Advanced Rehab Center Of Tustin
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 2210 E. First Street, Santa Ana, California 92705
- CMS Provider Number
- 055330
- Inspections on file
- 45
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Advanced Rehab Center Of Tustin during CMS and state inspections, most recent first.
A resident with moderately impaired cognition alleged that a CNA physically abused them during a shower, but the incident was not immediately reported to the Administrator or external authorities as required by policy. The CNA did not report the allegation, and there was no documentation in the medical record, resulting in a delayed notification to regulatory agencies and a lack of timely investigation.
A resident with a history of healed lower extremity wounds developed a new blister and erythema, which was documented by a nurse practitioner and a CNA. Despite this, licensed nurses did not assess, document, or monitor the skin impairment, nor was a care plan initiated. The DON and staff confirmed that required assessments and documentation were not completed, resulting in a failure to provide quality care.
A resident with cognitive impairment experienced a pressure injury that progressed from Stage 1 to Stage 3, but required Braden scale risk assessments were not performed at each stage of the wound's decline. Staff interviews confirmed that assessments were only completed at admission and not when the resident's condition changed, contrary to facility policy.
Two residents who lacked decision-making capacity experienced unwitnessed falls resulting in injuries—a laceration and a skin tear. In both cases, staff failed to develop and implement care plans to address these injuries, as confirmed by medical record reviews and staff interviews, despite facility policy requiring comprehensive, measurable care plans for such changes in condition.
A resident's medical record was found to be inaccurate when a fall was not properly documented in the Fall Risk Assessment, despite other records indicating the incident. Both an RN and the DON confirmed the error, noting that the assessment should have reflected the fall as required by facility policy.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident prescribed aripiprazole for psychosis did not have documented monitoring for medication side effects, despite facility policy and care plan interventions requiring such monitoring. The resident was cognitively intact and exhibited no behavioral symptoms, and the DON confirmed the lack of documentation regarding side effect monitoring.
A resident with moderate cognitive impairment reported to an RN that a CNA made her feel uncomfortable by sitting next to her and putting his arms around her. Although the incident was internally reported to the DON, SSD, and Administrator on the same day, the required abuse report was not submitted to the state agency until several days later, contrary to facility policy.
Surveyors found multiple failures in food labeling, dating, and discarding expired items, as well as poor maintenance of kitchen equipment and improper chemical sanitization testing. Food items in refrigerators and freezers were missing labels or use-by dates, and expired foods were not discarded. Kitchen equipment, including a plate lowerator and can opener, was in disrepair, and a microwave used for resident food was unclean. Staff also failed to properly test sanitizing solution concentrations, all of which were confirmed by facility staff.
Multiple infection control deficiencies were identified, including inaccurate infection surveillance logs, improper reuse and storage of gowns by laundry staff, and storage of personal belongings with clean linen. A resident with a pending C. difficile test was not placed on contact precautions, and two residents with central lines were not on Enhanced Barrier Precautions as required. Staff were also observed failing to change gowns between residents and transferring items between residents on and off precautions, increasing the risk of disease transmission.
A resident with a Stage 3 pressure injury, who was bedbound and unable to reposition independently, did not receive proper pressure ulcer prevention care when staff failed to return the low air loss (LAL) mattress to its alternating pressure mode after care. The mattress was repeatedly left on the static setting, contrary to physician orders and facility policy, resulting in the resident not receiving the intended pressure-relieving therapy.
The facility did not ensure safe smoking practices for three residents who were allowed to keep their own smoking materials and smoke unsupervised, despite assessments indicating they required supervision. Additionally, two residents at high risk for falls were not accurately assessed or provided with appropriate fall prevention care plans, with one resident's risk being incorrectly documented and another not having a care plan developed after multiple falls. These failures were confirmed through observations, interviews, and medical record reviews.
The facility did not obtain or document baseline measurements for PICC lines and failed to label PIV sites with the required date, time, and nurse initials for four residents. These deficiencies were confirmed through observation, medical record review, and staff interviews, and were inconsistent with facility policy and physician orders.
Several residents did not receive safe and appropriate respiratory care when oxygen and nebulizer equipment was found unlabeled, undated, or improperly stored, and required signage was missing. In some cases, there were no physician's orders or care plans for oxygen use, and staff confirmed these deficiencies during interviews.
Two residents with recent hip fractures did not receive pain management in accordance with physician orders, as Norco was administered outside prescribed pain levels and care plans addressing pain and high-risk medication use were not developed. Pain monitoring was inaccurately documented, and non-pharmacological interventions were not provided or recorded prior to medication administration, as required by facility policy.
Multiple deficiencies were identified in pharmaceutical services, including mismatched controlled drug records and MARs for two residents receiving hydrocodone-acetaminophen, lack of pain assessments, failure to rotate insulin injection sites for a resident with diabetes, a nurse not instructing a resident to chew aspirin as required, missing documentation for famotidine administration, and insulin glargine being held without proper physician orders or documentation. These issues were confirmed through observations, record reviews, and staff interviews.
Surveyors found that a resident's hydrocodone-acetaminophen was left in an IV cart after discharge, several ointments lacked expiration or received dates, medication disposal bins were left unlocked with insulin pens inside, and a supplement bottle was observed with sticky residue. Nursing staff and the DON confirmed these lapses in medication storage, labeling, and cleanliness.
The facility did not follow its posted menus for 20 residents, including 19 on a CCHO diet who were served canned fruit instead of the required diet gelatin with whipped topping, and one resident who did not receive the gelatin dessert as specified. Staff confirmed the substitutions were made due to lack of the correct item, but the menu was not updated and residents were not notified, nor were the substitutions documented as required by policy.
The facility failed to ensure that food served to residents was both palatable and maintained in nutritive content. Pureed carrots were held in a hot oven for over two hours before service, and several residents reported that the corned beef served was too tough to cut or chew. Staff confirmed multiple complaints about the meal's texture, and alternatives were offered to affected residents.
A resident with a physician's order for a pureed diet was served a mechanical soft meal due to discrepancies between the meal ticket and the diet report, and pureed BBQ chicken was observed to contain small chunks instead of a smooth consistency, affecting multiple residents on pureed diets. Staff were unable to immediately clarify the correct diet order, and food preparation did not meet required standards for residents with swallowing difficulties.
The facility did not provide adequate education to staff, residents, or visitors on safe food handling for foods brought in from outside, resulting in inconsistent and incomplete practices for reheating and storing food. Staff interviews revealed a lack of knowledge about proper food temperatures and safe storage, and educational materials available to families did not address safe food handling procedures.
The facility's Facility Assessment did not include active involvement from direct care staff, residents, or their representatives, and failed to address necessary staffing resources for weekends, recruitment and retention strategies, or a contingency staffing plan, as confirmed by the Administrator during review.
A facility failed to implement its antibiotic stewardship program by not ensuring that McGeer's criteria for true infection were fully documented for a resident prescribed antibiotics for pneumonia. Only two out of three required criteria were marked on the Infection SBAR, and the necessary documentation to confirm the presence of all criteria was not completed by the licensed nurse. Both the IP and DON acknowledged the incomplete documentation during review.
A resident with severe cognitive impairment and requiring maximum assistance with ADLs was found to have their call light out of reach, contrary to facility policy. Staff confirmed the call light was not accessible, and the DON verified the deficiency.
A resident and their representative were not provided with the required SNF ABN and NOMNC forms in a timely manner, resulting in the absence of signatures and confirmation before the last covered day of Medicare Part A services. The forms were only completed and signed after the coverage period had ended, as confirmed by facility staff.
The facility did not transmit MDS assessments within the required timeframe for a resident discharged with return anticipated and two residents discharged home. The MDS Discharge Assessments for these residents were completed and signed several weeks past the required deadlines, as confirmed by interviews with the MDS Coordinators, Administrator, and DON.
A Quality Control Log for a medication cart contained a discrepancy where the serial number on the glucometer device did not match the serial number recorded on the Quality Control Record. An LVN verified this documentation error during an interview and review.
A resident with severe cognitive impairment was transferred to an acute care hospital without proper notification or medical records, as required by facility policy. The RN involved could not recall if the report was called in or if records were given to ambulance personnel. The Administrator confirmed the hospital was not notified, and no records were sent, posing a risk to the resident's medical needs.
A facility failed to ensure the privacy and timely delivery of a mailed package for a resident, potentially violating the resident's rights. The package was opened and not delivered to the resident, who had been discharged to another care facility. The Admission Assistant was aware of the package but did not deliver it due to a busy schedule. The Administrator acknowledged the findings.
The facility failed to notify the LTC Ombudsman of the transfers of two residents to an acute care hospital. One resident lacked mental capacity, while the other had decision-making capacity. Despite physician orders for transfer, there was no documentation that notices were sent to the Ombudsman, as confirmed by interviews with facility staff.
A facility failed to inform a resident or their representative of the bed hold policy in writing before a hospital transfer. The resident, who lacked decision-making capacity, was transferred without documentation of the policy being communicated. The DON confirmed the omission, noting the informed consent section was blank upon admission.
The facility failed to maintain complete and accurate medical records for two residents and two nonsampled residents. Medications were not documented as administered according to policy, with missing entries for insulin, atorvastatin, melatonin, and other medications. An LVN admitted to administering the medications but failing to document them, which was confirmed by the ADON.
A resident with end-stage renal disease missed dialysis appointments, and the facility failed to notify the physician as required. Additionally, the facility did not inform the physician about the resident's complaints of blood in bowel movements or follow up on a change in condition regarding ear redness. Pain assessment interventions were also not documented.
The facility failed to protect residents from sexual abuse by another resident due to inadequate supervision. After an initial incident where a resident grabbed another's breasts, the facility did not implement 1:1 supervision as required, leading to a second incident where the same resident fondled another's breasts during an activity. Staff confirmed the lack of supervision was due to staffing shortages.
A facility failed to report a sexual abuse allegation involving two residents to the CDPH L&C and local law enforcement in a timely manner. Resident 4, with a BIMS score of 11, reported being fondled by another resident, which was witnessed by the Activities Assistant. The facility's policy requires such incidents to be reported and investigated, but this was not done promptly, as confirmed by interviews with the DON and SSD.
The facility failed to document and monitor an unwitnessed fall for a resident, neglecting necessary neurological assessments. Additionally, two residents who reported abuse were not monitored for psychosocial harm, despite care plans being initiated. The DON confirmed the absence of required monitoring and documentation, indicating a failure to follow facility policies.
A resident with a history of falls did not receive adequate fall prevention measures as outlined in their care plan. Floor mats were not placed as required, and the fall risk assessment was inaccurately completed, failing to reflect the resident's true risk level. Staff interviews confirmed these deficiencies, with a nurse acknowledging the incorrect placement of floor mats and another verifying the inaccurate risk assessment.
A resident with a swollen and discolored wrist complained of pain but did not receive the prescribed acetaminophen suppository due to being NPO. The nurse failed to contact the physician for alternative pain management and forgot about the existing order. The resident's medical records lacked documentation of any pain relief being offered or provided.
A facility failed to implement a care plan for a resident with dysphagia, resulting in a CNA feeding the resident without being informed of special dietary needs. The CNA, newly hired and not yet trained in meal services, fed the resident who then experienced difficulty swallowing. The DON confirmed no documented evidence of the CNA being educated on the resident's needs.
A facility failed to report a resident-to-resident altercation involving a knife to the appropriate authorities. The incident involved a resident with no cognitive impairment arguing with another resident with moderate cognitive impairment, and a third resident who lacked decision-making capacity. Despite being documented in progress notes, the incident was not formally reported, and the Administrator was informed days later, acknowledging it should have been reported as abuse.
A resident was administered psychotropic medications without proper informed consent and behavior monitoring. The facility failed to document necessary observations for PRN Ativan and Restoril, and did not monitor for adverse effects. The DON confirmed these deficiencies during interviews.
A resident did not receive prescribed medications on multiple occasions due to unavailability and lack of timely delivery, as noted in the MAR. The facility failed to notify the physician about these missed doses, and the contracted pharmacy confirmed that some medications were marked 'do not fill' by the facility. The DON verified the findings and could not provide documentation of physician notification or pharmacy contact.
A facility failed to follow a physician's STAT order for a psychiatric consultation for a resident, resulting in a nine-day delay. The order was placed, but the evaluation was not conducted until much later, potentially delaying necessary treatment. The DON confirmed that the ADON was responsible for ensuring STAT referrals were prioritized.
A resident's physician was not notified when their inhaler ran out and they experienced increased anxiety, leading to a significant decline in their condition. The facility's policy required notifying the physician of such changes, but no follow-up communication was documented. The resident refused alternative treatments, resulting in decreased oxygen levels and unresponsiveness, requiring CPR until paramedics arrived. Interviews revealed a lack of follow-up and communication with the physician or NP.
A facility failed to report an abuse allegation involving a resident to the State Agency, Ombudsman, and local law enforcement as required by their policy and federal regulations. The Social Services Director, present during the allegation, misunderstood the reporting requirements, leading to a delay. The Administrator was only informed after the Ombudsman visited, and the Nurse Consultant was unaware of the allegation, resulting in no investigation being conducted.
A facility failed to investigate an abuse allegation involving a resident in a timely manner, as required by its policy. The resident reported verbal abuse by family members during a tele-visit with a psychologist, who then reported it to APS and the Ombudsman. The Administrator learned of the allegation days later from the Ombudsman and indicated that the Interim DON should have investigated it. Interviews confirmed that the allegation was not reported or investigated promptly.
The facility failed to provide necessary care for two residents and maintain current emergency procedures. A resident did not have required daily skilled nursing notes, and another resident's psychiatry consult was delayed. Additionally, the facility's emergency procedures policy was outdated, referencing an AED that was not available. The DON confirmed these deficiencies during a review.
The facility did not adhere to its smoking policy, failing to supervise 21 residents who smoked. Observations showed residents smoking outside designated areas and without staff supervision, with cigarettes and lighters in their possession. Interviews confirmed the absence of structured smoking times and proper storage of smoking materials, posing a risk of injury.
A resident did not receive their prescribed albuterol inhaler due to a failure in the facility's medication management process. The resident's inhaler ran out, and the pharmacy could not refill it due to insurance denial. The facility did not complete the necessary authorization to cover the cost, leading to the resident receiving an unscheduled dose of ipratropium-albuterol solution without a physician's order.
The facility failed to accurately reconcile controlled medications for two residents, leading to discrepancies in the administration and documentation of Ativan. For one resident, tablets were removed from the supply without proper documentation or co-signatures, and for another, the MAR did not reflect the administration of the medication. The DON confirmed these discrepancies, highlighting a potential for drug diversion.
Failure to Immediately Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the appropriate authorities, as required by both facility policy and state law. A resident alleged that a CNA shook their shower chair, pulled and yanked their hands, and kicked them during a shower. The resident reported this incident to other CNAs and a nurse practitioner, but there was no documentation of the allegation in the resident's medical record. The facility's policy requires immediate reporting of suspected abuse to the administrator and various agencies, but neither the Administrator nor the DON were aware of the allegation until it was reported to the state months later. Interviews revealed that the CNA involved did not report the resident's allegation, stating she did not believe the accusation was true. The DON confirmed that all staff are mandated reporters and should report any abuse allegations immediately. The failure to report the allegation in a timely manner resulted in a delay in notifying the CDPH, Ombudsman, and law enforcement, as well as a lack of internal documentation and investigation at the time the incident was alleged to have occurred. The resident had a history of moderately impaired cognition but was assessed as having the capacity to understand and make decisions.
Failure to Assess and Monitor Skin Impairment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who had a newly observed skin impairment. Upon admission and readmission, the resident had a history of healed bilateral lower extremity wounds and was noted to have scar tissue with hyperpigmentation. Despite documentation by a nurse practitioner of trace erythema and a blister on the right lower extremity on multiple occasions, licensed nurses repeatedly documented that there was no skin breakdown in the weekly summaries. Additionally, a CNA documented areas of concern on the resident's lower extremities during a daily body check, which was signed by a licensed nurse. There was no evidence in the medical record that a licensed nurse assessed the resident's bilateral lower extremities following the CNA's documentation of skin concerns. The treatment administration record did not show any treatment or monitoring orders for the resident's lower extremity wounds, and no care plan problem was initiated for the documented blister. Interviews with staff confirmed that the expected process was for CNAs to report new skin issues to licensed nurses, who would then assess, document, notify the physician, and initiate monitoring and care planning as needed. However, this process was not followed in this case. The Director of Nursing and other staff acknowledged that there should have been a care plan and monitoring for the resident's blister, and that the required assessments and documentation were not completed. The failure to assess, document, and monitor the resident's skin impairment represented a lapse in providing quality care according to the facility's policies and procedures.
Failure to Perform Required Braden Scale Assessments for Pressure Injury Progression
Penalty
Summary
The facility failed to ensure that Braden scale risk assessments were performed as required for a resident with a pressure injury. According to the facility's policy, risk assessments should be conducted weekly for the first four weeks, upon significant changes in condition, or as often as needed based on the resident's status. Medical record review showed that a resident, who lacked capacity to make decisions, was readmitted and subsequently developed a Stage 1 pressure injury that progressed to Stage 2 and later to Stage 3. Documentation confirmed the progression of the wound, but there was no evidence that repeated Braden scale assessments were completed at the time of these changes. Interviews with facility staff, including an LVN and the DON, confirmed that Braden scale assessments were not performed when the resident's pressure injury advanced from Stage 1 to Stage 2 and then to Stage 3. The LVN stated that Braden assessments were only done upon admission and not when there was a change in the wound's condition. The DON verified that the required assessments were missed during the periods when the resident's skin condition changed.
Failure to Develop Care Plans for Residents After Falls
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address specific injuries for two residents following unwitnessed falls. For one resident, who lacked capacity to make decisions, a laceration to the right temporal area was documented after an unwitnessed fall. Despite this change in condition, there was no care plan created to address the laceration prior to the resident's transfer to an acute care hospital. Both the RN and DON confirmed that a care plan should have been initiated but was not present in the medical record. Similarly, another resident, also lacking decision-making capacity, sustained a skin tear to the left forearm after an unwitnessed fall. The medical record review and staff interviews confirmed that no care plan was developed to address the skin tear. The LVN and DON both acknowledged that a care plan should have been initiated following the incident, but it was not completed. These findings were based on interviews, medical record reviews, and review of facility policies and procedures.
Inaccurate Fall Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding documentation of falls. According to the facility's policies, nursing staff are required to identify and document resident risk factors for falls and maintain complete and accurate records. For one resident, the medical record review showed a discrepancy: although the resident experienced an unwitnessed fall, the Fall Risk Assessment form indicated that there had been no falls in the past three months. This was inconsistent with other documentation, such as the SBAR Communication Form, which recorded the fall. During interviews, both a registered nurse and the Director of Nursing confirmed the inaccuracy in the Fall Risk Assessment. They acknowledged that the assessment should have reflected the fall by indicating one to two falls in the past three months, rather than none. The failure to accurately document the fall in the resident's assessment resulted in an incomplete and inaccurate medical record, contrary to the facility's own policies and accepted professional standards.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving aripiprazole, an antipsychotic medication, was properly monitored for side effects as required by facility policy. The policy stated that nursing staff should monitor and report side effects of antipsychotic medications to the attending physician. Review of the resident's medical record, including the Medication Administration Record (MAR) and care plan, showed that while the resident was administered aripiprazole as ordered for psychosis, there was no documentation of monitoring for medication side effects. The resident in question had a diagnosis of psychosis and was noted to have fluctuating capacity to understand and make decisions, but was assessed as cognitively intact and exhibited no behavioral symptoms such as physical or verbal aggression. The baseline care plan included interventions to monitor for adverse effects and behavioral manifestations, with instructions to notify the physician as needed. Despite these documented interventions, there was no evidence in the MAR or other records that monitoring for side effects of aripiprazole was performed or documented, as confirmed by the Director of Nursing.
Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure the timely reporting of a staff-to-resident abuse allegation involving one resident. According to the facility's policy, allegations of abuse must be reported immediately, defined as within two hours if abuse or serious bodily injury is involved, or within 24 hours otherwise. In this case, a resident with moderate cognitive impairment reported that a CNA sat next to her, put his arms around her, and touched her in a way that made her feel uncomfortable and violated. The incident was reported by the resident to an RN, who then informed the DON, SSD, and Administrator on the same day the incident occurred. Despite the internal reporting, the facility did not submit the required SOC 341 report to the state licensing agency until six days after the incident was reported by the resident. Documentation shows the incident was reported to the CDPH, L&C Program on 4/10/25, even though the resident reported the event on 4/4/25. The delay in external reporting did not align with the facility's own policy and regulatory requirements for timely notification of authorities regarding abuse allegations.
Sanitary Failures in Food Storage, Equipment Maintenance, and Chemical Sanitization
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by improper labeling and dating of food items, failure to discard expired foods, and inadequate maintenance of kitchen equipment. During an initial tour of the kitchen, surveyors observed multiple food items in the walk-in refrigerator, freezer, and on counters that were either missing use-by dates, lacked labels, or were expired. Items included eggs, sour cream, jello, sandwiches, ham, ground meats, waffles, and juice containers, many of which were not properly labeled or dated. The facility's policies required all foods to be labeled and dated, but these procedures were not followed, as confirmed by staff interviews. Further observations revealed that kitchen equipment was not maintained in good condition. The plate lowerator had loose handles and dried food debris, the can opener had a chipped blade, and plate domes were warped and corroded. Additionally, the residents' refrigerator contained several food items brought in by visitors that were not labeled with use-by dates or were undated, and the residents' microwave was found to have dried, crusted food residue on its interior surfaces. These findings were verified by dietary and support staff during the survey. The facility also failed to ensure that kitchen staff correctly tested the chemical concentration of the quaternary sanitizing solution used for food contact surfaces. A dietary aide demonstrated improper testing technique by dipping the test strip for only one second instead of the required ten seconds, potentially resulting in inaccurate readings. All of these failures were acknowledged by facility staff and had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the kitchen.
Infection Control Deficiencies and Lapses in Standard Precautions
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as outlined in its policies and procedures. The Infection Prevention and Control Surveillance Log contained inaccurate documentation, with the 'Meet McGeer Criteria' column incorrectly marked as 'N/A' for several entries, rather than 'Yes' or 'No' as required. Both the Infection Preventionist (IP) and Director of Nursing (DON) acknowledged these errors, which could lead to confusion among staff regarding the identification of true infections. Laundry staff were observed reusing dirty gowns multiple times per day, hanging them in close contact with other used gowns, and storing personal belongings such as lunch bags and jackets inside clean linen carts. The Housekeeping Manager and IP confirmed these practices, noting that the gowns should not be reused or stored in a manner that allows cross-contamination, and that personal items should not be kept with clean linen due to the risk of contamination. Several lapses in resident-specific infection control were also identified. One resident with a pending Clostridium difficile test and a history of the infection was not placed on contact isolation precautions, and brown stains were observed on the shared toilet. Two residents with central lines were not placed on Enhanced Barrier Precautions (EBP) as required, with no signage or PPE supplies present. Staff were observed failing to change gowns between residents and transferring potentially contaminated items, such as a tissue box, between residents on EBP and those not on precautions. These failures were acknowledged by facility leadership and posed a risk for the transmission of communicable diseases.
Failure to Ensure Proper Use of Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure ulcers and promote healing of an existing pressure ulcer for a resident at high risk. The resident, who was bedbound and unable to reposition independently, had a Stage 3 pressure injury on the right heel and required substantial assistance for mobility. The care plan and physician orders specified the use of a low air loss (LAL) mattress, with daily checks to ensure the appropriate setting according to the resident's weight and comfort. Observations revealed that the LAL mattress was repeatedly left on the static setting when care or repositioning was not being rendered. The static mode is intended to provide a firm surface for transfers or repositioning and should only be used during such activities. Staff interviews confirmed that both licensed nurses and CNAs were responsible for ensuring the mattress was set correctly, but there were lapses in checking and adjusting the settings. One CNA admitted to sometimes forgetting to check the mattress settings and only verifying that the device was powered on, not whether it was in the correct mode. The failure to return the LAL mattress to its alternating pressure mode after care resulted in the resident not receiving the intended pressure-relieving benefits of the mattress. This was contrary to the facility's policy and the physician's orders, which emphasized the importance of pressure reduction surfaces and regular monitoring to prevent further skin breakdown and promote wound healing.
Failure to Ensure Safe Smoking Practices and Fall Prevention
Penalty
Summary
The facility failed to ensure safe smoking practices and adequate fall prevention measures for several residents. Three residents who smoked were not accurately or thoroughly assessed to determine if they could safely store their own cigarettes or lighters. Despite being assessed as requiring supervision while smoking or having a history of non-compliance with the facility's smoking policy, these residents were permitted to keep cigarettes, lighters, and other smoking materials in their possession. Observations confirmed that residents smoked in non-designated areas without staff supervision and kept their own smoking materials, contrary to facility policy and their care plans. Interviews with staff and review of medical records verified that these residents required supervision and should not have had access to smoking materials independently. Additionally, the facility failed to ensure accurate fall risk assessments and the development of appropriate care plans for two residents. One resident's admission assessment inaccurately recorded their fall risk as zero, despite multiple diagnoses that increased their risk, such as difficulty walking, muscle weakness, schizophrenia, epilepsy, and Parkinson's disease. The nurse responsible for the assessment admitted to entering incorrect information, and the Director of Nursing confirmed that the resident should have been identified as at risk for falls and had a fall prevention care plan developed. However, no such care plan was in place prior to the resident experiencing a fall. Another resident, who was cognitively impaired and had a history of falls, was not provided with a care plan addressing their high risk for falls upon readmission or after subsequent falls. Medical record review and staff interviews confirmed that no fall care plan was developed during the resident's stay, and a care plan was only initiated after the resident had expired. These failures were acknowledged by facility leadership and posed risks of injury from falls and fire to the residents involved.
Failure to Document and Label IV Access Sites According to Policy
Penalty
Summary
The facility failed to provide necessary care and services related to intravenous (IV) access for four residents, including both sampled and nonsampled individuals. Specifically, for two residents with peripherally inserted central catheters (PICC lines), the facility did not obtain or document baseline measurements of the external catheter length and arm circumference upon admission, as required by physician orders and facility policy. Additionally, there was no evidence that care plans were formulated to address the use of PICC lines for these residents. Medical record reviews confirmed the absence of required documentation, and staff interviews verified these omissions. For two other residents with peripheral intravenous (PIV) lines, the facility failed to ensure that the IV sites were labeled with the date, time, and licensed nurse's initials, as required by facility policy and standard practice. Observations showed that the PIV dressings were not properly labeled, and this was confirmed by both nursing staff and the Director of Nursing (DON) during interviews. Physician orders for these residents included instructions for IV medication administration and site rotation, but the required documentation and labeling were not present in the medical records. Throughout the investigation, staff members, including an RN and the DON, acknowledged the lack of baseline measurements, missing documentation, and improper labeling of IV sites. These failures were identified through direct observation, medical record review, and staff interviews, and were confirmed to be inconsistent with the facility's own policies and procedures for IV therapy and PICC line management.
Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to four residents by not adhering to established policies and procedures regarding oxygen and nebulizer equipment. For one resident, oxygen tubing and mask were found on the floor, unlabeled, and without a physician's order or care plan for oxygen use. Additionally, there was no posted signage indicating oxygen use on the doorway, as required by facility policy. Another resident's oxygen tubing and mask were stored in a clear plastic bag but were not labeled or dated, and there was also no posted oxygen signage on the doorway, despite an active physician's order for oxygen administration. A third resident's nebulizer tubing was observed on the floor, undated, and not stored in a clear plastic bag when not in use, even though there was a physician's order for nebulizer treatments. For a fourth resident, the nasal cannula tubing was touching the floor, and the nebulizer tubing was undated and not properly stored in a clear plastic bag. This resident had physician's orders for both continuous oxygen and nebulizer treatments. In all cases, staff interviews confirmed the observations and acknowledged that the equipment should have been labeled, dated, and stored according to policy, and that appropriate signage should have been posted. Medical record reviews further revealed missing physician's orders and care plans for oxygen use in at least one case, and staff verified these deficiencies during interviews. The facility's policies required labeling, dating, proper storage of respiratory equipment, and visible signage for oxygen use, but these procedures were not followed for the affected residents.
Failure to Provide Appropriate Pain Management and Documentation
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services. For one resident with a history of a displaced intertrochanteric fracture of the left femur, the facility did not administer pain medication according to the physician's order, as Norco was given for a pain level of 6 when the order specified it should be administered for severe pain at a level of 7-10. Additionally, there was no care plan developed to address this resident's pain or the use of Norco, despite the resident reporting ongoing pain and receiving pain medication. For another resident with a fracture of the neck of the left femur and a history of left hip surgery, the facility failed to accurately document pain monitoring and did not administer pain medication according to the physician's order. Norco was administered for a pain level of 6, which was outside the ordered parameters. The facility also failed to ensure non-pharmacological pain interventions were provided and documented prior to administering pain medication, as required. Documentation inconsistencies were noted, with pain levels recorded as 0 during shifts when pain medication was administered for higher pain levels, and non-pharmacological interventions were marked as not applicable without explanation or documentation of refusal. Both residents lacked care plans addressing their pain and the use of high-risk medications such as Norco, contrary to facility policy. Interviews with nursing staff and the DON confirmed these findings, including the absence of required care plans, improper documentation, and failure to follow physician orders for pain management and monitoring.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for several residents, as evidenced by discrepancies in controlled drug records, lack of pain assessments, improper medication administration, and incomplete documentation. For two residents, the Controlled Drug Record for hydrocodone-acetaminophen did not match the Medication Administration Record (MAR), and there was no documentation of pain assessments before and after administration, nor evidence of non-pharmacological interventions prior to giving the narcotic medication. These findings were verified by facility staff during medication cart inspections and medical record reviews. Another resident receiving insulin injections did not have injection sites rotated as required by the care plan, with repeated administration to the same abdominal quadrants on multiple occasions. This was confirmed through review of the Location of Administration Report and the resident's care plan, which specified site rotation as an intervention. Additionally, a medication administration observation revealed that a nurse failed to instruct a resident to chew an aspirin 81 mg chewable tablet, and there was no documentation of physician notification or order clarification when the resident was unable to chew the medication, as required by facility policy. Further deficiencies included missing documentation for the administration of famotidine for one resident, with the MAR lacking evidence of administration on a scheduled date and a delayed entry made weeks later. Another resident's insulin glargine was held on multiple dates due to vital signs being outside parameters, but there was no physician order specifying these parameters, nor were there progress notes or documentation of physician contact regarding the held doses. These findings were acknowledged by facility leadership during interviews.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in medication storage and labeling practices within the facility. A pack of hydrocodone-acetaminophen tablets prescribed to a discharged resident was found stored in the IV cart, with the Controlled Drug Record indicating the medication had not been properly removed or destroyed after the resident's discharge. Additionally, four Calmoseptine ointments were discovered in a treatment cart without expiration or received dates, and the nurse confirmed that the ointments should not have been kept since their receive date was unknown. Two unlocked medication disposal bins containing undissolved tablets, sharps containers, liquid medication bottles, nasal spray containers, and insulin pens were also observed, indicating a lack of secure storage for medications awaiting disposal. Further observations revealed a bottle of Pro-Stat Advanced Wound Care supplement with sticky brown residue on and around the cap and bottle, which was verified by the nurse as not being cleaned after use as required by facility policy. Interviews with nursing staff and the DON confirmed that licensed nurses were responsible for maintaining the cleanliness, storage, and labeling of medications in their assigned carts, and that these expectations were not met in the instances observed.
Failure to Follow Posted Menus and Document Dietary Substitutions
Penalty
Summary
The facility failed to follow its posted menus and dietary policies for 20 out of 93 residents who received food prepared in the kitchen. Specifically, 19 residents on a consistent carbohydrate (CCHO) diet were served canned fruit instead of the diet gelatin with whipped topping as indicated on the posted menu, and one resident was not served the gelatin with whipped topping as per the menu. Observations during lunch revealed that meal tickets for these residents specified the correct menu items, but the actual food served did not match. Staff interviews confirmed that the substitutions were made because the facility did not have the required diet gelatin with whipped topping available, and the menu was not updated to reflect this change. Additionally, residents were not notified of the menu change, and the required documentation of substitutions was not completed as per facility policy. The facility's dietary services supervisor (DSS) and registered dietitian (RD) acknowledged that the menu was not changed and that residents were not informed of the substitution. The facility's policies require that all substitutions be noted on the menu and filed according to established dietary policy, and that menus be posted and followed to meet residents' nutritional needs. The failure to provide the specified menu items and to document or communicate the substitutions resulted in residents not receiving the planned meals as per their dietary requirements.
Deficiency in Food Palatability and Nutrient Preservation
Penalty
Summary
The facility failed to ensure that food provided to residents was palatable, attractive, and maintained at a safe and appetizing temperature, as well as preserved in nutritive content. Observations revealed that pureed carrots were cooked and then held in a hot oven at 200 degrees Fahrenheit for over two hours prior to meal service. The pureed carrots were prepared at 9:45 AM and kept in the oven until the trayline at 11:30 AM, with a measured temperature of 172 degrees Fahrenheit on the steam table. The Registered Dietitian (RD) and Dietary Services Supervisor (DSS) acknowledged these findings during interviews, although the RD stated that nutrient loss was more related to preparation method than timing. Additionally, the facility did not ensure food palatability for residents. During lunch, a resident on a no added salt diet with regular texture and double portions for malnutrition and advanced age was unable to cut or eat the corned beef due to its toughness. The resident reported the issue to a nurse and requested alternative food brought by visitors. During a resident council meeting, two other residents also reported that the corned beef served was hard and difficult to chew or cut. Staff interviews confirmed that multiple residents complained about the toughness of the corned beef and requested alternative entrees, with staff assisting some residents in cutting the meat. The facility's documentation showed that the majority of residents received food prepared in the kitchen, including those on pureed diets. The menu for the meal in question included corned beef, and several residents expressed dissatisfaction with the meal's texture and palatability. The DSS and RD acknowledged awareness of the complaints, and staff confirmed that alternatives were offered to those who reported issues with the meal.
Failure to Provide Properly Prepared Diets for Residents with Modified Diet Orders
Penalty
Summary
The facility failed to ensure that residents on mechanically altered diets received food in a form that met their individual needs. Specifically, one resident with a physician's order for a regular pureed diet was initially served a regular dysphagia mechanical soft meal, as indicated on her meal ticket, rather than the pureed diet listed on the Diet Type Report. Staff were observed checking meal trays and discovered the discrepancy, but were unable to immediately explain why the meal ticket and Diet Type Report did not match. The resident's diet had been updated in the system by the speech therapist, but the physician's order was not updated in the electronic health record, leading to confusion about the correct diet order. Additionally, during the preparation of pureed BBQ chicken for residents on pureed diets, the food was observed to contain small chunks of chicken, rather than being of a smooth and moist consistency as required by the facility's policy. The dietary staff member responsible for preparing the pureed food used a blender but did not achieve the required texture, and the dietary services supervisor acknowledged the presence of chunks in the pureed chicken. These failures affected 11 residents on pureed diets and did not meet the facility's standards for food preparation for residents with chewing and swallowing difficulties.
Failure to Educate on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to ensure that staff, residents, and visitors were adequately educated on safe food handling practices for foods brought in from outside sources. The facility's policy required education on safe food handling to be provided and for educational materials to be available at the reception desk. However, interviews with multiple CNAs, an LVN, the DSD, the RD, and the Admissions Director revealed that staff either did not receive specific education on safe food handling or were unclear about proper procedures, such as reheating food to appropriate temperatures and safe storage practices. Staff members reported inconsistent practices regarding reheating and storing food brought in by families or visitors. Several CNAs stated they would microwave food for short periods based on resident preference, without knowledge of required temperatures for food safety. Some staff indicated they did not know how to check food temperatures or had not received education on this topic. The LVN and Admissions Director also confirmed that their education to residents and families focused on labeling and storage duration, but did not include specific safe food handling instructions. The DSD and RD acknowledged that while in-services and policies were reviewed with staff, there was no specific education provided on safe food handling. The educational materials available at the reception desk also lacked information on safe food handling. The facility's failure to provide comprehensive education on this topic was confirmed by the Administrator and DON during interviews.
Facility Assessment Lacks Required Stakeholder Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure its Facility Assessment was developed in accordance with updated CMS guidance. Specifically, the assessment did not demonstrate the active involvement of direct care staff, their representatives, residents, residents' representatives, or family members in its development. Additionally, the assessment lacked documentation of the resources necessary to care for residents during weekends, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. During an interview and document review, the Administrator confirmed that the Facility Assessment was not updated to reflect the latest CMS requirements. The Administrator acknowledged the absence of input from required stakeholders and the omission of critical components such as weekend staffing resources, recruitment and retention strategies, and contingency staffing plans. There were no specific residents or patient conditions mentioned in relation to the deficiency.
Failure to Implement Antibiotic Stewardship Program and Document McGeer's Criteria
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as outlined in its policies and procedures, specifically regarding the use of McGeer's criteria for identifying true infections. For one resident, the Infection SBAR - Respiratory Tract - Pneumonia form did not indicate whether McGeer's criteria were met, and only two out of the required three criteria were documented. The Infection Preventionist (IP) confirmed that the third criterion, acute functional decline, should have been marked, as the resident had shown a decline in function. The IP also stated that the licensed nurse should have documented whether the criteria were met or not met after completing the SBAR. The Director of Nursing (DON) acknowledged that the licensed nurse did not complete the necessary documentation to confirm that the resident met the criteria for signs and symptoms of pneumonia. The resident in question had a history of COPD and was prescribed levofloxacin for COPD/cough, but the documentation failed to fully support the diagnosis of pneumonia according to the facility's established protocol. Both the IP and DON verified these findings during interviews and medical record reviews.
Call Light Not Accessible to Resident Requiring Maximum Assistance
Penalty
Summary
The facility failed to provide reasonable accommodations for one resident by not ensuring the call light was within the resident's reach. During an initial tour, the call light button for the resident was observed hanging over a cord near the wall above the head of the bed, not accessible to the resident. The facility's policy required that a communication system be provided and accessible for residents to call staff for assistance, with urgent needs to be answered immediately. The resident in question had severe cognitive impairment and required maximum assistance with activities of daily living (ADLs), as documented in the medical record and MDS assessment. Multiple staff interviews confirmed that the resident needed staff assistance and that the call light was not within reach. A CNA and an LVN both acknowledged the call light was clipped to the wall and not accessible to the resident, and the DON verified these findings. The failure to ensure the call light was within reach did not align with the facility's policy and had the potential to negatively impact the resident's well-being.
Failure to Provide Timely Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to a resident or their representative, specifically the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 and the Notice of Medicare Non-Coverage (NOMNC) Form CMS 10123. Review of the resident's medical record showed that both forms were not signed by the resident or their representative. The Social Services Director (SSD) confirmed that the forms were not provided to the resident's representative before the last covered day of Medicare Part A services. Although the SSD stated that the notices were sent via email, there was no confirmation or receipt of signed forms from the representative. Further review and interviews revealed that the NOMNC and SNF ABN forms were only completed and signed after the last covered day, and not in a timely manner as required. The Medical Record Director acknowledged that the forms were not completed within the appropriate timeframe. The Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required timeframe for three residents. For two residents who were discharged home, the Discharge MDS Assessments were completed and signed more than nine and ten weeks past the required completion dates, which should have been no later than 14 days after discharge. The MDS Coordinator confirmed that these assessments were completed late. Additionally, for another resident who was discharged with return anticipated, the MDS Discharge Assessment was completed later than the required 14-day window following discharge, as verified by the responsible MDS Coordinator. Interviews with the MDS Coordinators, Administrator, and DON confirmed the late completion and transmission of the MDS Discharge Assessments for all three residents. The facility staff acknowledged that sometimes MDS submissions were delayed due to workload, resulting in the assessments not being transmitted within the federally mandated timeframe.
Inaccurate Documentation of Glucometer Serial Number on Quality Control Log
Penalty
Summary
The facility failed to ensure the accuracy of documentation on the Quality Control Log for one of four medication carts. During an interview and document review with an LVN, it was found that the serial number labeled on the glucometer device did not match the serial number documented on the Quality Control Record. The LVN confirmed this discrepancy.
Failure to Ensure Safe and Orderly Resident Transfer
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was transferred to an acute care hospital. The resident, who had severe cognitive impairment and a history of PTSD and TBI, was transferred without the hospital being notified and without the necessary medical records being sent. The transfer form did not document the name and title of the nurse who called in the report to the receiving facility, nor the name and title of the nurse who received the report. This lack of documentation and communication posed a risk to the resident's medical needs. Interviews with the RN and DON revealed that the facility's policy required the transferring nurse to notify the receiving facility and provide the resident's medical records. However, the RN could not recall if the report was called in or if the medical records were handed to the ambulance personnel. The Administrator confirmed that the acute care hospital had not been notified of the transfer, no medical records were sent, and there was no accepting MD. The facility's failure to follow its own policies resulted in the resident being transferred without the necessary medical information, as verified by the Administrator and DON.
Failure to Ensure Privacy and Delivery of Resident's Mail
Penalty
Summary
The facility failed to ensure the privacy and timely delivery of a mailed package for a resident, which had the potential to violate the resident's rights to receive mail. The facility's policy and procedure on resident rights, revised in December 2016, guarantees residents the right to communicate and access services with privacy, including the right to send and receive mail unopened. However, a complaint was received from a family member stating that a package sent to the resident was opened by the facility and not delivered to the resident, who had already been discharged to another care facility. An observation and interview with the Admission Assistant revealed that the package was in the admission's office, opened, and had not been delivered to the resident or returned to the sender. The Admission Assistant admitted to being aware of the package and had informed the family member of her intention to deliver it to the resident's current skilled nursing facility but failed to do so due to a busy schedule. The Administrator confirmed the facility's process of securing mailed packages and working with residents on delivery timeframes, but acknowledged the findings of the opened and undelivered package.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for two residents. Resident 1, who was admitted to the facility and later transferred to an acute care hospital, had impaired judgment and lacked the mental capacity to make decisions. Despite the physician's order for transfer, there was no documentation in Resident 1's medical record indicating that the notice of transfer was sent to the Ombudsman. Similarly, Resident 2, who had the mental capacity to make decisions, was transferred to an acute hospital following a physician's order. However, the medical record for Resident 2 also lacked evidence that the notice of transfer was sent to the Ombudsman. Interviews with the RN, DON, and ADON confirmed the absence of documentation or evidence that the required notices were sent, which posed a risk of the Ombudsman not being informed of the residents' transfer circumstances.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident or the resident's representative prior to a transfer to an acute care hospital. This deficiency was identified during a review of the facility's policy and procedure (P&P) titled 'Bed-holds and Returns,' which mandates that residents or their representatives be informed in writing of the bed hold and return policy before any transfers. The medical record review for a resident, who was admitted to the facility and later transferred to a hospital, revealed that the resident had impaired judgment and lacked the mental capacity to make decisions. Despite this, there was no documentation indicating that the resident or their representative was informed of the bed hold policy before the transfer. An interview with the Director of Nursing (DON) confirmed that the bed hold informed consent section was left blank upon the resident's admission, and the DON acknowledged that the policy should have been explained to the resident or their representative at that time.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for two sampled residents and two nonsampled residents. The medical records for these residents were found to be incomplete, as medications were not documented as administered according to the facility's policy and procedure. Specifically, Resident 3's medication administration record (MAR) did not show documentation for a scheduled insulin injection on a specific date. Similarly, Resident 7's MAR lacked documentation for the administration of melatonin, atorvastatin, and insulin on specified dates. Resident C's MAR was missing documentation for several medications, including alendronate, levothyroxine, and Protonix, as well as blood sugar monitoring. Resident D's MAR did not show documentation for Lispro insulin administration on multiple dates. Interviews conducted with LVN 6 and the Assistant Director of Nursing (ADON) confirmed these findings. LVN 6 admitted to administering the medications to Residents 3 and D but failed to document them as administered. The ADON verified the findings and acknowledged that LVN 6 forgot to document the medication administration. This lack of documentation had the potential to impact the residents' care needs, as the medical information was incomplete and inaccurate.
Failure to Notify Physician and Monitor Resident's Condition
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident with end-stage renal disease. The resident missed dialysis appointments on two consecutive days, and there was no documented evidence that the attending physician was notified of these missed appointments. The facility's policy required that the physician be informed of any missed dialysis sessions, but this was not adhered to, potentially affecting the resident's health. Additionally, the facility did not follow through on a communication form from the dialysis unit that instructed them to notify the attending physician about the resident's complaints of blood in bowel movements. There was no documented evidence that the facility assessed or informed the physician of these complaints, as required by the special instructions on the form. This oversight indicates a failure to address a significant change in the resident's condition. Furthermore, the facility did not adequately monitor or follow up on a reported change in the resident's condition regarding redness in the right ear. Although an SBAR communication form was initiated, there was no documented follow-up with the physician or reassessment of the condition. The care plan interventions for assessing pain were also not followed, as there was no documentation of assessing the location, onset, and cause of pain, despite the administration of pain medication for moderate pain levels.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse by another resident, resulting in two incidents involving inappropriate behavior by Resident 3. On 9/6/24, Resident 3 grabbed Resident 2's breasts in the smoking patio, causing Resident 2 to feel upset and violated. Despite this incident, the facility did not implement the necessary 1:1 supervision for Resident 3 as outlined in the care plan, which was intended to prevent further occurrences of such behavior. The lack of supervision allowed Resident 3 to engage in another incident on 9/8/24, where he fondled Resident 4's breasts during an activity in the dining room. This incident was witnessed by the Activities Assistant, who intervened by telling Resident 3 to stop. Resident 4, who was moderately impaired, reported feeling uncomfortable and moved away from Resident 3. The facility's failure to assign a dedicated staff member for 1:1 supervision of Resident 3, as required by the care plan, contributed to the continuation of these abusive behaviors. Interviews with facility staff, including the DON, RN 1, LVN 5, and CNA 4, confirmed that Resident 3 did not receive the necessary supervision due to staffing shortages. The facility's daily assignment sheets for the relevant dates showed no evidence of a staff member being assigned to provide 1:1 supervision for Resident 3. This oversight allowed Resident 3 to be unsupervised during activities, leading to the second incident of abuse involving Resident 4.
Failure to Report Resident Abuse Timely
Penalty
Summary
The facility failed to implement its policy and procedure to ensure the timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of sexual abuse involving two residents. Resident 4, who was moderately impaired with a BIMS score of 11, reported that her breast was fondled by another resident, Resident 3, while they were in the activity room. This incident was witnessed by the Activities Assistant, who confirmed that Resident 3 repeatedly touched Resident 4's breasts with an open palm. Despite the clear observation and report of the incident, the facility did not document or report Resident 4's abuse allegation to the California Department of Public Health Licensing and Certification Program (CDPH L&C) and local law enforcement in a timely manner. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) confirmed the failure to report the incident as required by the facility's policy and procedure, which mandates that all reports of resident abuse be reported to the appropriate authorities and thoroughly investigated.
Deficiencies in Fall and Abuse Monitoring
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for three of four sampled residents. For Resident 1, the facility did not report or document an unwitnessed fall that occurred on 8/28/24. The required 72-hour neurological and post-fall risk assessments were not completed. Interviews with staff revealed that Resident 1 was found sitting on the floor, but there was no documentation of this incident in the medical record. The Director of Staff Development (DSD) and Director of Nursing (DON) confirmed the lack of documentation and assessments. For Residents 2 and 4, the facility failed to monitor psychosocial harm following abuse allegations. Resident 2 reported being grabbed by another resident, and Resident 4 reported being fondled. Although care plans were initiated for both residents, there was no documented evidence of monitoring in their progress notes. The Social Services Director (SSD) was unaware of Resident 2's abuse allegation, indicating a communication breakdown. The DON confirmed that there was no post-Care of Concern (COC) monitoring for Residents 2 and 4, which should have included frequent checks every two hours per shift. This lack of monitoring and documentation potentially affected the residents' health and well-being, as the facility did not adhere to its policies and procedures for handling falls and abuse allegations.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide necessary care and services to prevent or minimize injuries from falls for a resident with a history of falls. The resident's care plan included the use of floor mats to mitigate fall risks, but these were not in place as required. Additionally, the fall risk assessment for the resident was inaccurate, failing to reflect the resident's true risk level. This oversight was identified during a review of the resident's medical records, which showed a fall on a specific date and an unwitnessed fall later, indicating a pattern of inadequate fall prevention measures. Interviews with facility staff revealed further deficiencies in the implementation of fall prevention protocols. A registered nurse acknowledged that the floor mats, which were supposed to be placed beside the resident's bed, were instead found against the wall. Another nurse confirmed that the fall risk assessment was not completed accurately, as it did not account for the resident's recent fall and intermittent confusion, which should have resulted in a higher risk score. The Director of Nursing also acknowledged these findings, highlighting a lapse in adherence to the facility's policies and procedures regarding fall risk management.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for a resident who complained of pain. On 8/28/24, the resident, who had a swollen and discolored right wrist, reported pain during a range of motion assessment. Despite having a physician's order for acetaminophen rectal suppository for mild pain, the medication was not administered because the resident was NPO. The nurse did not contact the physician for alternative pain management options and forgot about the existing order for the suppository. The resident's medical records did not show any documentation of pain relief being offered or provided on the day of the complaint. Interviews with the resident and RN confirmed the resident experienced pain and was not given any pain medication. The Director of Nursing acknowledged these findings, indicating a lapse in following the facility's policies and procedures for pain management and communication with the attending physician.
Failure to Implement Care Plan for Resident with Dysphagia
Penalty
Summary
The facility failed to implement a care plan for a resident with special feeding needs, which was necessary due to the resident's swallowing problem related to dysphagia. The care plan, initiated on 7/15/24, required all staff to be informed of the resident's special dietary and safety needs, including specific instructions for feeding. However, on 8/14/24, a CNA who was newly hired and had not yet completed skill checks for meal services and feeding, fed the resident without being informed of these special needs. This resulted in the resident experiencing difficulty swallowing after being fed three spoons of food. The CNA, who was an orientee at the time, stated during an interview that she was not given any special instructions on how to feed the resident. The Director of Nursing confirmed there was no documented evidence that the CNA was educated about the resident's special dietary and safety needs. This oversight in communication and training led to the potential for the resident not receiving care and services to meet their care needs.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This failure occurred when an incident involving a resident-to-resident altercation was not reported to the appropriate authorities, including the law enforcement agency, CDPH L&C Program, and Ombudsman office. The incident involved three residents, where one resident pointed a table knife at another, and the altercation was witnessed by staff members. Resident 1, who had no cognitive impairment, was involved in an argument with Resident 2, who had moderate cognitive impairment. The argument escalated when Resident 1 pointed a table knife at Resident 3, who did not have the capacity to understand and make decisions. Despite the severity of the incident, it was not reported to the necessary authorities as required by the facility's policy. The Director of Nursing (DON) and other staff members were aware of the incident but did not take the necessary steps to report it. Interviews with the residents and staff revealed that the incident was documented in Resident 1's progress notes, but no formal report was made. The Administrator was only notified of the incident several days later and acknowledged that the incident should have been reported as abuse. The lack of timely reporting of the incident had the potential to put residents at risk for further abuse.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by several deficiencies in the administration and monitoring of these medications. The resident, who had the capacity to make medical decisions, was prescribed Ativan and Restoril on a PRN basis for agitation, restlessness, and insomnia. However, the facility did not obtain informed consent from the resident for the use of Ativan, and the consent for Seroquel was not signed and dated by the physician. This lack of proper documentation and consent was verified by the Director of Nursing (DON) during interviews. Additionally, the facility did not adequately monitor the resident's behaviors or the efficacy and adverse effects of the medications. The Medication Administration Record (MAR) showed that Ativan and Restoril were administered without documented observations of the behaviors they were intended to address. The behavior monitoring was incomplete, with observations marked as 'x' or 'no,' indicating that the required behaviors were not observed. The DON confirmed that the medications were administered without the necessary behavior observations and acknowledged the incomplete monitoring. Furthermore, there was no documented evidence that the resident was monitored for adverse effects of the psychotropic medications. Interviews with nursing staff revealed a belief that monitoring was occurring, but the closed medical record review showed otherwise. The DON verified the absence of documentation for monitoring adverse effects, highlighting a significant oversight in the resident's care management.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that Resident 2 was free from significant medication errors, as the resident did not receive medications as ordered by the physician on multiple occasions. The medications involved included amlodipine, bumetanide, metoprolol, apixaban, and nifedipine, which were not administered on various dates in August and September 2023. The facility's Medication Administration Record (MAR) indicated reasons such as 'waiting delivery' and 'medication not available' for the missed doses. Additionally, the facility did not notify the resident's physician about these missed medications, which could have led to significant adverse effects. The facility's contracted pharmacy confirmed that the medications were sent within four to six hours of receiving the orders, except for amlodipine and bumetanide, which were marked as 'do not fill' by the facility. The Director of Nursing (DON) verified the findings and was unable to provide documentation showing that the physician was notified or that the pharmacy was contacted regarding the missed medications. This lack of communication and failure to administer medications as prescribed contributed to the deficiency identified in the report.
Delay in STAT Psychiatric Consultation
Penalty
Summary
The facility failed to adhere to a physician's order for a STAT psychiatric consultation for one of the residents, identified as Resident 3. The order was placed on 7/2/24, but the psychiatric nurse practitioner did not conduct the evaluation until 7/11/24, resulting in a nine-day delay. This delay in executing the STAT order had the potential to delay necessary treatment and services, which could negatively impact the resident's health conditions. During an interview on 8/2/24, the Director of Nursing (DON) confirmed that the Assistant Director of Nursing (ADON) was responsible for ensuring that STAT referrals were prioritized and followed up. The DON acknowledged that the nine-day delay did not meet the criteria for a STAT evaluation.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician of changes in a resident's condition, specifically when the resident's inhaler ran out and the resident experienced increased anxiety. The facility's policy and procedure required notifying the attending physician or physician on call in the event of a significant change in the resident's condition. However, the physician was not informed when the resident's albuterol inhaler was unavailable, and the pharmacy could not refill it due to the medication being too early for a refill. The resident was also experiencing anxiety, and a request was made to reinstate Ativan for anxiety, but there was no documented evidence of follow-up communication with the physician. The resident's condition deteriorated as they refused a nebulizer treatment and supplemental oxygen, leading to decreased blood oxygen levels and eventually becoming unresponsive. The resident's heart rate dropped, and they became pulseless, necessitating CPR until paramedics arrived. Interviews with the LVN and DON revealed that there was no follow-up call made to the physician or NP, and the oncoming shift was not informed to follow up on the physician's response. The DON confirmed that the staff should have made further attempts to notify the physician or NP about the resident's condition.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency was identified when an abuse allegation involving a resident was not reported to the State Agency, Ombudsman, and local law enforcement. The facility's policy, revised in April 2021, mandates that all allegations of abuse be reported and investigated within required timeframes. However, in the case of Resident 2, who alleged verbal abuse by family members during a tele-visit with a psychologist, the facility did not fulfill these reporting obligations. The Social Services Director (SSD) was present during the tele-visit and acknowledged the abuse allegation but incorrectly believed that only the Ombudsman needed to be notified, not the APS or law enforcement. The SSD admitted to being unsure about the reporting timelines and requirements. The facility's Administrator was informed of the allegation only after the Ombudsman visited the facility, indicating a delay in the reporting process. Additionally, the Nurse Consultant confirmed that no abuse allegation was reported to him, and he did not conduct any investigation. This series of inactions led to the failure to report the abuse allegation as required by the facility's policy and federal regulations.
Failure to Investigate Abuse Allegation Timely
Penalty
Summary
The facility failed to timely investigate an abuse allegation involving a resident, identified as Resident 2, which had the potential for not protecting the resident from abuse. The facility's policy and procedure on abuse prevention, revised in April 2021, required the identification and investigation of any abuse allegations within specified timeframes. On May 31, 2024, during a tele-visit with a psychologist, Resident 2 alleged verbal abuse by family members, which was deemed necessary to report to Adult Protective Services (APS) and the Ombudsman. However, the facility did not investigate the allegation promptly. The Administrator was informed of the allegation several days later by the Ombudsman and stated that the Interim Director of Nursing (DON) should have conducted the investigation. Interviews with the Administrator, Resident 2, and a Nurse Consultant revealed that the abuse allegation was not reported or investigated as required by the facility's policy.
Deficiencies in Resident Care and Emergency Procedures
Penalty
Summary
The facility failed to provide necessary care and services for two residents, as well as maintain current emergency procedures. For Resident 1, the facility did not complete daily skilled nursing notes despite orders for skilled services, including physical and occupational therapy. The Director of Nursing (DON) confirmed the absence of these notes during a review of Resident 1's medical records, acknowledging that such documentation was required for residents receiving skilled services. For Resident 3, the facility did not complete a timely psychiatry consult, which was ordered alongside antipsychotic and mood stabilizer medications. The psychiatry consult was not conducted within the expected three-day timeframe, as confirmed by the DON. Additionally, the facility's emergency procedures policy was outdated, referencing the use of an automatic external defibrillator (AED) that was not available in the facility. The DON and Administrator confirmed the absence of a defibrillator, and the policy had not been revised to reflect the actual emergency protocol in place.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to implement safety interventions and provide adequate supervision for 21 out of 27 sampled residents who smoked. The facility's policy required that residents be informed of the smoking policy upon admission, which included designated smoking areas and the use of disposable safety lighters stored by staff. However, observations revealed that residents were smoking outside designated areas and without staff supervision. Residents were found with cigarettes and lighters in their possession, contrary to the facility's policy that these items be stored by staff. Interviews with residents and staff indicated a lack of adherence to the smoking policy. Residents reported smoking at any time and place, including the patio, without staff presence. The Administrator and DON acknowledged that smoking assessments were conducted upon admission, but there was no structured process for designated smoking times or proper storage of smoking materials. This lack of supervision and policy enforcement posed a risk of injury to residents while smoking.
Failure to Provide Prescribed Respiratory Medications
Penalty
Summary
The facility failed to ensure that a resident received their prescribed respiratory medications as per the physician's orders. The resident had orders for albuterol sulfate inhalation aerosol powder to be inhaled every six hours as needed for shortness of breath or wheezing, and ipratropium-albuterol solution to be inhaled via nebulizer every six hours. However, the resident's medical administration record showed that the last dose of albuterol was administered on April 13, 2024, and the resident's inhaler ran out. The pharmacy was unable to refill the prescription due to insurance denial, and the facility did not complete the necessary authorization form to cover the cost of the medication. On April 15, 2024, the resident requested the albuterol inhaler due to increased anxiety, but it was unavailable. Instead, an unscheduled dose of ipratropium-albuterol solution was administered without a physician's order. Interviews with the LVN and DON confirmed that the albuterol should have been available and that the unscheduled administration of the ipratropium-albuterol solution was inappropriate. The pharmacy indicated that they had communicated the need for authorization to the facility, but the facility did not respond, resulting in the medication not being refilled.
Controlled Medication Reconciliation Failure
Penalty
Summary
The facility failed to ensure accurate controlled medication reconciliation for two residents, leading to discrepancies in the administration and documentation of Ativan, a controlled medication for anxiety. For Resident 3, the Antibiotic or Controlled Drug Record showed that Ativan tablets were removed from the supply on specific dates, but the Medication Administration Record (MAR) did not reflect these actions accurately. On one occasion, a tablet was marked as wasted without a required co-signature, and on another, it was marked as refused without proper documentation. The Director of Nursing (DON) confirmed these discrepancies during a review, acknowledging the lack of co-signatures and the failure to document whether the medication was administered or why it was not. Similarly, for Resident 1, the record indicated that an Ativan tablet was removed from the supply, but the MAR did not show that the medication was administered. The DON verified that the Ativan was not documented as administered, which should have been recorded. These documentation failures had the potential for drug diversion, as the controlled count sheet did not match the residents' MAR, indicating a lack of adherence to the facility's policy and procedure for controlled substances.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
