Ahmc Seton Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Daly City, California.
- Location
- 1900 Sullivan Avenue, Daly City, California 94015
- CMS Provider Number
- 555235
- Inspections on file
- 23
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Ahmc Seton Medical Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and vascular dementia had a cellphone, documented on their belongings inventory, go missing. Despite the facility's policy requiring replacement of inventoried items, the cellphone was not replaced after staff were unable to locate it, and the Social Worker did not arrange for a replacement as required.
A resident with significant cognitive and physical impairments experienced four falls, including one resulting in multiple toe fractures, due to the facility's failure to consistently investigate fall causes, conduct required fall risk assessments, and ensure proper use and evaluation of fall prevention devices. Staff did not always implement care plan interventions, and documentation regarding the use and function of alarms was unclear or missing.
The facility did not provide written bed hold notices to four residents or their responsible parties when the residents were transferred to a hospital. Instead, notifications were either verbal or not given, and there was no documentation in the EHR to show that written notices were provided. The residents had various diagnoses, and their responsible parties reported not receiving information about bed hold rights or the option to return after hospitalization.
A resident's grievance regarding tube feeding administration was not thoroughly investigated. The facility failed to recognize that the ordered feeding rate exceeded the pump's maximum capacity, did not clarify unclear physician orders, and did not measure the actual amount of formula delivered. Staff were unaware of the pump's error rate, and the facility did not provide required follow-up or written notification to the complainant or ombudsman, resulting in unresolved concerns.
A resident assessed as high risk for pressure ulcers developed a Stage 2 ulcer due to the facility's failure to implement necessary interventions, such as timely provision of a low air loss mattress and appropriate offloading measures. The resident's condition worsened due to lack of communication and timely reporting of skin condition changes.
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. One resident experienced side effects from Haldol without a dosage reduction, another was given Citalopram without a clinical indication, and a third was administered Risperdal without a proper diagnosis. Additionally, PRN orders for Ativan lacked stop dates and specific frequencies.
Facility staff failed to treat three residents with dignity by not responding to their call lights in a timely manner. Residents reported waiting 30-45 minutes for assistance, and staff interviews confirmed that the facility had issues with staffing and timely response to call lights.
The facility failed to inform residents about the grievance process and did not ensure grievances were resolved appropriately. Seven residents were unaware of the grievance process, and one resident reported missing personal items with no satisfactory resolution provided by the facility.
The facility failed to ensure accurate MDS assessments for three residents. One resident's dental status was incorrectly recorded, another's hemodialysis treatment was not documented, and a third resident's pressure ulcers were inaccurately coded. These errors were confirmed by staff interviews and record reviews.
The facility failed to develop comprehensive care plans for seven residents, leading to unmet nursing needs and goals. Issues included unfit dentures, use of medications like Lovenox and Zolpidem, undocumented use of gloves and alarms, unaddressed planned weight loss, unaddressed extreme fear, and inaccurate dialysis access documentation.
The facility failed to provide preventive treatment and services to maintain and improve ROM for four residents when the physician's order for ROM exercises was not implemented. Observations and record reviews revealed inconsistent documentation and performance of ROM exercises, leading to potential complications such as contractures.
The facility failed to maintain a sanitary environment by not properly cleaning a fixed kettle between uses and having uncovered drainage holes encrusted with food particles on prep tables. Dietary staff admitted to insufficient cleaning practices, contrary to the facility's policy.
The facility failed to provide community dining and activity areas on the 4th, 5th, and 7th floors, confining residents to their rooms for meals. Observations showed no common areas on these floors, and the shared room on the 9th floor was insufficient for the residents' needs. Interviews indicated no current plans for additional dining areas.
The facility failed to ensure a shower area was clean after use and that two window screens were properly maintained. The shower room was found with hair, empty bottles, a safety razor, an opened body wash bottle, and used gloves. Additionally, two rooms had missing window screens, which the RN acknowledged and stated would be fixed by maintenance.
The facility failed to act on the pharmacy consultant's recommendation regarding the use of psychotropic medication for a resident with mood disorder and major depressive disorder. Despite identified irregularities in the medication regimen review, no corrective action was taken by the physician or nursing staff, potentially exposing the resident to unnecessary medications and adverse health consequences.
The facility failed to maintain accurate records for three residents, leading to potential mismanagement of their care. Staff did not accurately document fluid intake for a resident with unplanned weight loss and another on fluid restriction. Additionally, the target behavior for a resident with bipolar disorder was incorrectly documented.
The facility failed to document vaccine education and follow-up for two residents, resulting in missing records of pneumovax vaccine administration, refusal, and education. An RN confirmed the absence of this information during a review.
The facility failed to document COVID-19 vaccine education and follow-up or refusals for two residents. One resident had no documentation of COVID-19 vaccine administration, refusal, or education, while another had no documentation for both COVID-19 and pneumovax vaccines. An RN confirmed the missing information during a record review.
An emergency cart's red plastic lock tag did not match the log book entry, and the facility's policy failed to address the responsibility of floor staff in documenting these checks, potentially compromising emergency readiness.
The facility failed to have a secure handrail in their corridor. During an initial tour, a handrail outside a room was found not secured properly to the wall. This observation was confirmed with an RN, who stated she would inform maintenance. The lack of a secure handrail did not ensure residents who relied on handrails for mobility and/or support would be safe from a fall.
Failure to Safeguard and Replace Resident's Personal Property
Penalty
Summary
The facility failed to safeguard the personal property of a resident with moderate cognitive impairment and vascular dementia, resulting in the loss of the resident's cellphone. The cellphone, which was documented on the resident's belongings inventory at admission, was discovered missing during routine rounds. Staff searched the resident's closet, bag, drawer, and dresser but were unable to locate the cellphone. The loss was reported to the police and appropriate state agencies, and the value of the cellphone was confirmed by the resident's former student. Despite the facility's Theft and Loss Policy, which requires the Social Worker to arrange for replacement of missing items listed in the inventory, the resident's cellphone was not replaced. Interviews with the Director of Nursing and the Social Worker confirmed that the missing cellphone was documented in the inventory, but no replacement was provided. The facility's policy and procedure on theft and loss specifically state that the Social Worker is responsible for arranging replacement if needed, but this step was not taken in this case.
Failure to Implement and Evaluate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, specifically in the implementation of its fall prevention program for a resident with multiple risk factors. The facility did not consistently conduct thorough investigations into the primary causes of the resident's falls, nor did it perform fall risk assessments after two of the resident's falls, as required by facility policy. Documentation was unclear or lacking regarding whether fall prevention devices, such as tab alarms and bed alarms, were properly applied or functioning at the time of the falls. Staff also did not consistently implement care plan interventions, such as ensuring alarms were in place and activated. The resident involved had significant cognitive and physical impairments, including dementia, Parkinson's disease, depression, anxiety, osteoarthritis, and movement disorders. She required substantial to maximal assistance with transfers and toileting and had no voluntary control over bowel and bladder functions. Despite being assessed as high risk for falls, the resident experienced four falls within a four-month period, one of which resulted in fractures to all five toes on her right foot. Observations and interviews revealed that the resident was able to unclip her tab alarm unassisted, and staff were aware of this but did not evaluate or implement alternative interventions. Interdisciplinary team (IDT) notes and interviews with facility leadership indicated that post-fall huddles and investigations were inconsistently documented and did not always address whether alarms were used or functioning. In some cases, staff presumed the cause of the fall without direct evidence, and there was no documentation of reminders to staff regarding the application of alarms. The facility's own policy required fall risk assessments after each fall, but these were not completed for at least two incidents. Only one root cause analysis was conducted for the resident's falls, despite multiple incidents.
Failure to Provide Written Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of bed hold rights to four sampled residents or their responsible parties at the time of transfer to an acute care hospital. In each case, interviews and record reviews confirmed that neither the residents nor their responsible parties received the required written notification regarding the option to request a bed hold during hospitalization or therapeutic leave. Instead, notifications were either given verbally or not at all, and there was no documentation in the electronic health records to indicate that written notices had been provided. The residents involved had various medical conditions, including encephalopathy, urinary tract infection, femoral neck fracture, congestive heart failure, hypertensive heart disease, and acute bronchitis. Responsible parties for these residents reported not receiving any written bed hold notices and were unaware of their rights regarding bed holds and the possibility of returning to the facility after hospitalization. Facility staff interviews further confirmed the absence of written notifications and revealed that the process for providing such notices was inconsistent and not documented as required by facility policy.
Failure to Thoroughly Investigate Tube Feeding Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance regarding the administration of tube feeding formula for a resident who was ordered to receive 325 ml of formula within one hour at four specified times daily. The investigation did not consider the maximum rate of the facility's tube feeding pumps, which was 295 ml/hr, making it impossible to deliver the ordered amount within the specified time using the pump alone. Additionally, the facility did not identify that the physician's order was unclear and unachievable with the available equipment, nor did staff question or clarify the order despite its impracticality. During the investigation, staff did not measure the total amount of tube feeding in the enclosed bag before and after feedings, nor did they verify the amount of formula remaining after the third feeding session. This omission made it difficult to determine if the resident was receiving the prescribed amount. Observations confirmed that after three feedings, significantly more formula remained in the bag than expected, indicating the resident was not receiving the full ordered amount. Furthermore, staff were unaware that the tube feeding pumps had a plus/minus 10% error rate, which could result in under-delivery of the formula. The facility unilaterally declared the grievance resolved without providing follow-up or written notification to the complainant or ombudsman, as required by their own grievance policy. Documentation confirming communication of the investigation's outcome to the complainant and ombudsman was not provided. The lack of a thorough investigation and failure to address the complainant's concerns led to the issue being escalated to the state health department.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of an avoidable pressure ulcer for a resident (Resident 22) who was assessed as high risk for pressure ulcers. Despite being identified as needing extensive assistance with bed mobility and being incontinent, the resident did not have appropriate interventions implemented to prevent skin breakdown. Observations revealed that the resident was often found lying in bed without any device to offload pressure from the coccyx, which is a critical measure to prevent pressure ulcers. The resident developed a Stage 2 pressure ulcer on the coccyx, which was first observed on 8/2/23 and continued to worsen over time due to the lack of appropriate interventions, such as the timely provision of a low air loss (LAL) mattress that was ordered but not delivered promptly. The wound management detail reports indicated a decline in the wound's healing status, with measurements showing an increase in the size of the ulcer and signs of maceration due to prolonged exposure to moisture. The facility's failure to implement the necessary interventions, such as the use of a therapeutic support surface and offloading measures, contributed to the resident's condition worsening. Interviews with nursing staff revealed that there was a lack of communication and timely reporting of changes in the resident's skin condition, which could have prevented the progression of the pressure ulcer. The care plan for the resident included goals and approaches to prevent skin breakdown, but these were not effectively executed, leading to the development and worsening of the pressure ulcer.
Failure to Ensure Residents Were Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 409 experienced side effects from the use of Haldol, an antipsychotic drug, and the facility did not lower the dosage for 96 days after side effects were identified. The resident's aggressive behaviors were linked to smoking restrictions, but non-medication interventions were not adequately implemented. Additionally, the resident was not started on Ingrezza, a medication to counteract Haldol's side effects, until much later, despite the recommendation to lower the Haldol dosage while waiting for approval for Ingrezza. Resident 70 was administered Citalopram, an antidepressant, without a clinical indication for its use. The resident's records did not show a diagnosis of depression, and the medication was administered continuously without proper justification. Furthermore, the PRN order for Ativan, a medication used to treat anxiety, did not have a stop date, which is against the recommended practice for psychotropic medications. Resident 86 was given Risperdal, an antipsychotic medication, without a proper clinical indication. The resident's records indicated diagnoses of stroke and depression, but not a psychotic disorder. Additionally, the PRN order for Ativan did not have a specific frequency and duration, which was identified as an irregularity by the pharmacist but remained uncorrected by the physician.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
Facility staff failed to treat three out of 24 sampled residents with dignity by not responding to their call lights in a timely manner. Resident 6, who had multiple diagnoses including respiratory failure, obesity, kidney failure leading to dialysis, and a wound near the tailbone, had to wait up to 45 minutes for assistance after having a bowel movement. His responsible party reported that staff cited being short-staffed as the reason for the delay. Resident 408, who had diagnoses including paraplegia, depression, respiratory problems, anxiety, chronic pain, and arthritis, also reported waiting 30-45 minutes for assistance and felt that newly transferred residents were treated like second-class citizens. Resident 82, with diagnoses including cancer, malnutrition, breathing problems, and a stomach feeding tube, reported waiting 5-35 minutes for staff to respond to his call light. Interviews with direct care staff confirmed that the facility had issues with staffing and timely response to call lights. A CNA reported that the facility was often short at least three CNAs. An RN stated that the facility was sometimes short of CNAs and LVNs, sometimes by one or two staff members. Another RN mentioned that the facility was usually short of direct care staff two to three days a week. These staffing shortages contributed to the delays in responding to residents' call lights, thereby failing to ensure that residents were treated with dignity and respect.
Failure to Inform Residents About Grievance Process and Resolve Grievances
Penalty
Summary
The facility failed to inform residents about the grievance process and did not ensure that grievances were resolved appropriately. During a resident council meeting, seven residents stated they were unaware of the facility's grievance process. Additionally, Resident 408 reported missing personal items during her transfer to the facility. The facility claimed that the resident's friend had the missing belongings, but the friend confirmed she only had limited possession of the items. The Director of Nursing (DON) was aware of the issue and filed a Theft & Loss Report but failed to provide proof of follow-up with the resident or her friend to confirm the resolution. The facility's grievance policy, revised in October 2023, requires informing residents of the resolution to ensure their satisfaction. However, the DON was unable to provide evidence that the grievance process was completed or that Resident 408 was satisfied with the resolution. This failure to inform residents about the grievance process and to follow through on grievance resolutions did not ensure that residents' concerns were addressed in a timely and appropriate manner.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three of 24 sampled residents. Resident 4's Minimum Data Set (MDS) dental assessment was inaccurate. During an observation, Resident 4's dentures were seen in a denture cup, and the resident mentioned difficulty chewing with them. The MDS for Resident 4 did not indicate the presence of dentures, which was confirmed by the Social Worker and Director of Nursing, who acknowledged a history of MDS discrepancies in the facility. The facility had stopped reauditing MDS assessments for the past six months due to relocation. Resident 6's MDS assessment inaccurately indicated that he was not on hemodialysis, despite his care plan showing a dialysis care plan initiated earlier. The MDS nurse confirmed the error and stated that a corrected MDS would be uploaded. For Resident 13, the MDS inaccurately recorded three pressure ulcers when there was only one. The MDS nurse admitted the coding error and was unable to explain why the sacral wound was identified incorrectly. These inaccuracies in the MDS assessments could potentially harm the residents by not providing the necessary care and services to maintain their highest level of functioning.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for seven residents, leading to unmet nursing needs and goals. Resident 4 experienced pain due to unfit dentures, which was reported to the nursing staff but not included in the care plan. Similarly, Resident 7's use of the blood-thinning medication Lovenox was not care planned until months after the medication was prescribed. Resident 70's use of Zolpidem for insomnia was also not included in the care plan until several months after the medication was ordered. Resident 78's care plan did not reflect the use of gloves to prevent self-scratching or the use of tab and bed alarms for fall prevention, despite these interventions being in place. Resident 38's planned weight loss was not documented in the care plan, even though the resident's weight had been gradually decreasing. Additionally, Resident 407's care plan did not address the specific target behavior of extreme fear for which Seroquel was prescribed. Finally, Resident 6's dialysis care plan inaccurately documented the dialysis access site, conflicting with other medical records that indicated the correct site. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors, highlighting the facility's failure to develop individualized, person-centered care plans for the residents involved.
Failure to Implement Physician-Ordered ROM Exercises
Penalty
Summary
The facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for four residents when the physician's order for ROM exercises was not implemented. Resident 12, who had diagnoses including dementia, stroke, hemiplegia, and hemiparesis, was observed with contracted lower extremities. The resident's records indicated that ROM exercises were ordered but not consistently documented or performed. Similarly, Resident 22, with severe cognitive impairment and hemiplegia, had an order for ROM exercises that was not consistently followed, as evidenced by incomplete documentation over several months. Resident 38, diagnosed with quadriplegia and stroke, was observed with contractures on both arms. The resident's care plan included ROM exercises, but documentation showed that these exercises were not performed consistently. Interviews with staff confirmed that ROM exercises were often not documented, indicating they were likely not performed. The Director of Nursing (DON) acknowledged that the facility lacked a dedicated Restorative Nursing Assistant (RNA) program, and all Certified Nurse Assistants (CNAs) were responsible for performing ROM exercises. Resident 14, who had multiple diagnoses including heart problems, high blood pressure, stroke, and paralysis, also had orders for ROM exercises that were not consistently documented. The DON confirmed that the standard practice was to document all ROM exercises, and any omissions in documentation indicated that the exercises were not performed. The facility's policy on ROM exercises emphasized the importance of these exercises in preventing contractures and maintaining muscle strength, but the policy was not followed consistently for the residents involved.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment by not properly cleaning one of the four fixed kettles between serving porridge and soup for lunch. During a kitchen observation, it was noted that only one of the four large built-in cooking kettles was functioning, and it was not adequately cleaned between uses. Additionally, two kitchen prep tables had uncovered drainage holes encrusted with dried, unidentifiable food particles. Interviews with dietary staff revealed that the cleaning process for the kettles was insufficient, with only occasional scrubbing for 'creamier' items. The facility's policy and procedure for food service equipment safety and sanitation required kettles to be cleaned and sanitized after each use, which was not followed.
Lack of Community Dining and Activity Areas
Penalty
Summary
The facility failed to provide a community dining and activity area on the 4th, 5th, and 7th floors, resulting in residents being confined to their rooms for all meals. During observations, it was noted that there was no common area or dining room on the 7th and 5th floors. Additionally, the room on the 9th floor, which was being used for a singing activity, lacked sufficient chairs and tables and was shared by residents from the 4th, 5th, and 7th floors, leading to limited capacity, especially with residents in wheelchairs accompanied by their CNAs. Interviews with the Director of Dietary and the Director of Admin revealed that there were no current plans for installing dining areas on each floor, and the facility was awaiting insurance estimates for future plans.
Failure to Maintain Clean Shower Area and Window Screens
Penalty
Summary
The facility failed to ensure a shower area was clean after use and that two window screens were properly maintained. During an initial tour with the Director of Nursing (DON), the shower room across from a specific room was found used and not cleaned, with strands of hair on the tile floor, a commode container full of empty plastic personal hygiene product bottles, a safety razor on the floor, an opened body wash bottle labeled 211A on the grab bar, and used plastic gloves in the recessed soap dish. The DON stated that staff should not leave the shower in this manner and should clean it after use. Additionally, during a tour with an RN, two rooms were found to have missing window screens, which the RN acknowledged and stated would be fixed by maintenance.
Failure to Act on Pharmacy Consultant's Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the pharmacy consultant's recommendation regarding the use of psychotropic medication for Resident 86 was acted upon. Resident 86, who was admitted with diagnoses including mood disorder and major depressive disorder, was prescribed Risperdal for mood disorder. The pharmacy consultant identified irregularities in the medication regimen review (MRR) on two occasions, noting that mood disorder is not an appropriate diagnosis for antipsychotic use and could be viewed as a chemical restraint. Despite these identified irregularities, no corrective action was taken by the physician or nursing staff. Interviews with the pharmacist and the Director of Nursing (DON) revealed that the identified irregularities were communicated to the RN and the physician, but the physician did not act upon them. The DON acknowledged that the irregularities were communicated verbally and documented in the progress notes, but admitted that the physician's inaction was possibly missed. This failure had the potential to expose Resident 86 to unnecessary psychotropic medications and adverse health consequences, negatively impacting the resident's mental, physical, and psychosocial well-being.
Inaccurate Documentation of Resident Records
Penalty
Summary
The facility failed to maintain accurate records for three residents, leading to potential mismanagement of their care. For Resident 397, who had multiple diagnoses including diabetes and excessive unplanned weight loss, staff did not accurately document fluid intake. Interviews with direct care staff revealed that they combined meal and fluid intake in their records, contrary to the Registered Dietitian's expectations. This inaccurate documentation could affect the management of the resident's weight loss and overall health condition. For Resident 396, who had diagnoses including anxiety, depression, schizophrenia, and bipolar disorder, the target behavior for bipolar disorder was incorrectly documented as delusion instead of hallucination. RN 8 acknowledged the need to revise this documentation. Additionally, Resident 25, who had conditions such as anemia, high blood pressure, kidney failure requiring dialysis, and diabetes, had inaccurate fluid intake and output records. RN 1 admitted that the intake and output records for January 2024 were not accurate, which is critical for managing the resident's fluid restriction due to dialysis.
Failure to Document Vaccine Education and Follow-Up
Penalty
Summary
The facility failed to ensure that education regarding protective vaccines was documented and that follow-up and/or refusals were recorded in the medical records of two residents. Specifically, for Residents 70 and 88, there was no documentation of the administration of the pneumovax vaccine, no record of refusal, and no evidence of education provided regarding the vaccine. During a concurrent record review and interview with RN 5, it was confirmed that the necessary information was missing from the records, and RN 5 was unable to locate the missing documentation. This failure did not ensure that residents and/or their responsible parties could make informed decisions regarding vaccines, nor did it ensure that residents' healthcare choices were honored.
Failure to Document Vaccine Education and Refusals
Penalty
Summary
The facility failed to ensure that education regarding the COVID-19 vaccine was documented and that follow-up and/or refusals were recorded in the medical records of two of four sampled residents. Specifically, Resident 89 had no documentation of COVID-19 vaccine administration, refusal, or education. Similarly, Resident 13 had no documentation of COVID-19 or pneumovax vaccine administration, refusal, or education. During a concurrent record review and interview with RN 5, it was confirmed that the necessary information was missing from the records, and RN 5 was unable to locate the missing documentation.
Emergency Cart Lock Tag Discrepancy
Penalty
Summary
An emergency cart's red plastic lock tag did not match the lock tag documented on the log, indicating a failure to follow procedure regarding logging lock tags. This discrepancy was observed during initial rounds and confirmed with an RN, who was unable to provide an explanation for the mismatch. The RN explained that once the cart is accessed, it is sent to central supply to be re-stocked, a new red plastic lock tag is installed, and the tag number is entered into the log book. The facility's policy on emergency crash carts, revised in March 2021, states that the carts will be checked every 30 days by pharmacy personnel, and new locks will be applied and documented. However, the policy did not address the responsibility of floor staff in documenting how the red tags are checked and logged. This gap in the policy contributed to the observed deficiency, as the emergency cart's lock tag did not match the log book entry, potentially compromising the availability of emergency devices and supplies.
Unsecured Handrail in Corridor
Penalty
Summary
The facility failed to have a secure handrail in their corridor. During an initial tour on 01/29/2024 at 10:29 AM, a handrail outside room [ROOM NUMBER] was found not secured properly to the wall. This observation was confirmed with RN 6, who stated she would inform maintenance. The lack of a secure handrail did not ensure residents who relied on handrails for mobility and/or support would be safe from a fall.
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.
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