated that all the food was bland. During an observation of trayline food service, Cook 1 admitted to not consistently measuring the temperature of the food. The temperature of three random pieces of chicken on trayline were measured and found to be below the required temperature, with readings of 100.2°F, 127°F, and 129.4°F. A test-tray sampled in the presence of the Food and Nutrition Services Director (FNSD) showed pureed food temperatures were also below the required levels, with pureed chicken at 108°F, mashed potatoes at 111.6°F, and pureed green beans at 107.8°F. The FNSD acknowledged that the food temperatures were too low and that the green beans needed seasoning. Registered Dietitian 1 (RD1) admitted to not tasting the food often due to being on a strict diet and last monitored food temperatures on trayline in July 2023. RD1 also stated she did not measure food temperatures at the point of service to residents and never conducted test trays. The facility's policy and procedure titled Meal Service indicated that food temperatures should be taken prior to service and recorded, with hot food serving temperatures required to be at or above 140°F. However, the observed practices did not align with these guidelines, leading to the deficiency in food palatability and temperature.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner. Specifically, Time Temperature Control for Safety (TCS) food temperatures were not measured after cooking, and food thermometers were neither sanitized nor calibrated. Additionally, fish was not thawed safely, and various kitchen surfaces, including cabinets, shelving, drawers, and walls, were not clean and had peeling paint. The floor in the dry storage room and the kitchen ceiling lights were also not clean. Food preparation utensils and equipment, including a microwave, wooden countertop, industrial can opener, cutting boards, coolers, food scale, toaster, and a knife handle, were not maintained in clean or good condition. Dessert bowls and sheet pans were stacked wet, and proper hand hygiene procedures were not followed. The sanitizer strength for cleaning surfaces and items in the 2-compartment sink was low, and containers of breadcrumbs and food thickener did not have appropriate tight-fitting lids. Cooler temperatures storing food were not monitored, and expired pureed food was stored in a freezer and available for use. During an interview and observation, it was noted that Cook 1 did not take the temperature of the food when setting up for lunch trayline foodservice. The temperatures of different pieces of chicken on the tray line were measured and found to be below the required temperature. The Food and Nutrition Services Director (FNSD) confirmed that tray line food should be held at or above 145 degrees Fahrenheit, and Registered Dietitian 1 (RD 1) stated that chicken on the tray line should be at least 165 degrees Fahrenheit. The facility's policy and procedure indicated that food temperatures should be taken prior to service, and poultry should be cooked to 165 degrees Fahrenheit or above. Further observations revealed that food thermometers were not sanitized, and Cook 1 was unaware of the last time they were sanitized. The facility's policy indicated that thermometers should be cleaned and sanitized after use. Additionally, thermometers were not calibrated correctly, and Cook 1 and Cook 2 did not know how to calibrate them to 32 degrees Fahrenheit. The facility's policy stated that thermometers should be calibrated each week. Raw fish was observed in standing water, and Cook 1 was unaware that water had to be running over thawing meat. The facility's policy indicated that meat should be thawed under running, potable water at a temperature of 70 degrees Fahrenheit or lower. The kitchen shelving, cabinets, and other surfaces were found to be dirty and in poor condition, with peeling paint and residue build-up. The facility's policy required that all equipment and surfaces be kept clean and in good repair.
Failure to Safely Store Food Brought in by Family and Visitors
Penalty
Summary
The facility failed to safely store food brought in by family and visitors for residents, which had the potential to result in decreased intake of food and foodborne illness for 35 residents who ate food by mouth. The facility's policy and procedure on foods brought by family/visitors required perishable foods to be stored in re-sealable containers with tight-fitting lids in the refrigerator, labeled with the resident's name, the item, and the use-by date. However, the policy did not provide guidance regarding timeframes for use-by dates. During an observation, a paper bag with Resident 16's name and room number was found in the reach-in refrigerator in the kitchen, containing a cooked rice mixture and soup. Cook 1 was unaware of when the food was placed in the refrigerator. Additionally, food belonging to Resident 14 was found in the staff refrigerator without proper labeling or a use-by date, and the Director of Nursing confirmed that resident food should not be stored in the refrigerator downstairs or in the kitchen. Interviews with staff revealed inconsistencies in the handling and storage of food brought in by families. LVN 1 stated that she asked families to take food home if the resident did not want to eat it right away and did not store food brought in by families. CNA1 mentioned that she stored food in the refrigerator downstairs and believed it could be stored for up to two days. The Director of Nursing stated that perishable food brought in by family and visitors for residents was not stored, and anything that needed to be reheated or chilled was not safe to store. Resident 14 confirmed that his spaghetti with meat sauce had been placed in the refrigerator by a staff member a few days ago. These actions and inactions led to the deficiency in safely storing food brought in by family and visitors for residents.
Failure to Secure and Document Controlled Medications
Penalty
Summary
The facility failed to store controlled medications securely, as evidenced by an unlocked padlock on the medication refrigerator containing a vial of injectable lorazepam. Additionally, an unlocked IV e-kit was found with missing saline solution bags, and an expired SPS e-kit was not replaced timely. The Director of Nursing (DON) acknowledged that all licensed nurses had access to the refrigerator padlock key, which should have been locked at all times. The facility's Policy and Procedure (P&P) indicated that Schedule II medications, including those requiring refrigeration, should be stored separately under locked compartments, which was not adhered to in this case. The facility also failed to ensure proper documentation and accountability for controlled medications during shift changes. A review of the controlled drug sign-in/sign-out sheets revealed 82 missing signatures between nursing shift changes, indicating that the required controlled medication reconciliation count was not consistently performed. The DON confirmed the missing signatures and acknowledged that nursing staff were expected to complete the reconciliation count and sign the sheets accordingly. This lack of documentation compromised the accountability of controlled medications. Furthermore, the facility did not have a secure chain of custody for discontinued controlled medications. The DON stored discontinued controlled medications in a rolling cabinet in her office without any witnesses to confirm the removal from the medication cart and placement into the cabinet. This process lacked accountability and documentation, increasing the potential for diversion. Additionally, discrepancies were found between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for a resident prescribed lorazepam, with missing documentation of administered doses. The DON confirmed these discrepancies and stated that nursing staff were expected to document the removal and administration of controlled medications immediately, which was not done in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had a 10.34% medication error rate when three medication errors out of 29 opportunities were observed during a medication pass for seven residents. One error involved a Licensed Vocational Nurse (LVN) preparing Humulin N insulin for a resident without mixing or rolling the vial first, contrary to the physician's order and manufacturer's specifications. The LVN admitted that intermediate-acting insulin should be shaken prior to administration, and the facility's policy indicated that medications should be administered in accordance with the manufacturer's specifications and good nursing principles. Another error was observed when the same LVN prepared lactulose for a resident but did not ensure the resident received the full dose due to the thick liquid medication coating the measuring cup. The facility's policy stated that suspensions and thick liquids should be rinsed with water to ensure the entire dose is given. Additionally, the LVN administered only one tablet of acetaminophen to a resident instead of the prescribed two tablets. The LVN could not recall the correct dosage during the observed medication pass and confirmed the error upon reviewing the medication administration record and physician's orders.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to monitor and log medication refrigerator temperatures twice daily, store food items separately from medications in the medication storage room refrigerator, timely dispose of refused/unused medications, remove an expired insulin pen from the medication cart, ensure nursing staff locked medication carts when unattended, and store discontinued controlled substances in a permanently affixed storage space. During an observation and interview with the Director of Nursing (DON), it was found that the medication refrigerator temperature logs were incomplete on seven occasions, and a can of soda was stored alongside patient medications in the medication room refrigerator. Additionally, a small paper medication cup with approximately seven tablets/capsules was found in the medication cart, which the DON confirmed were refused medications that should have been destroyed. An expired insulin pen was also found in the medication cart, which the DON acknowledged should have been removed. Furthermore, during two separate observations, a Licensed Vocational Nurse (LVN) left a medication cart unlocked and unattended, allowing residents and unlicensed staff access to the medications. The DON also confirmed that discontinued controlled medications were stored in a locked rolling metal cabinet rather than a permanently affixed storage space, as required by regulations. These deficiencies were observed through a combination of direct observation, interviews, and record reviews, highlighting lapses in the facility's adherence to its policies and procedures regarding medication storage and security.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to prepare pureed food in a form appropriate for a pureed diet, which had the potential to cause aspiration in four residents who received a pureed therapeutic diet. During an observation of trayline food service, it was noted that Cook 2 placed all pureed diets on divided plates, despite the tray tickets not indicating a need for such plates. A test-tray sampled in the presence of the Food and Nutrition Services Director revealed that the texture of the pureed green beans was very thin and runny. Interviews with RD1 and Cook 1 confirmed that pureed food should be firm, hold its shape, and be served on regular plates unless a physician's order specifies otherwise. The facility's Diet Manual for Long Term Care Facilities also indicated that pureed food should be of a smooth and moist consistency and able to hold its shape.
Failure to Administer Physician-Prescribed Fortified Diets
Penalty
Summary
The facility failed to ensure that 12 residents received physician-prescribed fortified diets, which are designed to increase calorie density for residents who cannot consume adequate amounts of calories and/or protein. During an observation of the lunch tray line food service, it was noted that the dietary aide did not communicate the need for fortified diets to the cook, resulting in these residents not receiving the additional calories required. Specifically, the fortified diets usually include extra gravy and/or butter, but on the observed day, all residents received the same amount of gravy as part of the menu, without the additional fortification for those prescribed such diets. Interviews with the cook and the Food and Nutrition Services Director confirmed that the fortified diets were not properly administered. The cook acknowledged that fortified diets should receive extra gravy or butter, but this was not done because gravy was already part of the menu for all residents. The facility's policy on fortified diets, which aims to increase calorie intake for residents at risk of malnutrition or weight loss, was not followed. This oversight placed the affected residents at potential risk for decreased caloric intake and possible malnutrition and/or weight loss.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program when ants were observed in the residents' dining/activity room over a period of three days. Multiple ants were seen crawling on the walls and tables during observations on 3/12/24 and 3/13/24. The Administrator acknowledged the issue and mentioned that pest control services the facility monthly. However, the Environmental Supervisor and other staff members were not previously aware of the ant problem and confirmed the presence of ants during interviews and observations on 3/14/24. The Environmental Supervisor stated that pest control should be called immediately for urgent needs, and the ants were considered an urgent situation. The Licensed Vocational Nurse also confirmed the presence of ants and noted that it posed a risk to residents by potentially causing negative feelings and contaminating their food. The facility's undated policy and procedure titled 'Pest Control' indicated that the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. Despite this policy, the presence of ants in the dining/activity room was not addressed promptly, leading to a potential risk for food-borne illness and negative resident experiences. The Director of Nursing acknowledged that ants were a nuisance and not acceptable in the facility.
Failure to Maintain Essential Equipment
Penalty
Summary
The facility failed to ensure essential equipment was maintained when there were no stopper/plugs available for the two-compartment sink. During an interview and observation, a cook described how the two-compartment sink would be used for warewashing if the dish machine was out of order. However, the cook stated that there were no stoppers to plug the drain holes, preventing the sinks from being filled as required. The facility's policy and procedure for manual dishwashing indicated that drain stoppers were necessary supplies for the three-compartment sink washing procedures when the dishwasher was inoperable.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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