Inspection Reports for
Lighthouse Healthcare Center
2222 Santa Ana Blvd S, Los Angeles, CA 90059, United States, CA, 90059
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
433% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Routine
Deficiencies: 2
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to evaluate the competency of nursing staff in providing care, specifically regarding the interpretation and implementation of physician orders for urinary catheter drainage bag changes and humidifier bottle replacement.
Findings
The facility failed to ensure that nursing staff correctly interpreted and followed physician orders for changing Resident 115's urinary catheter drainage bag every two weeks and as needed, and that staff were knowledgeable about the facility policy for replacing Resident 76's humidifier bottle weekly. These deficiencies placed residents at risk for infection and illness.
Deficiencies (2)
RN 1 did not correctly interpret or carry out Resident 115's physician order to change the urinary catheter drainage bag every two weeks and as needed.
RN 2 and LVN 4 did not know the facility policy and procedure for replacing Resident 76's humidifier bottle weekly, leading to failure to change the humidifier bottle as required.
Report Facts
Frequency of catheter drainage bag change: 14
Date of MDS assessment: Apr 19, 2025
Date of physician order: Jan 11, 2025
Date of humidifier bottle: May 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Did not correctly interpret or carry out Resident 115's physician order; interviewed regarding catheter and humidifier bottle care |
| RN 2 | Registered Nurse | Did not know facility policy for humidifier bottle replacement; job description reviewed |
| LVN 4 | Licensed Vocational Nurse | Did not know facility policy for humidifier bottle replacement; interviewed and job description reviewed |
| Director of Nursing | Director of Nursing | Clarified physician orders and facility policies; interviewed regarding staff competency and policy enforcement |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Interviewed regarding infection risks related to catheter drainage bag and humidifier bottle practices |
Inspection Report
Routine
Deficiencies: 16
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor resident care preferences, delays in conservatorship referrals, lack of informed consent for psychotropic medications, inaccurate resident assessments, incomplete care plans, inadequate personal hygiene assistance, improper medication administration, infection control lapses, and unsafe food storage practices.
Deficiencies (16)
Failed to honor a resident's preference regarding personal care by assigning a male CNA to provide showers despite resident's request for female CNAs.
Failed to timely submit referral for probate conservatorship for a resident lacking decision-making capacity.
Failed to obtain or renew informed consent for psychotropic medications for two residents.
Failed to ensure call lights were kept within reach for two residents.
Failed to ensure Minimum Data Sets accurately reflected residents' care and conditions for three residents.
Failed to develop care plans addressing specific resident needs including medication use, device care, and therapy refusals for five residents.
Failed to revise care plan and interventions after a resident's unwitnessed fall.
Failed to provide adequate bathing and grooming care to two residents.
Failed to ensure floor mats were properly placed to prevent injury for a resident at risk of falls.
Failed to provide appropriate catheter care including securing catheter tubing and providing daily catheter care.
Failed to change nasal cannula and humidifier weekly and store oxygen mask properly, increasing risk of respiratory infection.
Failed to provide pharmaceutical services and routine medications as ordered, including medication errors related to crushing extended-release medication and administering medication without food.
Failed to provide weighted utensils as ordered for a resident with hand tremors.
Failed to ensure safe and sanitary food storage practices including unlabeled food items and unsanitary can opener.
Failed to implement infection prevention and control measures including enhanced barrier precautions and hand hygiene between residents.
Failed to ensure a functioning call system was available in a resident's room and bathroom.
Report Facts
Medication errors: 2
Medication doses administered incorrectly: 14
Medication doses administered: 14
Medication doses administered: 6
Medication doses administered: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Did not correctly interpret or carry out Resident 115's urinary catheter drainage bag order; failed to follow physician order for Resident 23's medication. |
| RN 2 | Registered Nurse | Did not know facility policy for replacing humidifier bottles; administered medication without food. |
| LVN 4 | Licensed Vocational Nurse | Did not know facility policy for replacing humidifier bottles; administered medication without food. |
| LVN 1 | Licensed Vocational Nurse | Crushed and administered extended-release isosorbide mononitrate instead of immediate release. |
| LVN 2 | Licensed Vocational Nurse | Crushed and administered extended-release isosorbide mononitrate instead of immediate release. |
| CNA 5 | Certified Nursing Assistant | Failed to implement enhanced barrier precautions and hand hygiene between residents. |
| CNA 6 | Certified Nursing Assistant | Reported Resident 6's call light was not functional. |
| Pharmacist 1 | Pharmacist | Pharmacy delivered extended-release isosorbide mononitrate instead of immediate release and did not notify staff. |
| Director of Nursing | Director of Nursing | Provided multiple statements regarding care plan importance, medication administration, and infection control. |
| Dietary Supervisor | Dietary Supervisor | Responsible for food labeling and providing adaptive feeding equipment. |
| Minimum Data Set Nurse 1 | MDS Nurse | Provided multiple interviews regarding MDS accuracy and care plan deficiencies. |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Provided statements on infection control practices and risks. |
Inspection Report
Routine
Deficiencies: 3
Date: May 2, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards, focusing on activities of daily living assistance, treatment and care according to orders, and proper documentation practices.
Findings
The facility failed to ensure one resident was offered and provided showers and baths as required, failed to notify the Primary Care Provider of refusals of showers/baths and wound care treatment, and failed to document weekly skin checks timely. These deficiencies posed risks of skin irritation, infections, worsening skin conditions, and inaccurate communication among healthcare providers.
Deficiencies (3)
Failure to ensure one resident was offered and provided showers and baths as required.
Failure to notify the Primary Care Provider of the resident's refusals of showers/baths and wound care treatment.
Failure to ensure weekly skin checks were documented timely for one resident.
Report Facts
Refusals of wound care treatments: 7
Refusals of showers/baths: 4
Weekly skin checks documented late: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 2 | CNA | Stated staff should offer residents shower every day and document refusals. |
| Certified Nursing Assistant 3 | CNA | Stated not providing showers or baths could cause skin breakdown and dry skin; performed skin checks during showers and ADL care. |
| Director of Staff Development | DSD | Reviewed Resident 1's ADL Sheet for Bathing and stated no documentation of showers/baths on multiple dates; stated licensed nurses should notify PCP of refusals. |
| Director of Nursing | DON | Stated residents should be offered showers/baths daily and refusals reported; reviewed policies and stated facility was not following P&P by not informing PCP of refusals. |
| Licensed Vocational Nurse 4 | LVN | Stated nurses should inform PCP if resident refused shower after three attempts. |
| Licensed Vocational Nurse 3 | LVN | Created and added documentation for weekly skin checks days after assessments based on memory. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 28, 2024
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to provide safe transportation for a resident to a medical appointment, resulting in a serious accident.
Complaint Details
The complaint investigation revealed that Resident 1 was seriously injured and later died after the transportation van was double parked in the street and hit by a speeding vehicle. The facility failed to train staff on transportation safety, did not have a designated loading area, and did not follow policies to prevent accidents. Multiple staff interviews confirmed lack of training and unsafe practices.
Findings
The facility failed to ensure safe transportation for Resident 1, who was injured and later died after the medical transportation van was double parked and struck by another vehicle. The facility did not provide staff training on transportation safety, lacked a designated loading area, and failed to follow its policies on accident prevention and safety reporting.
Deficiencies (1)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents sampled: 3
Units of whole red blood required: 3
Rib fractures: 13
Femur fractures: 2
Date of survey completion: Nov 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor 1 | RN Supervisor | Witnessed Resident 1 lying injured in the transportation vehicle after the accident |
| CNA 1 | Certified Nursing Assistant | Observed the transportation vehicle double parked and witnessed the accident |
| Social Services Director | Social Services Director | Provided information about the accident location and lack of safety reporting system |
| Transportation Service Manager | Transportation Service Manager | Reported that drivers double parked due to lack of designated parking and no instructions from facility staff |
| ADM | Administrator | Acknowledged that transportation vehicles could park anywhere and that double parking was common |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident 1 was physically abused by Resident 2, who hit Resident 1 with a wet floor sign cone.
Complaint Details
The complaint investigation substantiated that Resident 1 was physically abused by Resident 2 on 10/5/2024 when Resident 2 threw a wet floor sign cone at Resident 1, causing injury. The incident was witnessed and reported by staff and residents.
Findings
The facility failed to protect Resident 1 from physical abuse by Resident 2, resulting in Resident 1 sustaining a bruise and cut on the right elbow. The wet floor sign cone was left unattended in front of residents' rooms, creating a safety hazard and risk for resident-to-resident physical harm.
Deficiencies (2)
Failed to protect Resident 1 from physical abuse by Resident 2 who hit Resident 1 with a wet floor sign cone.
Failed to ensure the environment was free from accident hazards by leaving housekeeping cones unattended in residents' rooms.
Report Facts
Residents affected: 1
Weight of wet floor sign cone: 5
Weight of wet floor sign cone: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Observed and reported the incident of Resident 2 hitting Resident 1 with a wet floor sign cone |
| RN 2 | Registered Nurse | Observed wet floor sign cones left unattended and stated it was a safety issue |
| HK 1 | Housekeeping Staff | Reported cleaning procedures involving leaving wet floor sign cones unattended |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 28, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to inform a resident about the lack of secondary medical coverage and failure to assist the resident in applying for secondary coverage.
Complaint Details
The complaint investigation found that Resident 1 was not informed about the lack of secondary coverage and was not assisted in applying for it. Interviews with the Administrator, Resident 1, Business Office Manager, and Director of Nursing confirmed these failures. Resident 1 was charged for stays after her medical coverage ended.
Findings
The facility staff failed to inform Resident 1 that she did not have secondary coverage during her stay and did not assist her in applying for secondary coverage. This resulted in Resident 1 living at the facility without knowledge of her coverage status and receiving a medical bill for uncovered services.
Deficiencies (2)
Failure to inform Resident 1 that she did not have secondary coverage for the length of her stay.
Failure to assist Resident 1 with the process of applying for secondary coverage.
Report Facts
Dates of uncovered stay: Resident 1 was charged for stays between 3/18/2021 and 4/28/2021.
Date of Medicare Eligibility form: Medicare Eligibility form dated 2/19/2021 indicated no recorded eligibility for requested date of service 2/1/2021.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Provided statements regarding verification of medical benefits and lack of documentation for informing Resident 1. |
| Director of Nursing | Director of Nursing | Stated staff responsibilities regarding informing residents about medical coverage and assisting with Medicare applications. |
| Administrator | Administrator | Provided information about Resident 1's last day of medical coverage and billing. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care to Resident 1, specifically related to hypoglycemia management and failure to notify the attending physician as ordered.
Complaint Details
The complaint investigation found substantiated failures related to hypoglycemia management for Resident 1, including failure to notify the physician, administer ordered medication, assess the resident, and follow facility policies, resulting in risk of severe harm.
Findings
The facility failed to ensure Resident 1 received treatment and care according to professional standards by not notifying the physician of a low blood sugar level of 55 mg/dl, not administering Glucagon as ordered, not assessing the resident when nonresponsive, and not promptly notifying the physician. These failures placed Resident 1 at risk for severe medical complications, hospitalization, and death.
Deficiencies (5)
Failure to notify the attending physician of Resident 1's blood sugar level of 55 mg/dl on 1/24/2024 at 11:30 a.m.
Failure to administer Glucagon 1 mg IM on 1/24/2024 at 11:30 a.m. as ordered for blood sugar less than 60 mg/dl.
Failure to assess Resident 1 when nonverbally responsive on 1/24/2024 at 11:41 p.m.
Failure to promptly notify the physician when Resident 1 was nonresponsive on 1/24/2024 at 11:41 p.m.
Failure to implement facility Nursing Manual and policies regarding hypoglycemia management and physician notification for blood sugar levels below 70 mg/dl.
Report Facts
Blood sugar level: 55
Heart rate: 48
Oxygen saturation: 88
Glipizide dosage: 10
Januvia dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Interviewed regarding failure to notify physician and administer Glucagon |
| Registered Nurse Supervisor 1 | Registered Nurse Supervisor | Interviewed regarding Medication Administration Record and failure to administer Glucagon |
| Director of Nursing | Director of Nursing | Interviewed regarding facility's failure to administer Glucagon and notify physician |
Inspection Report
Routine
Deficiencies: 14
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with health and safety regulations, including resident care, use of restraints, infection control, dietary services, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent and proper care plans for physical restraints, inaccurate resident assessments, inadequate communication accommodations for a deaf resident, improper food preparation and storage, failure to implement dietary recommendations, unsafe environmental conditions, and lack of required infection preventionist training.
Deficiencies (14)
Failure to ensure residents and/or responsible parties were informed and consented to the use of physical restraints including bedrails, lap trays, and bed placement against the wall for multiple residents.
Inaccurate Minimum Data Set (MDS) assessments for residents, including failure to document hallucinations and anxiety disorder diagnoses.
Failure to complete required Preadmission Screening and Resident Review (PASRR) Level II Mental Health Evaluations for residents with serious mental disorders.
Failure to develop and implement comprehensive care plans addressing residents' specific needs including psychotropic medication use, behavioral issues, wandering, denture use, and physical restraints.
Failure to provide timely perineal care and maintain good personal hygiene including nail care for several residents.
Failure to provide effective communication accommodations and interpreter services for a deaf and visually impaired resident, resulting in frustration, agitation, weight loss, and hospital transfer.
Failure to store medications according to manufacturer requirements, including storing Gabapentin solution at room temperature instead of refrigerated.
Failure to follow food production recipes and fortified diet guidelines, including serving unfortified diets, improperly prepared pureed foods, and incorrect portion sizes.
Failure to provide food that accommodates resident preferences and offer appropriate meal substitutes.
Failure to ensure safe and sanitary food storage and preparation practices, including unlabeled thawed foods, dirty ice machine, and cross contamination in food prep sink.
Failure to prevent development of pressure ulcers and provide appropriate wound care for a resident with a sacral pressure ulcer.
Failure to maintain a safe environment by leaving hazardous maintenance tools and nails unattended in resident rooms.
Failure to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medications for a resident with communication barriers.
Failure to assess medical need, obtain physician orders, informed consent, and entrapment risk assessments for the use of bedrails for multiple residents.
Report Facts
Weight loss: 39
Weight loss: 9
Pressure ulcer size: 5.4
Pressure ulcer size: 6.4
Pressure ulcer size: 1.2
Medication doses: 4
Medication doses: 16
Portion size: 2.5
Portion size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNS 1 | Registered Nurse Supervisor | Reviewed dietary progress note and care plans, stated unawareness of RD recommendations for RNA feeding program. |
| CNA 4 | Certified Nursing Assistant | Observed feeding Resident 66 and stated Resident 66 fed himself. |
| DON | Director of Nursing | Reviewed care plans and assessments, stated facility failed to obtain informed consent for bedrails and failed to provide interpreter services. |
| DS | Dietary Supervisor | Observed food service and confirmed residents did not receive fortified diets as ordered. |
| PA 1 | Physician Assistant | Assessed Resident 107 without interpreter, prescribed lorazepam for anxiety. |
| MDSN | MDS Nurse | Conducted MDS assessment for Resident 107, unaware of communication limitations. |
| IP | Infection Preventionist | Unable to provide documentation of required 10 hours continuing education for 2023. |
| MA 1 | Maintenance Assistant | Left tools unattended in resident rooms. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to the development and implementation of comprehensive care plans for residents, including monitoring of psychotropic medications, use of restraints, and other individualized care needs.
Findings
The facility failed to develop, implement, and update comprehensive care plans for 15 out of 25 residents, including failure to address psychotropic medication use, wandering behaviors, denture use, and physical restraints. This placed residents at risk for harm, including adverse medication effects, choking hazards, and unnecessary physical restraints. Care plans were also lacking for the use of bed rails and bed positioning against walls for multiple residents.
Deficiencies (8)
Failure to develop a comprehensive care plan for Resident 88's use of Buspirone and auditory hallucinations.
Failure to develop a comprehensive care plan for Resident 17's use of Ativan.
Failure to develop a comprehensive care plan for Resident 10's behavior of wandering into Resident 13's room.
Failure to develop a comprehensive care plan for Resident 66's use of dentures.
Failure to develop a comprehensive care plan for Resident 109's diagnosis of schizophrenia.
Failure to develop a comprehensive care plan for Resident 11's diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety disorder.
Failure to develop a comprehensive care plan for Resident 15's use of a lap tray restraint.
Failure to develop comprehensive care plans for the use of physical restraints (bed rails and bed placement) for Residents 71, 16, 88, 93, 40, 13, 36, and 112.
Report Facts
Residents affected: 15
Psychotropic medication Buspirone dosage: 5
Psychotropic medication Risperidone dosage: 1.5
Psychotropic medication Risperidone dosage: 2
Psychotropic medication Ativan dosage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNS 2 | Registered Nurse Supervisor | Interviewed regarding care plans for Residents 17, 109, and 11; stated care plans were missing for psychotropic medication monitoring |
| DON | Director of Nursing | Interviewed regarding failure to develop care plans for Residents 88, 17, 10, 66, 15, 71, and others; emphasized importance of care plans for medication monitoring and restraint use |
| CNA 5 | Certified Nursing Assistant | Reported incident of Resident 10 found in Resident 13's room with unbuttoned clothing |
| RNS 1 | Registered Nurse Supervisor | Reviewed care plans and physician orders for multiple residents including Residents 10, 15, 66, and 71 |
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding use of bed rails and bed placement for Resident 16 and Resident 88 |
| LVN 1 | Licensed Vocational Nurse | Observed Resident 15's lap tray and discussed restraint use |
Inspection Report
Routine
Deficiencies: 3
Date: May 3, 2024
Visit Reason
The inspection was conducted to evaluate compliance with care plan implementation, accuracy of blood pressure monitoring for orthostatic hypotension, and supervision to prevent falls in the nursing facility.
Findings
The facility failed to implement care plans requiring two staff assists for repositioning a resident, inaccurately obtained orthostatic blood pressure readings for two residents, and failed to adequately supervise a resident at high fall risk, resulting in an avoidable fall with injury.
Deficiencies (3)
Failed to implement the care plan by providing two staff assist when turning and repositioning Resident 2.
Failed to accurately obtain orthostatic blood pressure readings for Residents 1 and 2, leading to potential delayed medical interventions.
Failed to ensure Resident 1 was supervised while walking despite being assessed as requiring moderate assistance, resulting in a fall causing a right hip fracture.
Report Facts
Blood pressure readings: 3
Blood pressure readings: 6
Fall incident date: Apr 14, 2024
Distance ambulated: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding care plan implementation and supervision |
| CNA 2 | Certified Nurse Assistant | Interviewed about repositioning Resident 2 without two staff assist |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding orthostatic blood pressure procedures and fall incident |
| DON | Director of Nursing | Interviewed about orthostatic blood pressure procedures and Resident 1's fall risk |
| PTA | Physical Therapy Assistant | Reviewed Resident 1's PT treatment notes and communicated functional status |
| RPT | Registered Physical Therapist | Reviewed Resident 1's PT discharge summary and functional status |
| SG | Security Guard | Witnessed Resident 1's fall in the front lobby |
| LVN 2 | Licensed Vocational Nurse | Interviewed about Resident 1's walking supervision |
| CNA 1 | Certified Nurse Assistant | Interviewed about Resident 1's walking supervision |
| DOR | Director of Rehabilitation | Interviewed about communication between rehab and nursing staff |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 9, 2024
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to notify the physician of behavior changes in a resident and failure to timely report a resident-to-resident abuse incident to the State Survey Agency.
Complaint Details
The complaint investigation focused on failure to notify the physician of behavior changes and failure to timely report a resident-to-resident abuse incident. The abuse incident involved Resident 2 attacking Resident 1 in self-defense. The facility delayed reporting the incident to the State Survey Agency beyond the required 2-hour timeframe due to a failed fax transmission.
Findings
The facility failed to notify the physician of behavior changes for one resident, which had the potential to cause harm. Additionally, the facility did not report a resident-to-resident altercation to the State Survey Agency within the required 2-hour timeframe, potentially placing the resident at risk for elder abuse.
Deficiencies (2)
Facility staff failed to notify the physician of behavior changes for one out of four sampled residents (Resident 2).
Facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency within 2 hours after the allegation occurred for one of four sampled residents (Resident 1).
Report Facts
Residents sampled: 4
Incident date: Mar 23, 2024
Report fax delay: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Stated there was no documentation that the physician was notified of Resident 2's behavior change |
| RN 1 | Registered Nurse | Stated abuse had to be reported to the State Survey Agency within 2 hours |
| Administrator | Facility Administrator | Reported fax to State Survey Agency did not go through initially and resent report |
| Activities Director | Activities Director | Stated staff should inform charge nurse and abuse coordinator immediately if resident-to-resident abuse is witnessed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report a resident-to-resident altercation between two residents within the required two-hour timeframe.
Complaint Details
The complaint investigation found that the facility did not report a resident-to-resident altercation within the required two-hour timeframe. The altercation occurred on 2/27/2024 at 6:30 PM but was reported on 2/28/2024. The delay was acknowledged by staff including the Activities Assistant and Director of Social Services. The Director of Nursing confirmed all allegations of abuse must be reported within two hours.
Findings
The facility failed to report an incident of a resident-to-resident altercation between Resident 1 and Resident 2 within two hours of occurrence, potentially delaying necessary investigations and increasing risk of further altercations. Interviews and record reviews confirmed the altercation occurred on 2/27/2024 but was reported only on 2/28/2024.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of altercation: Feb 27, 2024
Reporting deadline: 2030
Date of report faxed: Feb 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Director of Social Services | Interviewed regarding the failure to timely report the altercation and responsibility of staff |
| Activities Assistant | Activities Assistant | Witnessed the altercation and did not report it immediately |
| Director of Nursing | Director of Nursing | Confirmed reporting requirements and importance of timely reporting of abuse allegations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to honor a resident's Physician Orders for Life-Sustaining Treatment (POLST), specifically a Do Not Attempt Resuscitation (DNR) order.
Complaint Details
The complaint investigation found that Registered Nurse 1 administered CPR to Resident 1 despite the resident's active DNR order on the POLST. The Director of Nursing confirmed this was a violation of the resident's rights and facility policy.
Findings
The facility failed to honor Resident 1's POLST DNR order, resulting in the resident receiving CPR despite the DNR status. This violated the resident's end-of-life care wishes and rights. Interviews with staff confirmed the error and the facility's policy requires adherence to DNR orders.
Deficiencies (1)
Failure to ensure Physician Orders for Life-Sustaining Treatment (POLST) for Resident 1 was honored, resulting in CPR being administered despite a Do Not Attempt Resuscitation (DNR) order.
Report Facts
Residents Affected: 1
CPR duration: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Administered CPR to Resident 1 despite DNR order |
| Director of Nursing | Director of Nursing | Confirmed violation of resident rights and facility policy regarding DNR orders |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control measures related to COVID-19, specifically regarding isolation, transmission-based precautions, and cohorting of COVID-19 positive and exposed residents.
Findings
The facility failed to properly isolate a COVID-19 positive resident from exposed but negative residents, failed to ensure exposed residents wore masks, and staff did not consistently wear proper PPE or perform hand hygiene. The Administrator and Director of Nursing misinterpreted public health guidelines, resulting in potential increased risk of COVID-19 transmission within the facility.
Deficiencies (8)
Resident 1, who was COVID-19 positive, was not isolated from other residents (Resident 2 and Resident 3) from 12/5/2023 to 12/12/2023 while other rooms were empty.
Resident 2 and Resident 3, who were exposed to COVID-19 but negative, were kept in the same room as a COVID-19 positive resident from 12/5/2023 to 12/12/2023 while other rooms were empty.
Resident 2 and Resident 3 were not wearing face masks before or after eating in the room.
Resident 2 left her room without a mask.
Resident 2 and Resident 3 were not tested for COVID-19 using a PCR test within or after five days of exposure.
Certified Nurse Assistant (CNA) 3 did not wear proper PPE before entering and providing care to COVID-19 positive and exposed residents.
CNA 3 did not perform hand hygiene after exiting and providing care to COVID-19 positive and exposed residents and before getting straws from a medication cart.
Administrator and Director of Nursing misread and misinterpreted guidelines for isolation, transmission-based precautions, and cohorting of COVID-19 positive and exposed roommates.
Report Facts
Date of survey completion: Dec 12, 2023
Number of residents involved: 3
Duration of exposure: 7
Isolation duration recommended: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 3 | CNA | Named in findings for not wearing proper PPE and failing to perform hand hygiene |
| Director of Nursing | DON | Misinterpreted COVID-19 isolation and cohorting guidelines |
| Administrator | ADM | Misinterpreted COVID-19 isolation and cohorting guidelines |
| Registered Nurse 2 | RN | Provided census and resident information during interview |
| Licensed Vocational Nurse 2 | LVN | Provided information on COVID-19 transmission and PPE requirements |
| Public Health Nurse | PHN | Provided guidance on COVID-19 isolation and testing requirements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure the Interdisciplinary Team (IDT) was involved in developing a discharge plan that reflected the resident's discharge needs, goals, and treatment preferences for Resident 1.
Complaint Details
The complaint investigation found that the facility did not involve the IDT in discharge planning for Resident 1 as required. The Responsible Party reported lack of assistance with the discharge process and no IDT meeting was documented or conducted despite scheduled meetings. The facility's Social Services Assistant and Director acknowledged the lack of IDT involvement and communication failures.
Findings
The facility failed to involve the IDT in discharge planning for Resident 1, resulting in incomplete or ineffective discharge planning. Interviews and record reviews confirmed no IDT meeting was held for discharge planning despite policy requirements, and the resident's Responsible Party was not assisted adequately with the discharge process.
Deficiencies (1)
Failure to ensure the Interdisciplinary Team was involved in developing a discharge plan reflecting the resident's discharge needs, goals, and treatment preferences.
Report Facts
Date of admission record: Jan 24, 2023
Date of MDS assessment: Jan 4, 2023
Date of IDT meeting note reviewed: Oct 21, 2022
Date of telephone interview: Jan 19, 2023
Date survey completed: Feb 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Assistant | Social Services Assistant (SSA) | Interviewed regarding discharge planning and IDT meeting involvement |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding IDT meetings and discharge planning communication |
| Administrator | Administrator (Admin) | Interviewed regarding IDT meeting requirements and discharge planning |
Inspection Report
Routine
Deficiencies: 16
Date: Apr 29, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, care and treatment, infection control, medication management, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete informed consent processes, inadequate privacy measures, improper use of restraints and alarms, inaccurate resident assessments, incomplete care plans, inadequate pain management, failure to perform gradual dose reductions for psychotropic medications, improper medication labeling, food safety violations, and infection control lapses during a COVID-19 outbreak.
Deficiencies (16)
Failure to use dignity bags for Foley catheter drainage and failure to serve meals simultaneously with roommates affecting resident dignity.
Failure to obtain valid informed consent for medication administration and failure to update facility policy for residents without decision-making capacity.
Failure to document advance directives properly in resident medical records.
Failure to maintain resident privacy during care by not closing privacy curtains or doors.
Failure to properly assess and document use of physical restraints including alarms, and failure to obtain consent and individualized care planning.
Failure to accurately reflect resident medical status in Minimum Data Set assessments for multiple residents.
Failure to follow up on Pre-admission Screening and Resident Review (PASRR) Level II mental health evaluation and incorporate recommendations into care plan.
Failure to develop and implement person-centered care plans addressing resident preferences, goals, and medical needs including skin tears and mobility limitations.
Failure to provide appropriate treatment and care including management of diarrhea, restorative nursing services, supervision to prevent falls, and timely pain relief.
Failure to perform gradual dose reductions for psychotropic medication within required timeframes.
Failure to label insulin pens with open dates in medication carts, risking administration of expired medication.
Failure to properly calibrate food thermometers using accepted methods, risking food safety.
Failure to follow the regular diet menu as planned, risking nutritional adequacy.
Failure to maintain sanitary conditions in the kitchen including unclean ice machine, foreign object in refrigerator, lack of temperature monitoring and undated food items in dry storage.
Failure to properly dispose of resident-identifiable information on tube feeding bags, risking HIPAA violations.
Failure to prevent unvaccinated or partially vaccinated residents from attending indoor communal dining during a COVID-19 outbreak and failure to ensure proper PPE use by staff.
Report Facts
Bowel movements: 126
Days alarm used: 64
Days alarm used: 35
Range of motion loss: 50
Range of motion loss: 26
Fall risk score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 6 | LVN | Confirmed Foley drainage bag was not concealed with dignity bag. |
| Registered Nurse Supervisor 1 | RN Supervisor | Stated Foley drainage bags should be covered with dignity bag. |
| Director of Nursing | DON | Confirmed dignity bag use, policy deficiencies, pain management issues, and restraint use concerns. |
| Certified Nurse Assistant 5 | CNA | Reported no set schedule for meal assistance and delay in serving Resident 17. |
| Director of Social Services | DSS | Explained lack of informed consent and IDT process deficiencies for Resident 105. |
| Registered Nurse 1 | RN | Confirmed invalid informed consent and pain management issues. |
| Certified Nurse Assistant 9 | CNA | Reported Resident 105's alarm use and bowel movement observations. |
| Licensed Vocational Nurse 9 | LVN | Confirmed Resident 105's fall and alarm use, pain medication administration. |
| Director of Rehabilitation Services | DOR | Confirmed Resident 22's refusal of joint mobility assessment and lack of IDT notification. |
| Dietary Manager | DM | Confirmed food menu discrepancies, ice machine and refrigerator issues. |
| Licensed Vocational Nurse 8 | LVN | Confirmed insulin pens not labeled with open dates. |
| Licensed Vocational Nurse 4 | LVN | Admitted to improper disposal of tube feeding bag with resident information. |
| Infection Preventionist | IP | Confirmed unvaccinated residents attended communal dining during COVID-19 outbreak. |
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