Latest Serious Citations

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of bipolar disorder, depression, anxiety disorder, and memory impairments eloped from the facility. The resident, who was assessed as requiring supervision when walking and had impaired decision-making, was last seen by staff near the entrance. The facility's policy required staff to monitor residents at risk for elopement and to initiate a missing resident action plan if a resident could not be located. On the day of the incident, the resident was able to leave the facility, likely through the front door when it was opened for visitors. The receptionist, responsible for monitoring the entrance, did not observe the resident leaving. Subsequently, both a nurse and an aide noticed the resident was missing from the unit but did not initiate the missing resident action plan as required by facility policy. The facility did not become aware of the resident's absence until approximately 90 minutes later, when local police contacted them after finding the resident about two miles away. The resident was taken to the hospital for evaluation and was found to have no injuries related to the elopement. The failure to provide adequate supervision and to follow established procedures for monitoring and responding to a missing resident resulted in a deficiency and an Immediate Jeopardy situation.

Removal Plan

• The facility conducted a count of all residents to ensure all were accounted for.
• All doors were checked by maintenance and were found to be in good working order.
• All safety devices were checked to ensure they were in place, including electronic devices applied to residents to prevent doors from opening (Wanderguard).
• Resident 1's room was changed from the first floor to the third, and a Wanderguard was placed on the resident. The resident's care plan was updated to include risk for elopement.
• Elopement drills were conducted to ensure that all staff are proficient in the facility's procedure if a resident was missing. Additional future drills were scheduled.
• All residents were audited to ensure they were assessed for risk of elopement, and that care plans were in place for those at risk.
• The facility educated all staff in the facility on the facility's procedure for finding a missing resident. Receptionist staff were educated on their responsibilities to ensure only authorized people leave the building.
• The Director of Nursing or designee was to initiate audits and report results to the QAPI (Quality assurance, performance improvement) committee.
• All staff members were required to be trained on this plan before being permitted back to work.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe cognitive impairment, multiple sclerosis, bipolar disorder, and dementia, who was assessed as an elopement risk, was inadequately supervised. The resident was known to require extensive assistance for transfers and had a care plan in place that included interventions such as a Wander Alert device, an air tag, and staff education to prevent entry into restricted areas. Despite these measures, the resident was able to independently operate a power wheelchair and access a non-residential area of the facility. On the day of the incident, the resident was last seen in the dining room and later in a hallway, where staff instructed the resident to return to their unit. Subsequently, the resident could not be located, and staff initiated a search throughout the facility. The resident was missing for approximately four hours before being found at the bottom of a stairwell, still strapped into the wheelchair, after having fallen down a flight of stairs. The door to the stairwell had been left open accidentally, and there was no alarm or security device on the door, as it was not considered part of the resident area. The resident sustained multiple serious injuries, including rib fractures, a clavicle fracture, a subdural hematoma, a pneumothorax, a finger dislocation, and a scalp laceration requiring stitches. The incident was confirmed through staff interviews, clinical documentation, and hospital records. The failure to provide adequate supervision and to secure non-residential areas directly led to the resident's prolonged absence and subsequent injuries.

Removal Plan

• Assess the safety of residents utilizing power wheelchairs.
• Facility assessment for resident safety with use of power wheelchairs was completed.
• Facility identified five residents that are at potential at risk based on the completed audit.
• Resident R1 was assessed upon his return from hospitalization by rehabilitation services.
• Resident R1 was set up for manual wheelchair for safety.
• Ensure all doors are locked to non-resident areas.
• Set up of keypad lock to Morris Building to limit resident access to non-residential area.
• Education of staff that was responsible for non-compliant with security door process.
• Updated security process to monitor and audit identified doors to non-residential areas to ensure resident safety.
• Revise/ review resident safety policies to include power wheelchairs, locked doors, stairwells, and elopements.
• Facility review of resident safety policy initiated.
• Ensure development of care plan interventions to prevent residents from entering non-resident areas.
• Care plan for identified residents at risk were updated based on facility audit.
• Resident R1's care plan was updated upon return from hospitalization.
• Ensure doors are functioning properly and staff are in-serviced on areas in the building where residents are restricted related to resident safety.
• Ongoing security department monitoring and audit of identified doors to ensure that the doors are secured and functioning properly.
• Provide staff training on ensuring residents don't enter areas of the building where residents are restricted from being related to resident safety.
• Inglis House staff training on ensuring residents don't enter areas of the building where residents are restricted from related to resident safety started and is ongoing.
• Facility has completed approximately 50 percent of the training and is expected to complete 100 percent compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure ongoing training, competency, and supervision of staff in the safe use of manual and mechanical lifts, resulting in an avoidable accident involving a resident with obesity, a history of multiple strokes, and significant functional limitations. The resident, who was care planned for manual or mechanical lift transfers, sustained a left heel bone fracture after her foot became trapped between the lift and the wheelchair during a transfer. The resident reported that staff did not place her feet correctly on the lift, and despite her attempts to alert them, her foot was not repositioned, leading to the injury. Documentation revealed that the staff member involved had not received recent or adequate training or competency evaluation for lift use, and the facility could not provide evidence of such training for other staff members assigned to similar duties. Observations and interviews indicated that staff continued to use the manual lift for the resident after the incident, and that other residents were also transferred using improper techniques, such as not ensuring feet were fully supported on the lift's footrest. Staff interviews revealed a lack of recent training, with some staff unable to demonstrate or explain proper lift use. Personnel files for multiple CNAs lacked documentation of training, in-service, or competency evaluations related to lift use. Additionally, a worn and damaged sling was observed in use during a transfer, contrary to manufacturer instructions and facility policy, which require slings to be discarded if damaged. The facility's investigation into the incident was incomplete, with missing or insufficient documentation and a lack of comprehensive staff interviews. The Director of Nursing and Administrator were unaware of the incident until days later, and the incident was not properly reported or investigated according to facility policy. Manufacturer instructions for the lift and sling emphasized the need for trained caregivers and proper equipment inspection, which were not followed. These failures created an imminent danger and substantial probability of serious harm for all residents requiring lift transfers.

Plan Of Correction

On 06/20/2025, Resident #48 was assessed by the DON/Designee; no additional issues were identified. On 6/19/2025, the Administrator reported the incident to AHCA, DCF, and law enforcement as required, with a thorough investigation initiated. On 6/30/2025, the Administrator reported the incident involving the lift to the FDA in accordance with the Safe Medical Device Act of 1990. Resident #33's lift pad was immediately taken out of service and replaced upon discovery on 6/21/2025. All current residents requiring the use of mechanical lifts have the potential to be affected. The DON/Designee audited all residents in the facility; 45 residents were identified that require the use of facility lifts. All 45 residents were assessed on 06/20/2025, with no injuries noted. The DON/Designee assessed all mechanical lift slings on 06/21/2025, to ensure all lift slings were in proper working condition, with any findings addressed as identified. The DON/ADON have reviewed, revised, and implemented new competency evaluation forms for all facility lifts to provide more specific instructions on 06/19/2025. The DON/Designee will educate Licensed Nursing Staff, Certified Nursing Assistants, Physical and Occupational Therapists regarding the proper use of all facility lifts by 07/25/2025. All new employees will receive the training as part of their new hire orientation. The DON/Designee will audit ten residents requiring mechanical lifts weekly for four weeks, then five residents requiring mechanical lifts weekly for eight weeks, to ensure the safe use of facility lifts and prevent avoidable accidents. The Administrator/Designee will submit the audit findings to the QAPI Committee monthly for review and further recommendations. Date of completion is 07/25/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A Certified Nursing Assistant (CNA) recorded a video of a resident without obtaining consent from the resident or the resident's responsible party. The CNA subsequently posted the video on her personal social media account, specifically Instagram, which was confirmed through interviews and review of the complaint submitted to the District Office. The resident involved had severe cognitive impairment, as documented in the Minimum Data Set, and required moderate to maximal assistance with activities of daily living. The resident was not aware that a video had been taken or posted and expressed distress upon learning about the incident, stating a desire for privacy regarding his stay and condition. The facility's Director of Nursing (DON) reviewed the complaint and confirmed that the images in question were of the CNA and the resident. The DON acknowledged that the CNA did not follow facility policies and procedures regarding the prohibition of taking or releasing images or recordings of residents without explicit written consent. The facility's policies clearly state that staff may not take or release images or recordings of any resident without explicit written consent, and that unauthorized disclosure of resident information is prohibited. The CNA initially denied taking or sharing photos but later admitted to posting a video of the resident on social media without informing the resident or obtaining consent. Interviews with the resident's responsible party revealed that the resident was a private individual who would not have consented to being photographed or having his image shared, especially in his current condition. The responsible party expressed concern about the violation of the resident's privacy, dignity, and respect, and questioned how many people had access to the unauthorized images. Additional interviews with facility staff confirmed that taking photos or videos of residents without consent is not allowed and is considered a violation of residents' rights and privacy.

Plan Of Correction

Immediate corrective action(s) for those Resident(s) affected by the deficient practice: • HIPAA Privacy Consultant was notified by the Administrator via email of the incident on 6/5/25 at 5:38 PM and an investigation was initiated. • CNA 1 was interviewed by the Administrator and Director of Nursing (DON) on 6/5/25 at 3:30 PM, and the nature of the video clip was assessed at approximately 7:00 PM. The Administrator witnessed CNA 1 delete the video from her private Instagram account and trash bin; and verified that it was not stored in the cloud. CNA 1 received verbal 1:1 counseling regarding policy violations at this time. The 5 facility employees who had potential to view the video clip were interviewed on 6/7/25 by the Administrator and QA Nurse at approximately between 1:00-1:30 PM and 4:18 PM. MR 1, CNA 3, and CNA 5 stated they did not view the video, and CNA 2 and CNA 4 stated they viewed the video but did not screenshot, forward, or share it. CNA 1's employee file was reviewed by the Administrator on 6/5/25 at 4:30 PM. Her background and reference checks were completed. No previous disciplinary actions were noted. CNA 1 received written counseling for her HIPAA violation and 1:1 re-training with the facility Administrator on 6/5/25 at approximately 6:00 PM. The topics covered included responsibilities in protecting personal health information (including patient images) and the facility policy prohibiting unauthorized audio/visual recordings of Residents and/or posting PHI to social media. CNA 1 signed for HIPAA Retraining Inservice. CNA 1 was suspended on 6/6/25 at approximately 12:45 PM as a provision for immediate jeopardy abatement plan acceptance. The HIPAA Privacy Consultant provided an additional re-education on HIPAA with CNA 1, and she signed her Corrective Action Form on 6/6/25 at approximately 8:00 PM. The HIPAA Privacy Consultant determined that HIPAA Sanctions Policy will be followed for corrective action and remediation for CNA 1. At the direction of CDPH, CNA 1 was to remain suspended until CMS-2567 Form is received. On 6/18/25, the facility received notice from CDPH that it opened an investigation into the CNA involved in this incident. Resident 1's wife was notified of the incident on 6/5/25 by the Social Services Director (SSD) at 5:04 PM. The wife verbalized that she was satisfied with the steps the facility took, and she feels no harm was done. Resident 1's Physician was notified by the Administrator on 6/5/25 at 9:30 PM. No new orders were noted. Beginning on 6/7/25, Resident 1 was monitored and observed for any changes in mood, behavior, or exhibiting any distress by the SSD; and beginning on 6/8/25 by nursing staff. On 6/6/25, the SSD referred Resident 1 for a third-party psychological evaluation and determination of any residual effects related to this social media incident. The psychiatrist is scheduled to visit on 6/9/25 at approximately 3:00 PM. Plan/Process to identify other Resident(s) potentially affected by the same deficient practice: From 6/6/25 through 6/7/25, our SSD or designee conducted interviews with 115 facility Residents to determine if any had experienced privacy violations, including being videotaped or having their picture taken without written consent. No issues or concerns were identified and noted in their clinical record progress notes. The 115 residents were interviewed by the social services staff on 6/7/25 to assess if they are aware of or have experienced any privacy violations, including being videotaped or having their picture taken. No issues or concerns were identified and noted in their clinical record progress notes. On 6/6/25, facility grievances and Resident Council minutes were reviewed by the Administrator at approximately 2:00 PM for the past 3 months, and no other instances of unauthorized images, recordings, or PHI disclosures were reported. Facility measures and systemic changes to ensure the deficient practice does not recur: By 6/9/25, Department Managers will be in-serviced by the Clinical Resource Consultant regarding Resident Rights to Privacy and Dignity, and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of Residents without explicit written consent. Facility policies prohibiting the use of personal cell phones or other handheld computer devices while working will also be reviewed, and a HIPAA Competency Test will be completed. By 6/30/25, facility staff will receive in-service training with the DON and/or designee on Resident Rights to Privacy and Dignity, and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of Residents without explicit written consent. Facility policies prohibiting the use of personal cell phones or other handheld computer devices while working will be reviewed, and a HIPAA Competency Test will be completed. Upon hire, facility staff will receive training on Resident Rights policies and HIPAA policies prohibiting audio or visual recordings of Residents without explicit written consent. Employees will acknowledge receipt and understanding of the employee handbook, which includes policies for Resident Rights and prohibiting the use of personal cell phones or other handheld computer devices while working. On 6/7/2025, the facility provided postings in common areas to remind staff and/or visitors regarding common HIPAA violations and no personal cellphone use while working in residents' care areas. The DON advised RN supervisors and/or Licensed Nurses on duty to remind staff during nursing huddles that personal cellphones are prohibited in residents' care areas. Department Managers were also advised to remind staff that personal cellphones are prohibited in resident care areas. Monitor performance to ensure solutions are sustained: Beginning 6/7/25, interdisciplinary team members will conduct random quality monitoring rounds three times per week to monitor staff compliance in maintaining a cell phone-free environment in resident rooms and other areas where residents gather. DSD and/or designee will conduct random observation rounds and resident interviews three times per week to monitor staff compliance with personal cell phone use. Identified non-compliance will be addressed immediately through counseling and re-education. The Administrator or designee will conduct a weekly QAPI subcommittee, including the DON, DSD, HR, Social Services Director, Activity Director, or designees, to review quality rounds results for any instances of non-compliance requiring additional follow-up or remedial planning. The Activities Director or designee will conduct targeted queries during monthly Resident Council meetings to monitor compliance with cell phone use and maintaining residents' rights to privacy and dignity. Results of quality rounds, Resident Council feedback, and grievance reports will be reviewed by the facility QAPI Committee to monitor compliance with maintaining residents' rights, privacy, and dignity each month, or until substantial compliance is maintained for a minimum of three months. Compliance trends will be evaluated for additional remedial planning and monitoring needs as indicated. Responsible Person: Administrator Date of Completion: 6/30/2025

Removal Plan

• CNA 1 was interviewed by the ADM and DON, and the nature of video clip was assessed. The ADM witnessed CNA 1 deleted the video from her private Instagram account and trash bin; and verified it was not stored in the cloud.
• CNA 1's employee file was reviewed by ADM. Her background and reference checks were completed. No previous disciplinary actions noted.
• RP 1 was notified of incident by the Social Services Director (SSD). RP 1 verbalized that she was satisfied with the steps the facility took, and she feels no harm was done.
• Health Insurance Portability and Accountability Act (HIPAA) Privacy Consultant was notified by the ADM via email of the incident and an investigation was initiated.
• CNA 1 received immediate counseling for her HIPAA violation and 1:1 re-training with the facility ADM. The topics covered included responsibilities in protecting personal health information (including patient images); and facility policy prohibiting unauthorized audio/visual recordings of residents and/or posting PHI to social media. CNA 1 signed the HIPAA Retraining Inservice.
• Resident 1's Physician was notified by the ADM. No new orders were noted. The Primary Physician and MDR was informed of the incident. The ADM will monitor for compliance and report findings or trends to the QAA/QAPI Committee. A weekly QAA/QAPI Meeting will be conducted to review for compliance and any further recommendations for improvement as needed until substantial compliance is achieved.
• CNA 1 was suspended. The HIPAA Privacy Consultant provided an additional re-education on HIPAA with CNA 1, and she signed her Corrective Action Form. The HIPAA Privacy Consultant determined that the HIPAA Sanctions Policy will be followed for corrective action and remediation for CNA 1. CNA 1 remains on suspension until CMS-2567 form is received. The facility will report CNA 1 to the certification board.
• The SSD referred Resident 1 for a 3rd party psychological evaluation and determination of any residual effects related to this social media incident. The psychiatrist is scheduled to visit.
• Facility grievances and Resident Council Minutes were reviewed by the ADM for the past 3 months, and no other instances of unauthorized images, recordings, or PHI disclosures were reported.
• Resident 1 was monitored and observed for any changes in mood, behavior, or exhibiting any distress by the SSD; and by nursing staff.
• Facility provided postings in common areas to remind staffs and/or any visitors regarding common HIPAA violations and no personal cellphone use while working in residents care areas.
• The five facility employees who had potential to view the video clip were interviewed by the ADM and Quality Assurance Nurse (QAN). Medical Record Assistant 1 (MRA 1), Certified Nursing Assistant 3 (CNA 3) and Certified Nursing Assistant 5 (CNA 5) stated they did not view the video and Certified Nursing Assistant 2 (CNA 2) and Certified Nursing Assistant 4 (CNA 4) stated they viewed the video, but did not screenshot the video or forwarded or shared the video.
• The SSD and/or Designee conducted interviews with the 11 residents CNA 1 was assigned to to determine if any had been photographed or recorded without their written consent. No issues or concerns were identified and noted in their clinical record progress notes. The 115 residents were interviewed by the social services staff if they are aware of or have experienced any privacy violations including being videotaped or having their picture taken. No issues or concerns were identified and noted in their clinical record progress notes.
• The ADM, DON, ADON, Director of Staff and Development (DSD), SSD, Minimum Data Set Nurse (MDSN), Rehabilitation and Maintenance/Housekeeping Directors were in-serviced by the CRC regarding Resident Rights to Privacy and Dignity; and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of residents without explicit written consent. Facility policies prohibiting use of personal cell phones or other handheld computer devices while working was also reviewed. The additional Department Heads will be in-serviced by the CRC and a HIPAA Competency Test completed prior to their next scheduled shift.
• The DON and/or Designee began in-serving facility staff regarding Resident Rights to Privacy and Dignity; and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of Residents without explicit written consent. Facility policies prohibiting use of personal cell phones or other handheld computer devices while working was also reviewed and a HIPAA Competency Test completed. Education and training for staff on leave, vacation, per diem or registry status will be completed prior to their next scheduled shift, until substantial training compliance is achieved.
• During huddles, Registered Nurse (RN) supervisor's and/or Licensed Vocational Nurses (LVN) on duty; and Department Managers will remind staff that personal cellphones are prohibited in residents care areas. Department managers will assist on monitoring compliance during random rounds utilizing the Compliance Monitoring Quality Assurance (QA) Checklist. The HIPAA Sanctions Policy will be followed if any staff are found not in compliance. The ADM will monitor for compliance.
• The Quality Assurance Quality Assurance and Assessment/Quality Assurance Performance Improvement (QAA/QAPI) Meeting, (attendees: Medical Director (MDR), ADM, DON, DSD, Infection Preventionist (IP), SSD, Director of Community Relations, Dietary Manager, Activities Director (AD), Medical Records, Customer Service, Business Office Manager (BOM), Staffing Coordinator (SC) led by the ADM, addressed Root Cause Analysis and a QAPI for HIPAA, Privacy and Resident Rights.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a diagnosis of nontraumatic intracerebral hemorrhage in the brain stem, severe cognitive impairment, and at risk for elopement was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident had previously been assessed as low risk for elopement, but on the day of the incident, was observed by a CNA packing belongings and expressing a desire to leave. Despite this, the resident was not immediately reassessed for elopement risk, and no detailed monitoring plan or interventions were implemented in accordance with the facility's elopement policy. Staff, including the DON and Social Services Assistant, were made aware of the resident's intent to leave and were instructed to monitor the resident and ensure the facility doors were supervised. However, the doors were not continuously monitored, as the receptionist responsible for this task was not present and no other staff were specifically assigned to this duty. As a result, the resident was able to exit the facility undetected, travel to a previous residence, and remain away from the facility for over six hours before being returned by an unidentified individual. Interviews and record reviews confirmed that staff failed to follow the facility's policy and procedure for elopement prevention, including reassessment of risk and implementation of appropriate interventions when a resident demonstrates behaviors such as packing belongings and verbalizing a desire to leave. The lack of immediate supervision and failure to monitor facility exits directly led to the resident's elopement.

Removal Plan

• Resident agreed to be transferred to the acute care hospital for further evaluation. The attending physician issued the order for transfer.
• Resident will remain on 1 to 1 (1:1) supervision for safety until transportation arrives for pickup. An order was obtained by the physician, and a log was used by the staff to document.
• The facility will implement 24-hour monitoring of the doors to strive and prevent harm to all our patients.
• Resident refused to be transferred to the General Acute Care Hospital (GACH) when transport arrived.
• Received orders from physician to apply a wander guard to Resident.
• Obtained informed consent from Resident's Responsible Party (RP).
• Resident continued to refuse the wander guard despite several attempts and education on safety. Physician and Resident's RP made aware.
• Resident will remain on 1:1 monitoring with a log for staff to document to ensure safety and continuous 24-hour monitoring of doors to prevent another incident reoccurring.
• Resident's elopement assessment was updated to reflect Resident being at high risk for elopement.
• Situation, Background, Assessment Recommendation (SBAR) documentation initiated for Resident and 72-hour SBAR documentation initiated.
• Resident's care plan was updated with interventions implemented to prevent a repeat event.
• Resident spoke with a psychiatrist via resident's telephone for evaluation for psychological support and emotional distress. The psychiatrist ordered a follow-up with social services for discharge. Resident was placed on psychological monitoring.
• Resident will be seen by a psychologist for evaluation for psychosocial distress related to the recent event of elopement.
• All residents have had an elopement risk evaluation assessment. All residents will be assessed upon admission, quarterly and in the event of a significant change with care plans updated.
• Residents who are at high risk for elopement will be added to the quarterly Quality Assurance and Performance Improvement (QAPI) committee to identify other residents who have the potential to be affected.
• Care plans will be updated for all residents who are at low, moderate or high risk for elopement and will include strategies and interventions to maintain the residents' safety.
• The facility has identified only one resident at high risk for elopement which is Resident.
• The facility will put a system in place for residents who are identified as low to moderate elopement risk for frequent visual monitoring.
• The facility has put into place 24-hour door monitoring to ensure the deficient practice does not reoccur.
• The Director of Nursing (DON) and Director of Staff Development (DSD) in-serviced staff members concerning the facility's policy to preserve and maintain resident safety by instituting measures to monitor and prevent resident from opportunities of wandering and eloping away from facility. DSD will in-service all licensed staff and before working assigned shift, staff will be in-serviced. As new hires come in, they will be educated and in-serviced on the elopement policy as well.
• The facility will place an elopement binder at each nursing station identifying which residents are at low, moderate, and high risk for elopement. Included in the binder will be policy and procedures related to elopement, face sheets with clear picture identifiers of residents at risk and protocols for the event of an elopement.
• The facility will implement a system that when an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner, get help from staff immediately in the vicinity, instruct the charge nurse and or DON that the resident is attempting to leave or has left the premises.
• The facility will implement a system that when a resident is missing, the facility will initiate the elopement/missing resident emergency procedure, initiate a search of the building and premises and notify the Administrator (ADM), the DON, the resident's responsible party, physician, law enforcement, ombudsman, and CDPH.
• The facility will implement a system for when the resident who eloped is found, the DON and or charge nurse will examine the resident for injuries, contact the physician, report findings and conditions of the resident, notify the resident's responsible party, notify local law enforcement that the resident has been located, and initiate 72-hour SBAR documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility administration failed to utilize its resources effectively and efficiently to maintain a safe and comfortable temperature for residents when multiple central air conditioning units broke down in several halls and common areas. Despite being aware of ongoing issues with the air conditioning units, as documented in resident council meeting minutes from January through April, administration did not implement immediate and effective measures to address the excessive heat. Residents repeatedly raised concerns about uncomfortable temperatures, and the administration acknowledged the problems but only noted that the concerns were being addressed, without evidence of timely or sufficient action. On multiple occasions, temperatures in residents' rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended comfort range. Several residents reported ongoing discomfort, difficulty sleeping, and feeling overheated for weeks, with some stating that the issue had persisted for months. The facility's temperature monitoring logs did not include resident rooms and were only conducted twice a month in common areas, failing to capture the actual conditions experienced by residents. The Director of Nursing confirmed that interventions to mitigate heat exposure, such as providing ice, water, and monitoring vital signs, were not implemented until after temperatures had already reached excessive levels. Interviews with residents and staff further revealed that the excessive heat was a persistent problem, with residents expressing that their complaints were not adequately addressed. The administration's approach relied on hallway temperature checks to trigger room checks, which proved insufficient. The lack of timely and comprehensive action to ensure a safe and comfortable environment for all residents created a likelihood of serious harm or death due to prolonged exposure to excessive heat, resulting in the determination of Immediate Jeopardy.

Removal Plan

• Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
• Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
• Took temperatures throughout the facility at multiple times and verified they were within the range of 71 to 81 degrees.
• Facility will continue to maintain hourly temperature logs until all air conditioner units are repaired.
• Completed education with the Administrator and Director of Nursing (DON) by the President of Clinical Operations regarding their responsibility to implement the facility excessive heat emergency plan related to broken air conditioning units.
• Education included the monitoring process and notification procedure to the Chief Executive Officer/Chief Nursing Officer and to ensure residents are provided with a clean, comfortable environment.
• Chief Nursing Officer educated the Administrator and DON on their job descriptions, emphasizing responsibility to ensure proper temperatures and a safe, comfortable environment.
• Reviewed the agenda and staff sign-in page for the Quality Assurance and Performance Improvement (QAPI) meeting, which included a review of the affected regulations and implementation of the facility's Excessive Heat Emergency Plan.