Alameda Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Burbank, California.
- Location
- 925 W. Alameda Ave., Burbank, California 91506
- CMS Provider Number
- 555690
- Inspections on file
- 50
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 52
Citation history
Health deficiencies cited at Alameda Care Center during CMS and state inspections, most recent first.
A resident with dementia, encephalopathy, and DM experienced episodes of blood‑tinged urine, but the COC form showed an inaccurate time for family notification, documenting contact before the first reported episode. An RN and an LVN performed straight catheterizations on two occasions to obtain urine for UA and C&S, yet neither invasive procedure nor the resident’s tolerance was documented in the medical record. Later, UA and urine culture results indicating possible infection were reported by the lab, but there was no documentation that the physician was notified of these results, contrary to the facility’s charting policy requiring complete, accurate documentation of treatments, services, and provider notifications.
A resident with dementia, encephalopathy, diabetes, and total incontinence experienced two episodes of blood‑tinged urine during a night shift, which were reported by a CNA to an LVN. Although hematuria was documented at 3 a.m. and again at 6:30 a.m., the physician was not notified until the oncoming RN contacted the physician after 7 a.m. Later, a urinalysis with culture and sensitivity ordered for this resident was reported to the facility in the evening, but the physician was not notified until the following afternoon, as shown by a delayed text of the lab report from the facility phone. Multiple nurses and the DON stated that the physician should have been notified immediately of both the hematuria and the lab results, and facility policy requires prompt physician notification for changes in condition such as hematuria and for laboratory reports.
A resident with dementia, encephalopathy, diabetes, and documented severe cognitive impairment experienced episodes of blood-tinged urine, which were reported by a CNA to an LVN and led to physician orders for urinalysis with culture and sensitivity and possible straight catheterization for urine collection. Although the urine specimen was obtained via straight catheterization and the resident did not have an indwelling catheter, the resulting care plan documented interventions for monitoring and caring for a Foley catheter, including catheter care every shift and maintaining catheter alignment. The DON later confirmed that the resident never had an indwelling catheter and that the care plan was not individualized or accurate, despite facility policy requiring individualized care plans based on resident needs and physician orders.
Surveyors found that staff failed to provide ordered skin treatments and obtain or act on dermatology consult orders for three residents with rashes. One resident with severe cognitive impairment had physician-ordered hydrocortisone cream for chest and abdominal rashes, but multiple treatment entries on the TAR were left blank, and nursing leadership confirmed this meant the treatment was not given. Another cognitively impaired resident with generalized dermatitis had an order for clotrimazole-betamethasone cream, yet no treatments were documented for nearly two weeks after the order lapsed, and an existing dermatology consult order was never acted upon for months while only a wound care NP followed the case; the NP reported being told by facility leadership not to order scabies testing or aggressive treatment. A third resident with rashes on multiple body areas had an order for dermatology consultation and ongoing rash documentation, but dermatology was not notified and the resident was not seen by a dermatologist until about a month later, when a dermatologist finally visited to evaluate multiple residents with rashes.
During a scabies outbreak, the facility failed to follow its infection control, skin assessment, and communicable disease reporting policies. A resident was readmitted with rashes, but weekly rash assessments were not documented, and the wound care provider and dermatologist were not properly notified despite existing orders and care plan interventions. When two residents ultimately tested positive for scabies at acute care hospitals, the facility did not document one of the notifications in the medical record and did not report the second confirmed case to the State Survey Agency, contrary to its outbreak and unusual occurrence policies. Several exposed residents, including a roommate and dining contacts, did not receive documented daily skin assessments as required by facility guidelines, and a staff member with a rash was treated but not evaluated with a skin scraping or tracked via a line list of resident contacts. The facility also did not provide training or competency validation on skin scraping for treatment nurses before they performed the procedure.
Surveyors found that the facility did not develop or implement person-centered care plans for two residents with significant behavioral and skin integrity needs. One resident with dementia and Alzheimer’s disease exhibited new spitting and aggressive behavior during showering, which was reported by staff but never incorporated into a behavior care plan. Another resident with a pressure ulcer was observed using a wedge pillow to offload the sacral area, yet there was no care plan addressing this device, and staff confirmed its absence. The same resident repeatedly refused repositioning, with CNAs reporting refusals to an LVN, but no care plan was created to address the refusal, and the issue was not escalated to an RN, despite facility policies requiring assessment, documentation of refusals, and comprehensive, measurable care plans for such problems.
A resident with severe cognitive impairment, incontinence, and existing sacral and heel pressure injuries did not consistently receive ordered daily wound treatments, as multiple entries on the TAR were left blank without documented reasons, despite detailed physician orders and facility policy requiring verification and documentation of wound care. Prior to transfer to a hospital, an RN completed transfer paperwork but only inspected the sacral area and did not perform or document a full head-to-toe skin assessment, contrary to the facility’s transfer and pressure injury prevention policies. Additionally, staff used a wedge pillow to offload the resident’s sacral area without obtaining a physician order, even though facility policy required physician-ordered pressure reduction surfaces and device selection to minimize tissue damage.
The facility failed to timely report an allegation that a CNA slapped a cognitively impaired resident during a supervised shower. The resident, who had dementia, Alzheimer's disease, and generalized weakness and required staff supervision for bathing, became agitated and spit at the CNA during the shower. A student later told another CNA that the CNA had slapped the resident in the face. That CNA did not directly report the allegation to the ADM, despite facility policy requiring mandated reporters to ensure all alleged abuse is reported to the state agency, Ombudsman, and law enforcement within two hours. The ADM later confirmed the allegation had not been reported as required and stated that failure to report could cause psychological distress and potential further abuse for the resident.
A resident with severe cognitive impairment, incontinence, and existing pressure injuries had inconsistent and inaccurate skin documentation, including a Skin Issues record that listed multiple stage 3 and stage 4 pressure ulcers when staff later confirmed only one stage 4 sacrococcyx ulcer was present. Additionally, the MAR showed that LVNs documented administration of Depakote, Mirtazapine, and Potassium on days when the resident was actually hospitalized and not in the facility. Staff interviews confirmed that these entries were incorrect and not in accordance with facility policies requiring accurate, complete charting and verification of resident presence and identity before documenting medication administration.
The facility failed to follow professional standards and its own scabies policies for multiple residents with rashes and pruritus. One resident with a history of dermatitis, diabetes, and Parkinson’s disease had progressively spreading, itchy rashes documented over several months without timely skin scraping or dermatology consultation, and was later confirmed positive for scabies. The facility did not promptly identify and assess all exposed residents, initially limiting its contact list to roommates and only later adding dining companions, with no documented assessments for other contacts. A roommate with generalized rashes received prophylactic permethrin and contact isolation, but skin scraping was ordered and performed only after treatment, and there was no evidence of dermatology evaluation before or during this process. Several direct-care staff, including a treatment nurse, CNA, and LVN, were not informed of the confirmed scabies case until days after the facility learned of the result, and a CNA was observed providing care to an exposed resident under enhanced barrier precautions without PPE. Leadership acknowledged delays in skin scraping, lack of timely assessments of exposed residents, and reliance on absent dermatology services, while a NP reported management pushback on ordering skin scrapings due to concerns about outbreak designation and fines.
The facility failed to ensure that treatment nurses and an IPN were competent to perform skin scraping procedures used to help diagnose skin conditions. Employee file reviews showed that competency assessments completed for these nurses did not include skin scraping, and there was no documentation that this skill was assessed upon hire or annually. The DSD and DON acknowledged that skin scraping was not part of the nurses’ competency evaluations and that, without this assessment, the procedure might not be performed correctly, potentially affecting diagnostic accuracy, despite facility policies and scabies control guidelines requiring appropriate clinical skills and demonstrated competency before assignment.
Staff failed to maintain accurate and timely medical records for several residents, including one who was documented as receiving topical treatment after being transferred to a hospital, and multiple residents who underwent STAT skin scrapings for dermatitis. In these cases, the nurse who actually performed the procedures did not document them on the TARs, while another nurse who only observed later signed the TARs days after the procedures and guessed the times. One resident’s initial admission assessment documented no skin issues, but a reassessment the next day showed widespread rashes, and the subsequent STAT skin scraping was not properly recorded at the time it was performed. These actions conflicted with facility policies requiring complete, objective, and accurate documentation of treatments, including the date, time, and identity of the staff providing care.
A resident with dementia and high fall risk was left unsupervised at a dining room entrance and subsequently fell. After the incident, the facility did not promptly update the care plan, complete a Fall Risk Evaluation, or provide required 72-hour monitoring. Documentation and notifications to the MD and responsible representative were also delayed, contrary to facility policy.
A resident with dementia and high fall risk experienced a fall after being left in the dining room entrance by a CNA. Staff interviews and record review showed that required notifications to the MD and resident representative were not made, and the Change in Condition assessment and monitoring were not completed until several days later, contrary to facility policy.
A facility did not report an allegation of staff-to-resident physical abuse to required authorities after a staff member claimed a CNA pushed a resident with dementia and high fall risk. The administrator did not report the incident, citing lack of injury and considering the allegation as hearsay, despite facility policy requiring immediate reporting of suspected abuse.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Surveyors observed that facility trash bins were repeatedly overfilled and left uncovered, with cardboard bins open and overflowing. Both the DSS and DON confirmed that these conditions did not comply with facility policies requiring covered waste containers and timely disposal, as outlined in the waste control and pest control procedures.
A facility failed to create and implement a care plan for a resident exhibiting disrobing behavior, despite repeated incidents and staff awareness, and did not document required monitoring for adverse effects in a resident receiving carbidopa-levodopa for Parkinson Disease. These deficiencies were confirmed by staff interviews and record reviews, showing a lack of adherence to person-centered care planning and monitoring policies.
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents with diabetes, administering repeated injections in the same areas despite physician orders, facility policy, and manufacturer guidelines requiring site rotation. This practice was confirmed through record review and staff interviews, and was inconsistent with professional standards of care.
Surveyors found that several residents with cognitive impairments and high fall risk had furniture or equipment placed on their fall mats, and two residents had bed controllers with exposed wires. Staff and the DON confirmed these practices compromised resident safety and did not follow facility policies or manufacturer instructions, which require keeping mats clear and equipment in good repair.
The facility failed to ensure proper pharmaceutical services by not documenting the disposition of an extra Augmentin tablet for a resident, administering carbidopa-levodopa ER at the wrong time for another resident with Parkinson's disease, and not reconciling a controlled medication emergency kit in a medication room at each shift change, as required by facility policy.
A Pharmacy Consultant did not identify or report irregularities in the monthly drug regimen reviews for two residents. One resident prescribed valproic acid for bipolar disorder did not have specific behavior monitoring in place, and another resident on carbidopa-levodopa for Parkinson Disease lacked documentation of monitoring for adverse effects. The consultant acknowledged these omissions, and facility policies required such monitoring and reporting to the DON and prescriber.
A resident prescribed carbidopa-levodopa for Parkinson’s Disease was not monitored for adverse effects as required by their care plan and facility policy. Review of the MAR showed no documentation of monitoring, and both nursing staff and the DON confirmed the absence of required monitoring for side effects such as dyskinesia. This failure to implement the care plan and follow policy resulted in noncompliance with medication monitoring standards.
A resident received four medications at times not consistent with physician orders, as an LVN administered famotidine, buspirone, hydrochlorothiazide, and losartan outside the facility's required 60-minute window. This resulted in four medication errors out of 26 opportunities, leading to a medication error rate of 15.38%, which was confirmed by both the LVN and DON as not following facility policy and the '5 rights' of medication administration.
Surveyors found that two residents with diabetes received subcutaneous insulin injections without proper rotation of injection sites, as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff and the DON confirmed that insulin was repeatedly administered in the same anatomical areas, and records showed multiple instances of this practice. This failure constituted a significant medication error.
Surveyors found that two residents' inhalation medications were not labeled with open dates as required by manufacturer instructions and facility policy, making it impossible to determine if the medications were expired. An LVN and the DON confirmed that multi-dose products must be labeled with the date opened, and the lack of labeling prevented staff from verifying the medications' effectiveness.
Several residents with medical conditions requiring No Added Salt (NAS) diets were provided with extra salt packets on their meal trays, despite clear dietary orders and facility policy prohibiting this. Both residents with intact and impaired cognition were affected, and staff interviews confirmed that kitchen staff did not check tray tickets for NAS diet orders, resulting in the failure to follow prescribed therapeutic diets.
The facility failed to ensure complete and accurate medical records for three residents, including missing documentation of informed consent verification for psychotropic medications and failure to record the administration of an antibiotic in the MAR. Staff and leadership confirmed these omissions, resulting in incomplete records regarding treatment discussions and medication administration.
Personal belongings, including bags, a sweater, a cellphone, and sunglasses, were found in the clean laundry room by a laundry staff member, contrary to facility infection control policies. The items were observed near clean linens, and staff interviews confirmed that personal belongings are not allowed in this area, as lockers are provided elsewhere for storage. Facility leadership acknowledged the failure to maintain the cleanliness and infection control standards required for the laundry area.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or evaluate antibiotic administration to residents.
Several residents were found with unsafe equipment, including a fall mat with peeling covers and bed remote controls with frayed or exposed wires. Staff and the DON confirmed these issues were not identified or reported as required, despite facility policies mandating regular checks and maintenance to ensure a safe environment.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
Residents were not fully informed or did not fully understand their health status, care, and treatments, as they were not provided with sufficient information about their medical condition and the care or treatments being administered.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
Two residents did not receive pressure ulcer prevention interventions as ordered, including the failure to apply heel protectors for a resident with a stage three sacral ulcer and not setting a low air loss mattress according to another resident's weight, despite clear physician orders and facility policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive required face-to-face visits from the attending physician or psychiatrist, as all visits were conducted by nurse practitioners instead. Facility records lacked documentation of direct physician visits, and staff confirmed that the mandated visits by the AP and Psych MD did not occur, contrary to facility policy.
Two residents were not aware of the location or availability of the facility's latest survey results, as the survey binder was stored in an inaccessible location with an unreadable label. Staff confirmed that residents were only told to ask for the binder, rather than having direct access, which did not align with facility policy requiring survey results to be easily accessible.
Nineteen rooms were found to provide less than the required 80 square feet per resident, with three-bed rooms ranging from 195 to 238 square feet. Staff and residents reported no issues with space, and observations confirmed adequate movement and care provision, but the facility's own policy and federal requirements for room size were not met.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was subjected to undignified treatment when a CNA raised her voice and threw a spoon back at the resident after the resident became aggressive during lunch. This response was inconsistent with facility policy requiring staff to treat residents with dignity and sensitivity, especially those with cognitive impairments.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with Alzheimer's and cognitive deficits had their call light on the floor, while another with COPD and muscle weakness had their call light tangled and inaccessible. Staff failed to notice or correct the issue, and the DON acknowledged the oversight, which violated the facility's policy requiring call lights to be accessible.
The facility failed to notify the physician when two residents experienced changes in their skin condition, including rashes and itchiness. One resident was observed with raised, open, and red skin rashes, while another reported persistent itchiness affecting sleep. The LVN did not notify the physician, contrary to facility policy requiring prompt notification for any change in condition.
Two residents with severe cognitive impairments experienced unmanaged skin conditions due to the facility's failure to notify the physician of changes. One resident had a rash and itchiness, while the other suffered from persistent itchiness affecting sleep. Despite facility policy, staff did not inform the MD, leading to potential risks for both residents.
The facility failed to maintain an effective infection control program during an IGAS outbreak, as high touch areas at two nursing stations were not routinely disinfected. Disinfection logs showed multiple instances where LNs did not document their activities, suggesting non-compliance with disinfection protocols. Interviews confirmed the outbreak and the importance of regular disinfection, but the absence of documentation implied it was not done, leading to a deficiency in the infection control program.
A resident with Alzheimer's and severe cognitive impairment experienced a delay in receiving a STAT X-ray after a fall, which was ordered to assess a suspected fracture. The facility's staff did not follow up with the radiology provider, resulting in the X-ray not being conducted within the required timeframe. The resident was later transferred to a hospital, where the fracture was confirmed.
The facility was found to have several deficiencies in its food storage and preparation practices, including chipped refrigerator shelves, unclean freezers, and improper storage of dented cans. Additionally, the knife container and scoops were not properly cleaned, and food carts had dried spills. A resident's food from home was not labeled, posing a risk of incorrect diet administration. These issues could lead to harmful bacteria growth and cross-contamination, potentially causing foodborne illnesses among residents.
The facility lacked a comprehensive policy for the safe storage and handling of food brought by family and visitors, potentially affecting 78 residents. The existing policy discouraged outside food due to safety concerns but allowed it as a resident's right. The Registered Dietitian and Director of Nursing acknowledged the policy's lack of specific storage guidelines, which could lead to emotional changes and weight loss among residents.
The facility failed to maintain cleanliness in the trash area, with observations revealing soiled utensils, trash, and liquid drippings around the dumpster. Interviews with the Dietary, Maintenance, and Housekeeping Supervisors confirmed the lack of proper cleaning, despite facility policies requiring clean surroundings and covered receptacles. This posed a potential infection risk to all residents.
The facility failed to maintain sanitary conditions in the food services department, as a fly was observed landing on a can opener and a baked good. The Dietary Supervisor acknowledged the fly could have entered from the breakroom or office and expressed concern about potential germ transmission. The facility's Pest Control Policy requires an effective pest control program to keep the building free of insects.
The facility failed to ensure call lights were available and within reach for five residents, leading to a deficiency in accommodating resident needs. Residents with cognitive impairments and mobility issues were observed without accessible call lights, risking delayed care and potential accidents. Staff confirmed the importance of having call lights within reach, as per facility policy, to prevent unassisted movements and falls.
The facility failed to maintain and document advance directives (ADs) for three residents, violating their rights to have their healthcare wishes respected. Despite indications of executed ADs, these documents were missing from the residents' charts, as confirmed by staff interviews and record reviews. This deficiency could lead to conflicts with the residents' healthcare preferences.
Failure to Maintain Accurate and Complete Medical Record for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with significant cognitive impairment and multiple medical diagnoses. The resident was admitted with encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and total bowel and bladder incontinence. On a change of condition (COC) form dated 2/13/2026, a CNA reported to an LVN that the resident had blood‑tinged urine in their diaper at 3 a.m. and again at 6:30 a.m. However, the COC also showed that the family member was notified at 12 midnight, a time that preceded the first documented episode of blood‑tinged urine. During review, the DON confirmed that the midnight entry was not an accurate time and stated that the LVN should have documented the actual time the family member was called. The facility also failed to document invasive nursing procedures performed to obtain urine specimens for ordered urinalysis and culture and sensitivity testing. Physician orders dated 2/13/2026 included urinalysis with culture and sensitivity and allowed straight catheterization if a clean‑catch specimen could not be obtained. An RN stated that on 2/13/2026 she, with assistance from an LVN, performed straight catheterization on the resident to obtain a urine sample, but there was a labeling issue with the specimen. The assisting LVN confirmed she helped with the straight catheterization on 2/13/2026 and that she later performed another straight catheterization on 2/14/2026 after learning the specimen should have been placed in a tube instead of a cup. The LVN acknowledged that neither the initial nor the repeat straight catheterization was documented in the resident’s medical record, despite recognizing that these were invasive procedures and that documentation of how the resident tolerated them was important. The DON confirmed that these procedures should have been documented and that the facility failed to record two invasive procedures in the resident’s record. Additionally, the facility did not document physician notification of the resident’s laboratory results. Laboratory reports showed that the urine specimen was received on 2/17/2026, with urinalysis results reported to the facility that evening and urine culture results reported three days later. Review of the resident’s progress notes for those dates revealed no documentation that the physician was notified of either the urinalysis or urine culture results. An RN stated she worked earlier shifts on both days and that LVNs on later shifts should have received the faxed lab results and sent them to the physician, and she acknowledged that the results may have indicated signs of a urinary infection and that nurses should have documented physician notification. The DON confirmed there was no documented evidence of physician notification for these lab results and stated that failing to document meant physician notification was not done, and that the facility’s charting and documentation policy—which requires complete, accurate, objective documentation of services, procedures, and notifications—was not followed, resulting in an incomplete and inaccurate medical record for the resident.
Failure to Promptly Notify Physician of Hematuria and Abnormal Urinalysis Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a resident’s change in condition and subsequent abnormal laboratory results. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions, with severely impaired cognitive skills and complete bowel and bladder incontinence. On the night in question, a CNA reported to an LVN at 3 a.m. that the resident’s diaper contained blood‑tinged urine. The LVN documented hematuria with no associated pain or burning. At 6:30 a.m., the CNA reported a second episode of blood‑tinged urine. Despite these findings, the physician was not notified until 7:13 a.m., when the oncoming RN contacted the physician after being informed that hematuria had occurred at 3 a.m. and again at 6:30 a.m. Interviews with nursing staff and the DON confirmed that the LVN on duty should have notified the physician immediately upon the first observation of blood‑tinged urine at 3 a.m., in accordance with facility expectations. RN 2, LVN 2, RN 1, and the DON each stated that the physician should have been informed right away of the hematuria, and that there was a delay in physician notification. The facility’s Change in Condition policy, which lists hematuria and laboratory reports as changes requiring prompt handling, specifies that the physician shall be called promptly upon any change in condition, with documentation of all contacts or attempts. A second failure occurred related to the resident’s urinalysis with culture and sensitivity, which had been ordered on the same date as the hematuria. The laboratory results were reported to the facility on 2/17/2026 at 7:37 p.m. RN 1, who worked only until 3 p.m. that day, stated that after her shift the assigned LVNs should have received any faxed lab results and sent an electronic message with the results to the physician that same day. Review of facility phone text messages with the DON showed that a picture of the resident’s urinalysis result was not sent to the physician until the following afternoon, and there was no indication of physician notification on the date the results were received. The DON stated that LVNs should have notified the physician of the urinalysis result when it was received so the physician could proceed with an appropriate plan of care, and acknowledged there was a delay in physician notification.
Failure to Accurately Individualize Care Plan for Resident With Hematuria
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered care plan for a resident who experienced hematuria. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions and having severely impaired cognitive skills. The MDS indicated the resident was always incontinent of bowel and bladder. On one date, a Change of Condition note documented that a CNA reported to an LVN that the resident had blood-tinged urine in their diaper on two occasions during the early morning. A physician order was obtained for a urinalysis with culture and sensitivity, with permission to perform straight catheterization for urine collection if a clean catch specimen could not be obtained. The resident’s care plan, initiated in response to the hematuria, documented interventions related to monitoring and caring for an indwelling Foley catheter, including monitoring the catheter and changing it or the bag as ordered, providing Foley catheter care every shift, and maintaining proper alignment of the Foley catheter. However, interview and record review confirmed that the resident did not have an indwelling catheter and that urine for the ordered tests was obtained via straight catheterization. The DON acknowledged that the care plan was not individualized or accurate, stating that the resident never had an indwelling catheter and that the care plan should have reflected the use of straight catheterization and been consistent with the resident’s actual needs and orders, in contrast to the facility’s policy requiring individualized care plans.
Failure to Provide Ordered Rash Treatments and Timely Dermatology Consultations
Penalty
Summary
The deficiency involves the facility’s failure to provide skin treatments and specialty consultations as ordered, and to obtain necessary physician orders, for three residents with rashes. For one resident with schizoaffective disorder, dementia, and chronic hepatitis B, a skin reassessment on 1/15/2026 documented rashes on the chest and abdomen, and a physician order was in place to cleanse the rash and apply hydrocortisone 1% cream on the day and evening shifts for four weeks. Review of the Treatment Administration Record (TAR) for 1/2026 showed blank entries for the ordered treatment on multiple shifts, and both the Registered Nurse Supervisor and the MDS nurse stated that blank TAR entries meant the treatment was not provided or signed. Facility policy on administering medications required that medications and treatments be administered in accordance with prescriber orders and documented with date, time, dosage, route, and the initials/signature of the person administering. A second resident, admitted with Parkinson’s disease, dementia, and unspecified dermatitis, had a physician order dated 10/2/2025 to cleanse generalized rashes on the bilateral upper and lower extremities and chest with normal saline and apply clotrimazole-betamethasone cream on day and evening shifts for four weeks. Wound care NP notes on 10/28/2025 and 11/11/2025 documented generalized dermatitis and a plan to cleanse with normal saline and apply clotrimazole 1% and betamethasone 0.05% cream twice daily. However, the November 2025 TAR showed no treatment documented from 11/1/2025 to 11/13/2025. Treatment Nurse 1 stated that the resident still had rashes during that period, that the treatment order had not been renewed, that there was no documented physician order for the rash during those dates, and that no treatment was provided. The RNS and MDS nurse confirmed that without a physician order and documentation, the rash treatment was not provided for 13 days, despite facility policies on administering medications, non-pressure sore management, and alteration in skin integrity that required assessment, physician notification, and treatment orders for skin alterations. The same resident had an order on 5/17/2025 for a dermatology consultation and follow-up treatment as indicated, but wound care notes from 2/25/2025 through 12/25/2025 repeatedly documented generalized fungal or unspecified dermatitis without any documentation that a dermatologist evaluated the resident. The Infection Preventionist confirmed that the resident was transferred to an acute care hospital on 1/16/2026 with body rashes, and Treatment Nurse 1 stated the resident was never seen by a dermatologist and was only seen by the wound care NP. The RNS stated that the dermatologist did not assess the resident’s rashes from the date of the order until transfer, a period of almost eight months, and that the NP was a wound care specialist, not a dermatologist. The NP reported that he had raised the issue of scabies testing and treatment with the DON before 12/25/2025 but was told not to order scabies tests or aggressive treatment because of concerns about a potential scabies outbreak and staffing, and that the facility intervened to prevent him from ordering scabies tests and treatment. Facility wound care policy required verification of a physician’s order for wound procedures, and the submitted scabies prevention guideline called for access to clinicians experienced in recognizing scabies and confirmation by skin scraping. A third resident, admitted with cerebral infarction, dementia, and pneumonia, had an order dated 12/25/2025 for a dermatology consult and follow-up treatment as indicated. A skin reassessment on 12/26/2025 documented rashes on the bilateral upper and lower extremities, chest, and back, and a care plan dated 1/5/2026 included an intervention to notify dermatology of non-response. Skin rash reports on 1/9/2026 and 1/24/2026 documented ongoing rashes, and the TAR for 1/2026 showed the resident received triamcinolone twice daily for dermatitis throughout the month. Treatment Nurse 1 stated this resident was the roommate of the resident later confirmed with scabies in the hospital, had rashes since 12/26/2025, and was not seen by a dermatologist until 1/26/2026, when the dermatologist came to evaluate multiple residents with rashes after the other resident’s positive scabies test. The RNS stated the facility should have followed the physician order for dermatology consultation and that a one-month delay in notifying dermatology could worsen the resident’s rashes. Treatment Nurse 1 further stated that RNs obtain dermatology consultation orders and notify dermatology by fax or phone, but she did not call because the facility did not have a dermatologist until 1/26/2026. Facility policies on non-pressure sore management and change in condition required physician notification and follow-through when residents developed rashes, and the RNS stated that when this resident developed rashes on 12/26/2025, a change in condition should have been created and the physician order followed.
Failure to Implement Scabies Outbreak Control, Skin Assessment, and Reporting Procedures
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, skin assessment policies, and communicable disease reporting procedures during a scabies outbreak. One resident was readmitted with documented rashes on the chest and abdomen, but weekly Skin Rash Reports were not initiated or completed after the readmission, despite facility policies requiring weekly skin inspections and documentation of non‑pressure skin conditions and rashes. Treatment nurses and other nursing staff acknowledged that weekly rash assessments were not performed or documented on multiple Thursdays, and the Minimum Data Set nurse and Resident Nursing Supervisor confirmed that the facility’s policies on Prevention of Pressure Injuries/Skin Breakdown, Body Checks, and Alteration in Skin Integrity were not followed. Staff stated that without weekly rash documentation, the progress of the rash and effectiveness of treatment could not be evaluated, and that the resident’s rashes could worsen. The facility also failed to notify the wound care provider and dermatologist and to document key clinical information related to the scabies outbreak. After the resident’s readmission with rashes, there was no documentation that the wound care physician or nurse practitioner was informed, and no subsequent wound care notes were found. The nurse practitioner, infection preventionist, MDS nurse, RN, and Resident Nursing Supervisor all stated that the wound care provider should have been notified and that there was no documentation of such notification. Although there was an order and care plan intervention for a dermatology consult, treatment nurses did not ensure that the dermatologist who visited on two separate dates was informed of this resident’s rashes, and the dermatologist’s progress notes showed that only nine other residents were evaluated and treated. The administrator and infection preventionist stated that the dermatologist should have been notified of all residents with rashes, including this resident. Additionally, when the facility was notified by an outside hospital that this resident tested positive for scabies, the marketer relayed the information verbally to the administrator, but there was no documentation of this notification in the resident’s medical record, contrary to the facility’s Charting and Documentation policy requiring complete and accurate documentation. The facility did not properly recognize and report the scabies outbreak to the State Survey Agency and did not complete required surveillance and assessments for exposed residents and staff. One resident had previously tested positive for scabies at another hospital, and the infection preventionist stated the facility was informed of this result. When a second resident later tested positive for scabies at a different hospital, the administrator acknowledged being notified but did not report this second confirmed case to the State Survey Agency, despite facility policies and county guidelines defining an outbreak as two or more cases and requiring reporting within 24 hours. The administrator later acknowledged that the facility’s Scabies: Prevention and Control policy and Unusual Occurrences policy were not followed. The infection preventionist and Resident Nursing Supervisor confirmed that the facility was considered to be in a scabies outbreak and that such outbreaks should be reported. The facility also failed to perform and document daily skin assessments on four residents who were identified as exposed through room sharing and dining contact, despite facility guidelines and policies requiring daily skin assessments on exposed residents and daily assessments for roommates of infected residents until the case was resolved. The deficiency further includes failures related to staff training, competency, and case tracking. The Director of Staff Development/Infection Preventionist and Resident Nursing Supervisor stated that no in‑service education, training, or competency evaluation on skin scraping was provided to the treatment nurses before they performed skin scrapings on residents during the outbreak. They acknowledged that the nurses were not checked for competency and that training should have been done before skin scraping procedures were carried out. Additionally, a certified nursing assistant who developed lower back rashes was treated with Elimite cream but was not assessed for scabies via skin scraping, and the facility did not develop a line list identifying this staff member’s resident contacts for the six weeks prior to symptom onset, as required by the facility’s submitted Acute Communicable Disease Control Program–Scabies Prevention and Control Guidelines. These guidelines also required preparation of line lists for symptomatic healthcare workers and residents and daily skin assessment documentation on all exposed residents, which the facility did not complete.
Failure to Develop Person-Centered Care Plans for Behavior, Pressure Ulcer Interventions, and Treatment Refusals
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing specific behaviors and clinical needs for two residents. For one resident with dementia, Alzheimer’s disease, and generalized weakness, the admission record showed the resident was admitted in September 2025, and a subsequent H&P documented that the resident lacked capacity to understand and make decisions. An MDS assessment later indicated the resident could sometimes understand others and make self-understood and required supervision with toileting and showering. Progress notes from early January 2026 documented that this resident became verbally and physically restless and had an anger outburst before a shower, then became physically aggressive during the shower, yelling and spitting at a CNA. Multiple staff, including the DSD and Administrator, confirmed that the resident had spit at the CNA, and the MDS nurse stated the resident had behaviors of spitting and kicking but acknowledged there was no care plan addressing the spitting behavior. The facility also failed to develop a care plan for another resident’s use of a wedge pillow and for that resident’s refusal of repositioning. During observation in early February 2026, a wedge pillow was seen on the resident’s left side in the room. The treatment nurse explained that the wedge pillow was used to keep the resident’s sacral area off the bed to prevent worsening of a pressure ulcer, but confirmed there was no care plan for the use of the wedge pillow. The MDS nurse and RN 1 both reviewed the care plans and stated there was no care plan for the wedge pillow, and the MDS nurse stated there should be a care plan for its use because it guides nurses on how to care for the resident. The RN supervisor stated that interventions provided to address the resident’s pressure ulcer should have a care plan, and that without a care plan, nurses would not be able to evaluate if the intervention was effective and it could possibly cause worsening of the pressure ulcer. In addition, the same resident was described by the treatment nurse as noncompliant with repositioning, and other staff confirmed ongoing refusals. The MDS nurse stated there was no care plan developed for the resident’s refusal to be repositioned and that a care plan helps minimize further decline or prevent worsening of pressure ulcers, and that without such a care plan the resident’s wound can worsen. An LVN reported that CNAs had informed her of the resident’s refusal to be repositioned; she spoke with the resident, who continued to refuse, but she did not develop a care plan and did not report the noncompliance to an RN, stating that RNs develop care plans. The LVN stated a care plan should have been developed and that without a care plan for refusal of repositioning, the resident’s wound could worsen. The RN supervisor similarly stated that a care plan should have been developed to address the resident’s refusal of repositioning to ensure resident rights for refusal were followed and to prevent worsening of the pressure ulcer. Facility policies on behavioral assessment, pressure ulcer prevention, wound care, and comprehensive person-centered care plans all required assessment of new behaviors, individualized interventions, documentation of refusals, and development and revision of care plans with measurable objectives and timeframes, which were not followed in these instances.
Failure to Provide Ordered Wound Care, Complete Transfer Skin Assessment, and Obtain Order for Wedge Pillow
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with physician orders and facility policy for a cognitively impaired resident with existing pressure injuries. The resident was admitted with metabolic encephalopathy, dementia, and pressure ulcers to the sacral area and left heel, and was documented as severely impaired in decision-making, fully dependent for ADLs, and always incontinent of bowel and bladder. Physician orders dated 7/19/2025 directed specific daily wound care for left heel and sacrococcyx deep tissue injuries, and subsequent orders on 11/11/2025, 12/17/2025, and 1/20/2026 specified detailed daily treatments for sacrococcyx stage 3 and later stage 4 pressure injuries, including cleansing solutions, topical agents, and dressings. Review of the Treatment Administration Records (TARs) from August 2025 through January 2026 showed multiple dates on which the ordered treatments were left blank, including 8/3/2025, 11/25/2025, 12/24/2025, 1/20/2026, and 1/27/2026. Interviews with the MDS nurse, RN supervisor, and other nursing staff confirmed that blank entries on the TAR indicated the treatment nurse did not sign for and therefore did not perform the ordered wound care. Staff acknowledged that if the treatment was not done, the pressure ulcer could worsen. The facility’s wound care policy required verification of a physician’s order, performance of the ordered wound care, and documentation of the type of wound care given, the date and time, the resident’s position, and the name and title of the person performing the care. The RN supervisor stated that if treatment is not done, the treatment nurse must document the reason, such as resident refusal or being too busy and endorsing the task to other staff, but such documentation was not present for the missed treatments. The deficiency also includes the facility’s failure to perform and document a complete head-to-toe skin assessment prior to the resident’s transfer to a general acute care hospital. On the transfer date, the resident’s Interact Assessment Form noted generalized weakness and decline in ADLs, and the Resident Transfer Record documented a sacrococcyx stage 3 pressure ulcer. RN 1 stated that for any transfer, a complete head-to-toe skin assessment should be done and documented on the transfer form and reported to the receiving hospital. RN 2 reported that, at the DON’s direction, she completed the Discharge Summary Report and Resident Transfer Record but only looked at the sacral area and did not perform a full body skin assessment, and therefore could not say whether the resident had rashes elsewhere. The facility’s Transfer/Discharge policy required a complete body check when possible, with findings documented, and the Prevention of Pressure Injuries policy required comprehensive skin assessments on admission, with each risk assessment, and prior to discharge. Additionally, the facility failed to obtain a physician order for the use of a wedge pillow for this resident. During observation, a wedge pillow was seen on the resident’s left side. The treatment nurse stated the wedge pillow was used to keep the sacral area off the bed to prevent worsening of the pressure ulcer. Review of the physician orders showed no order for the wedge pillow, and both RN 1 and the treatment nurse acknowledged that a physician order was required before the resident could use a wedge pillow and that the DON or RN supervisor should have obtained such an order. The facility’s policies on pressure ulcers and prevention of pressure injuries specified that the physician orders pertinent wound treatments, including pressure reduction surfaces, and that medical devices should be selected with consideration to minimizing tissue damage, reinforcing the need for an order for this device.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of employee-to-resident abuse involving Resident 2 to the State Survey Agency, Ombudsman, and local law enforcement within two hours as required by its abuse policy. Resident 2 had been admitted with dementia, Alzheimer's disease, and generalized weakness, and a subsequent H&P documented that the resident did not have capacity to understand and make decisions. An MDS later indicated Resident 2 could sometimes understand others and make self-understood and required staff supervision for toileting and showering. On the date of the incident, progress notes documented that Resident 2 became verbally and physically restless and angry before a shower, then calmed and agreed, but became physically aggressive, yelled, and spit at CNA 1 during the shower. During interviews, CNA 2 reported that while CNA 1 was showering Resident 2 and CNA 2 and a student were showering another resident in the same shower room, the resident became agitated. After the shower, Student 1 told CNA 2 that CNA 1 had slapped Resident 2 in the face. CNA 2 stated she instructed the student to report it and the student said she already had, and CNA 2 did not report the allegation directly to the Administrator, even though she acknowledged she should have. The Director of Staff Development stated CNA 1 reported only that Resident 2 became combative and spit at her, and that CNA 1 tried to block the spit with her hands. The Administrator, referencing the facility’s abuse and mistreatment policy, confirmed that all alleged and substantiated violations must be reported to the state agency and other required agencies within two hours, and stated that CNA 2 did not report the allegation on the day of the incident, resulting in the failure to meet the facility’s reporting requirements. The Administrator stated that not reporting allegations of abuse could cause Resident 2 psychological distress and potentially further abuse.
Inaccurate Skin and Medication Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with multiple serious medical conditions. The resident was admitted with diagnoses including metabolic encephalopathy, a stage 4 sacral pressure ulcer, and unspecified dementia, and was documented as having severely impaired cognitive skills and total dependence on staff for activities of daily living, with bowel and bladder incontinence. An admission reassessment documented pressure ulcers on the left heel and sacrococcyx, and the MDS indicated two unstageable pressure injuries present on admission. Subsequent skin documentation was inconsistent and inaccurate. A Skin Issues record dated 12/11/2025 indicated one stage 3 sacrococcyx pressure ulcer, while a Skin Issues record dated 1/6/2026 indicated four stage 3 pressure ulcers and one stage 4 pressure ulcer. During interviews and concurrent record review, the Treatment Nurse stated that the 1/6/2026 Skin Issues entry was not accurate and that the resident had only one stage 4 sacrococcyx pressure ulcer. The Treatment Nurse and a Registered Nurse both acknowledged that this inaccurate documentation made the medical record inaccurate and could cause confusion in care. The facility’s Charting and Documentation policy required that documentation in the medical record be objective, complete, and accurate. The facility also failed to accurately document medication administration for this resident while the resident was hospitalized. The resident’s orders included Depakote three times daily, Mirtazapine at bedtime, and Potassium chloride daily. The resident was transferred to a general acute care hospital on 1/14/2026 and returned on 1/19/2026. However, the January MAR showed that one LVN documented administration of Depakote on 1/15/2026 at noon, and another LVN documented administration of Mirtazapine, Potassium, and Depakote on 1/16/2026 at various times, despite the resident being in the hospital on those dates. The MDS nurse confirmed that check marks on the MAR indicated medications were administered and stated this documentation was incorrect because the resident was not in the facility. Nursing staff and the Registered Nurse Supervisor stated that nurses are supposed to verify that residents are in the facility, verify identity, and sign the MAR after actual medication administration, in accordance with the facility’s Charting and Documentation and Administering Medications policies, which require accurate recording of medications administered.
Failure to Timely Identify, Test, and Communicate Scabies Cases and Exposures
Penalty
Summary
The deficiency involves the facility’s failure to follow its own scabies identification and control policies and professional standards of practice for multiple residents with rashes and pruritus. One resident with a history of dermatitis, diabetes mellitus type 2, and Parkinson’s disease was admitted and later readmitted with progressively spreading rashes on the chest, bilateral upper and lower extremities, back, and abdomen. The resident’s care plan for skin integrity noted a skin rash and included interventions such as administering treatment as ordered and notifying dermatology for non-response. Over several months, skin rash reports documented complaints of itchiness on multiple dates, but there was no documented evidence that a skin scraping was performed or that a dermatologist was consulted, despite staff acknowledging that skin scraping is used to confirm scabies and that the facility had a scabies policy describing diagnostic procedures. The resident was eventually transferred to an acute care hospital for altered mental status and abnormal vital signs, with documentation noting a body rash, and a subsequent scabies examination on a later date showed a positive result for scabies. After the positive scabies result for this resident, the facility did not promptly or comprehensively identify and assess all exposed residents and staff as required by its scabies policy and the referenced Acute Communicable Disease Control (ACDC) guidelines. The Director of Staff Development (DSD) produced a new Scabies Case Contact Line List that initially included only the resident and two roommates, with no documented assessments of other exposed residents. The DSD later stated that residents who sat beside the affected resident in the dining room were only added to the line list several days after the facility became aware of the positive scabies result, and the Director of Nursing (DON) acknowledged that residents exposed in the dining room were not assessed after the positive test. Another cognitively impaired resident who attended the same dining room and activities and was identified as exposed was not assessed for scabies, and there was no documentation of assessments for other contacts beyond roommates and later-identified dining companions. The facility also failed to ensure timely and appropriate diagnostic testing and treatment sequencing for the roommate with generalized rashes. This roommate was admitted without documented skin issues, but a skin reassessment the following day showed rashes on bilateral upper and lower extremities, chest, and back. The care plan identified skin rash with interventions to administer treatment as ordered and notify dermatology of non-response. Physician orders later directed prophylactic permethrin cream application and contact isolation for possible exposure to rashes, and the medication administration record showed the permethrin was given. However, staff interviews and record review revealed that a skin scraping for this resident was ordered and performed only after the permethrin treatment had already been administered, and there was no documented evidence that a dermatologist had assessed this resident or that a skin scraping was done prior to treatment. During observation, this resident was noted to have extensive pruritic rashes in classic scabies distribution, and a CNA was seen in the room under enhanced barrier precautions without wearing PPE while touching room surfaces. Communication failures compounded these issues, as several staff members who provided direct care to the resident with confirmed scabies were not promptly informed of the positive result. A treatment nurse, a CNA, and an LVN each reported that they were not notified of the positive scabies diagnosis until two to four days after the facility became aware of it, despite having been assigned to care for the resident and having observed or managed the resident’s itching and rashes. The DSD stated she did not know if staff who cared for the resident before the positive test were notified, and the nurse practitioner reported that he was not informed of the positive scabies result. The nurse practitioner also stated that he received pushback from facility management, including the administrator, DON, and infection preventionist, when he raised concerns about ordering skin scrapings for residents with rashes, and that management expressed concern that positive scabies findings could trigger an outbreak designation and fines. The DON acknowledged that the facility had not had a dermatologist for two years, that they waited for dermatology services to determine which residents needed skin scraping, and that the facility failed to consider timely skin scraping tests and assessments for residents exposed to the confirmed scabies case. The facility’s own scabies policy and the ACDC guidelines it referenced required careful examination of roommates of infected residents, daily assessments of asymptomatic exposed residents, prompt evaluation of patients on affected units, immediate placement of suspected cases on contact precautions, preparation of line lists of symptomatic residents and their contacts, evaluation of contacts, and provision of prophylactic treatment to contacts within a short time frame. Despite these written procedures, the survey findings showed that only limited contact tracing and delayed listing of dining room contacts occurred, that not all exposed residents were assessed, that diagnostic skin scrapings were delayed or not performed for symptomatic residents, and that staff and practitioners were not promptly informed of a confirmed scabies case. Staff interviews, observations, and record reviews consistently demonstrated gaps between the written policies and the actual practices related to scabies identification, testing, communication, and contact management.
Failure to Ensure Nurse Competency in Skin Scraping Procedures
Penalty
Summary
The facility failed to ensure that three licensed nursing staff members were competent to perform skin scraping procedures, a skill necessary for diagnosing certain skin conditions. Review of the employee file for Treatment Nurse 1, hired on 11/13/2024, showed a competency skills assessment dated 1/14/2025 that did not include skin scraping. Treatment Nurse 2, hired on 2/11/2025, had a competency skills assessment dated 2/12/2025, also without any documented assessment of skin scraping. The Infection Preventionist Nurse, hired on 6/12/2024, had a competency skills assessment dated 10/13/2025, which likewise did not include skin scraping procedures. There was no documentation that any of these staff had been assessed for competency in performing skin scraping upon hire or annually. During interviews and concurrent review of employee files, the Director of Staff Development acknowledged that the competency assessments for these nurses did not include skin scraping and stated that without such assessments, the facility would not know if the nurses were performing the procedure correctly. The Director of Nursing confirmed that there were no skin scraping competency assessments completed on the licensed nurses and stated that, without these assessments, the procedure had the potential not to be done properly and could negatively affect the accuracy of results. Review of the facility’s Scabies Prevention and Control Guidelines indicated expectations for evaluation of residents and staff for scabies and access to diagnostic skills of clinicians experienced in recognizing scabies. The facility’s Competency Assessment policy stated that each employee must demonstrate competency related to skills and techniques necessary to provide care and that competency must be completed prior to assignment, which was not met for the skin scraping procedure for the identified staff.
Inaccurate and Late Documentation of Treatments and Skin Procedures
Penalty
Summary
The deficiency involves failures in maintaining complete, accurate, and professionally acceptable medical records for multiple residents. For one resident with diagnoses including dermatitis, type 2 diabetes mellitus, and Parkinson's disease, the facility admitted the resident in December 2024 and later readmitted them. The resident’s MDS dated early December 2025 showed severely impaired cognitive skills for daily decision making. Physician orders dated January 9, 2026, directed application of clotrimazole-betamethasone cream twice daily for unspecified dermatitis. A Change of Condition Interact Assessment Form dated January 16, 2026, showed the resident was transferred to a general acute care hospital on that date. However, the Treatment Administration Record (TAR) for January 2026 contained the treatment nurse’s initials on January 17, 2026, as if care had been provided while the resident was already hospitalized. The treatment nurse stated she forgot to change the chart code to hospitalized and acknowledged the documentation was not accurate. Another deficiency involved inaccurate and incomplete documentation of a second resident’s skin condition and related procedures. This resident, admitted in January 2023 with diagnoses including cerebral infarction, muscle weakness, and essential hypertension, had an MDS indicating moderately impaired cognitive skills for daily decision making. A clinical admission assessment dated December 25, 2025, documented the resident’s skin as warm, dry, with normal color and turgor and no skin issues. However, a skin reassessment dated December 26, 2025, documented rashes on bilateral lower and upper extremities, chest, and back. Physician orders dated January 26, 2026, directed a STAT skin scraping for unspecified dermatitis. The TAR for January 2026 initially showed no licensed nurse initials or time for the STAT skin scrape. A treatment nurse later stated he had only observed another treatment nurse perform the skin scraping, signed the TAR two days after the procedure, did not remember the actual time, and guessed the time for this and other residents’ procedures. The nurse who actually performed the skin scraping confirmed she did not document the procedure in the TAR and that the documentation was not timely or accurate. Similar documentation issues occurred for two additional residents with cognitive impairment and multiple medical diagnoses, including unspecified dementia, essential hypertension, age-related osteoporosis, and metabolic encephalopathy. For both residents, physician orders dated January 26, 2026, directed STAT skin scrapings for unspecified dermatitis. Their TARs for January 2026, when first printed, showed no licensed nurse initials or times for the ordered STAT skin scrapings. The observing treatment nurse later reported he had been watching another treatment nurse perform the procedures because he had not done skin scrapings before, and he signed both residents’ TARs two days after the procedures. He stated he did not remember the actual times and guessed the times, documenting the same time for both residents. The treatment nurse who performed the procedures confirmed she did not document the skin scrapings in the TARs and acknowledged the documentation was not timely or accurate. The Director of Nursing, when reviewing these records, stated that the documentation for all involved residents was not accurate and that the facility failed to follow its own charting and documentation policies, which require objective, complete, and accurate documentation of treatments, including date, time, and the name and title of the individual providing care.
Failure to Implement and Document Post-Fall Interventions and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to implement and document appropriate interventions following a resident's fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left at the entrance of the dining room by a CNA who then clocked out. Shortly after, the resident was found on the floor, having fallen, with no staff witnessing the actual fall. Following the fall, the facility did not develop or update a care plan with interventions specific to the incident. The Fall Risk Evaluation was not updated after the event, and there was no documentation of 72-hour post-fall monitoring as required by facility policy. The Change of Condition (COC) assessment and care plan updates were not completed until several days after the fall, rather than during the same shift or the following day as expected. Additionally, there was no documented evidence that the physician or responsible representative were notified at the time of the incident. Facility policy required immediate and thorough documentation, including a complete body check, notification of the physician and family, care plan entry, and post-fall assessment, none of which were completed in a timely manner. The lack of prompt assessment, documentation, and intervention following the fall placed the resident at risk for further incidents and did not ensure adequate supervision or accident prevention.
Failure to Notify Physician and Resident Representative After Resident Fall
Penalty
Summary
The facility failed to notify the medical doctor and the resident representative after a resident experienced a fall. The resident, who had diagnoses including dementia, Alzheimer's disease, muscle weakness, and difficulty walking, was identified as high risk for falls upon admission. On the day of the incident, the resident was left in the dining room entrance by a CNA, and subsequently found on the floor by staff. Multiple staff interviews confirmed the fall occurred, but there was no immediate documentation or notification to the physician or resident representative. A review of the electronic medical record revealed that a Change in Condition (COC) assessment was not completed on the day of the fall, and was only created several days later. The Director of Nursing confirmed that the COC should have been completed during the same shift as the incident, and that the required 72-hour monitoring and care plan updates were not performed until a week after the fall. There was also no evidence that the physician or resident representative were notified at the time of the incident. Facility policies require prompt documentation and notification following a change in condition or incident, including notifying the physician and family, completing a COC assessment, and implementing monitoring. The lack of timely documentation and notification was confirmed by both record review and staff interviews, indicating a failure to follow established procedures after the resident's fall.
Failure to Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of employee-to-resident physical abuse to the State Survey Agency, the ombudsman, and local law enforcement as required by its own policy. The incident involved an activities assistant alleging that a certified nursing assistant pushed a resident in a wheelchair, which was considered a potential act of abuse. Despite the allegation, the administrator did not report the incident, citing that the resident had no injuries and that the information was considered hearsay rather than a direct report. The resident involved had significant cognitive and physical impairments, including dementia, Alzheimer's disease, muscle weakness, and a high risk for falls. The resident was dependent on staff for most activities of daily living and did not have the capacity to make decisions. On the day of the incident, the resident was found on the floor after being left in the dining room by the CNA, and there were conflicting accounts from staff regarding how the resident ended up on the floor. The administrator reviewed CCTV footage but did not preserve it, as it was automatically erased after five days. Interviews with staff revealed that the term "push" was used by the activities assistant, leading to the CNA's suspension and eventual termination. The administrator acknowledged that any allegation of abuse, including those based on staff statements or hearsay, should be reported within two hours according to facility policy. However, the administrator did not report the incident, stating it was not directly reported to her and was considered hearsay, despite recognizing that the use of the word "push" raised concerns for abuse.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Improper Disposal and Storage of Facility Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on multiple occasions. On two separate mornings, the blue trash bin was found overfilled with its lid not fully shut, and the cardboard box bin was left open without a lid. Photographic evidence was taken to document these findings. During interviews, the Dietary Service Supervisor acknowledged that the trash bins were not closed and that the cardboard bin was overflowing and uncovered. The Director of Nursing also confirmed, upon reviewing the photographs, that the facility did not follow its own policy and procedure regarding garbage disposal, which requires bins to be covered to prevent pest attraction and disease spread. A review of the facility's policies indicated that all waste should be disposed of daily and as needed, trash bins should be covered at all times, outside garbage bins must remain closed, and cardboard boxes should be broken down and disposed of promptly. The pest control policy also requires the facility to maintain an effective pest control program and prohibits the accumulation of garbage and trash, mandating daily removal. The observed failure to keep trash bins closed and to promptly dispose of cardboard boxes was inconsistent with these established policies.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with disrobing behavior. The resident, who had diagnoses including mood disorder, major depressive disorder, and psychotic disorder, was noted to have severely impaired cognition and was dependent on staff for dressing. Despite observations and staff interviews confirming that the resident had been removing her clothes repeatedly over a two-week period, there was no care plan addressing this behavior. Nursing staff acknowledged awareness of the behavior but did not assess or create a care plan to address the resident’s dignity and respect needs related to disrobing. Additionally, the facility failed to implement a care plan for another resident prescribed carbidopa-levodopa for Parkinson Disease. The care plan indicated the need to monitor for adverse effects of the medication, such as dyskinesia, and to alert the physician if necessary. However, review of the Medication Administration Record (MAR) revealed no documentation of monitoring for adverse effects throughout the month. Both the RN and DON confirmed that monitoring should have been documented and that the lack of monitoring could result in adverse effects going unnoticed. Interviews with staff, including the DON and Pharmacy Consultant, confirmed that the facility did not follow its own policy and procedure for comprehensive, person-centered care planning. The policy required measurable objectives and timetables to meet residents’ needs, including monitoring for medication side effects and addressing behavioral issues. The failure to develop and implement appropriate care plans for both residents resulted in deficiencies related to maintaining residents’ dignity and monitoring for unnecessary medication use.
Failure to Rotate Insulin Injection Sites per Professional Standards
Penalty
Summary
Licensed nursing staff failed to provide care in accordance with professional standards by not rotating subcutaneous insulin administration sites for two residents with diabetes. For one resident with dementia and severe cognitive impairment, records showed repeated insulin injections were administered in the same areas of the abdomen and arms over several months, despite physician orders and manufacturer guidelines specifying the need to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that injection sites were not rotated as required, and staff acknowledged this practice was inconsistent with both facility policy and professional standards. A second resident, diagnosed with metabolic encephalopathy, diabetic neuropathy, and moderate cognitive impairment, also received insulin injections at repeated sites without proper rotation. Review of medical records and interviews with nursing staff revealed multiple instances where insulin was administered in the same location, contrary to physician orders and facility policy. The Director of Nursing confirmed that staff should have checked previous injection sites in the electronic health record to ensure proper rotation, which was not done. Facility policy and manufacturer guidelines for all types of insulin administered to these residents clearly indicated the necessity of rotating injection sites to prevent complications. Despite these clear directives, the nursing staff did not adhere to the required procedures, as evidenced by documentation and staff interviews. This failure to rotate injection sites was directly observed and confirmed during the survey process.
Failure to Maintain Accident Hazard-Free Environment and Equipment Safety
Penalty
Summary
Surveyors identified that the facility failed to maintain a resident environment free from accident hazards for seven residents reviewed for accidents. Specifically, multiple residents who were assessed as high risk for falls and had orders for low beds with bilateral floor mats were found to have furniture or medical equipment placed on top of their fall mats. Observations included chairs, side tables, and bed wheels positioned on the mats, which staff and the DON acknowledged could compromise the mats' effectiveness in preventing injury. Facility policies and manufacturer instructions for the mats explicitly stated that heavy objects should not be left on the mats, as this could cause indentations and damage, reducing their protective function. In addition to the issues with fall mats, two residents were found to have bed controllers with visible, frayed, or exposed wires. Staff interviews confirmed that such conditions should have been reported to maintenance for immediate replacement, as per facility policy. The DON stated that exposed wires on bed controllers are not acceptable and should be addressed promptly to prevent potential harm. Facility policies required the maintenance department to keep all equipment in a safe and operable condition at all times. The residents involved had significant cognitive impairments, including diagnoses such as Alzheimer's disease, dementia, Parkinson's disease, and other conditions affecting their ability to make decisions or care for themselves. Many were dependent on staff for mobility and activities of daily living and had documented histories of falls or high fall risk. Despite these vulnerabilities and the presence of care plans and physician orders intended to mitigate injury risk, the facility did not ensure that environmental safety interventions were properly implemented and maintained.
Failure to Ensure Proper Pharmaceutical Services and Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents and in one medication room, resulting in multiple deficiencies. For one resident with a history of cerebral infarction, dementia, and urinary tract infection, the facility received eight tablets of Augmentin as ordered by the physician. However, only seven tablets were administered and documented, with the remaining tablet unaccounted for. The Medication Disposition Log was not completed for the extra tablet, and the bubble pack was missing. The Director of Nursing acknowledged that the medication was likely discarded without proper logging, contrary to facility policy, which requires all discontinued or leftover medications to be logged and destroyed in the presence of two licensed nurses. Another resident with Parkinson's disease was prescribed carbidopa-levodopa extended-release to be administered at midnight, in addition to immediate-release doses throughout the day. The Medication Administration Record showed that the extended-release dose was consistently given at 6:30 a.m. instead of midnight, as ordered by the physician. Both the registered nurse and the Director of Nursing confirmed that this constituted a medication error, as the medication was not administered according to the prescriber's order, and the timing was not in accordance with facility policy. Additionally, in one medication room, an emergency medication kit containing controlled medications was not reconciled at every shift change as required. The kit, stored in a refrigerator, lacked an accountability log for the month reviewed. Staff interviews confirmed that all controlled medications, including those in emergency kits, should be reconciled at each shift change to ensure accountability and prevent diversion. The Director of Nursing confirmed that this process was not followed for the emergency kit in question.
Pharmacy Consultant Failed to Identify and Report Medication Monitoring Irregularities
Penalty
Summary
The Pharmacy Consultant (PC) failed to identify and report irregularities during the monthly drug regimen review (MRR) for two residents. For one resident with bipolar disorder, the PC did not ensure that there was monitoring for specific, measurable target behaviors related to the use of valproic acid, a psychotropic medication. The resident's records indicated a prescription for valproic acid to address extreme irritability affecting activities of daily living, with instructions to monitor episodes of irritability and aggression. However, the MRRs for May and June did not document any identified irregularities or report the lack of behavior monitoring to the attending physician or Director of Nursing (DON). For another resident with Parkinson Disease, the PC did not ensure monitoring for adverse effects associated with the use of carbidopa-levodopa. The care plan indicated a risk for adverse effects and the need for monitoring, but the Medication Administration Record (MAR) did not contain documentation of such monitoring. The MRRs for April, May, and June did not identify or report the absence of adverse effect monitoring to the attending physician or DON. During interviews, the PC acknowledged failing to identify and report the lack of appropriate monitoring for both residents in the monthly written reports. Facility policies and procedures required comprehensive MRRs, evaluation of medication therapy responses, and documentation and reporting of resident-specific irregularities or clinically significant risks to the DON and prescriber. The PC's failure to follow these requirements resulted in the deficiencies cited.
Failure to Monitor for Adverse Effects of Carbidopa-Levodopa
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not monitoring for adverse effects associated with carbidopa-levodopa, a medication prescribed for Parkinson’s Disease. The resident’s care plan specifically identified the risk of adverse effects, such as dyskinesia, and directed staff to monitor for these effects and alert the physician as needed. However, a review of the Medication Administration Record (MAR) for the relevant period showed no documentation of such monitoring. Interviews with both a registered nurse and the Director of Nursing confirmed that monitoring for adverse effects should have been documented on the MAR, in accordance with the care plan. Both staff members were unable to locate any evidence of monitoring for adverse effects related to carbidopa-levodopa during the specified timeframe. The lack of documentation indicated that the care plan was not implemented as intended, and the resident’s needs were not adequately addressed. The facility’s policies and procedures required monitoring for adverse consequences of medications and prompt reporting of any such events. The policies also specified that licensed nurses should review drug regimens for adequate monitoring and that adverse consequences should be minimized by following clinical guidelines. Despite these requirements, the facility did not ensure that monitoring for adverse effects of carbidopa-levodopa was performed or documented for the resident, resulting in a failure to comply with both internal policy and regulatory standards.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required by regulation. During an observation, a Licensed Vocational Nurse (LVN) administered four medications—famotidine, buspirone, hydrochlorothiazide, and losartan—to a resident at a time different from what was ordered by the resident’s physician. The medications were given outside the facility’s policy window of 60 minutes before or after the scheduled administration time, which was confirmed by both the LVN and the Director of Nursing (DON) during interviews. The LVN acknowledged not following the '5 rights' of medication administration, specifically the right time, and identified these as medication errors. The resident involved had a medical history including anxiety, hypertension, and gastro-esophageal reflux disease, and was prescribed the medications for these conditions. The Medication Administration Record (MAR) and physician orders specified exact times for each medication, which were not adhered to during the observed administration. The facility’s policies and procedures clearly outlined the requirement to administer medications within a one-hour window of the prescribed time, and to verify the correct time before administration. A review of facility policies further confirmed that administering medications at the wrong time constitutes a medication error. The incident resulted in four medication errors out of 26 opportunities, leading to a medication error rate of 15.38%, which exceeds the regulatory threshold. Both the LVN and DON confirmed that the medications were not administered according to physician orders or facility policy, and these actions were classified as medication errors.
Failure to Rotate Insulin Injection Sites Leads to Significant Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin administration sites as required by physician orders, manufacturer guidelines, and professional standards. For one resident with dementia and type 2 diabetes, records showed repeated insulin injections were administered in the same anatomical areas over multiple dates, despite explicit orders and care plan interventions to rotate sites. Interviews with the MDS Coordinator and nursing staff confirmed that insulin administration sites were not rotated, and staff acknowledged this was contrary to both the physician's orders and best practice guidelines. A second resident, diagnosed with metabolic encephalopathy and diabetes with neuropathy, also received insulin injections without proper site rotation. Documentation revealed multiple instances where insulin was administered repeatedly in the same location, such as the left lower quadrant of the abdomen or the same arm, over several days. Nursing staff and the DON confirmed that the administration sites were not rotated as required, and acknowledged that staff should have checked previous administration sites in the electronic health record to avoid repetition. Review of facility policies and manufacturer guidelines for insulin administration further supported the requirement to rotate injection sites to prevent complications. The facility's own policy, as well as the prescribing information for the insulins used, specified that injection sites should be rotated within the same general area. Despite these clear directives, the facility did not ensure compliance, resulting in a significant medication error for both residents.
Failure to Label and Store Inhalation Medications per Manufacturer and Facility Policy
Penalty
Summary
Surveyors observed that the facility failed to properly label and store certain inhalation medications in accordance with manufacturer requirements and facility policy. Specifically, an open budesonide inhalation solution foil pouch for one resident was found in a medication cart without a date indicating when the pouch was opened, and three inhalation solutions remained inside the open pouch. Manufacturer guidelines require that once opened, the foil pouch should be stored at room temperature and the contents used or discarded within two weeks. The lack of labeling made it impossible to determine if the medication was still within its effective period. Additionally, an open and used budesonide and formoterol inhalation aerosol for another resident was found stored at room temperature without a date indicating when the inhaler was removed from its foil pouch. According to manufacturer instructions, this inhaler should be used or discarded within three months of opening. The absence of an open date meant staff could not verify whether the medication was still effective or had expired. Interviews with the LVN and DON confirmed that facility policy requires multi-dose products to be labeled with the date opened to track expiration, and that failure to do so prevents staff from determining the beyond-use date. Review of facility policies and manufacturer instructions further supported the requirement for proper labeling and timely use or disposal of these medications. The observed deficiencies were limited to the medications found in one medication cart and involved two residents receiving inhalation treatments for respiratory conditions.
Failure to Follow No Added Salt Diet Orders for Multiple Residents
Penalty
Summary
The facility failed to follow its own menu and nutritional guidelines by providing extra packets of salt to residents who were prescribed No Added Salt (NAS) diets. Multiple residents with medical conditions such as hypertension, heart disease, and impaired cognition were observed to have received salt packets on their meal trays, despite clear dietary orders specifying NAS diets. This was confirmed through record reviews, resident interviews, and direct observation of meal service, where kitchen staff routinely added salt and pepper packets to all trays without checking individual dietary restrictions. Residents affected included those with intact cognition who reported receiving extra salt packets, as well as residents with impaired cognition who were unable to advocate for themselves. The dietary orders for these residents specifically required NAS diets due to their medical conditions, including hypertension, heart failure, and atherosclerotic heart disease. The facility's menu and policy also indicated that NAS diets should not include salt packets, and that dietary staff are responsible for ensuring therapeutic diets are prepared and served as ordered. Interviews with the Dietary Service Supervisor and the Director of Nursing confirmed that the kitchen staff did not check tray tickets for NAS diet orders and acknowledged that this practice could negatively impact residents' medical conditions. The deficiency was identified through a combination of record review, resident council feedback, direct observation of meal trays, and staff interviews, all of which demonstrated a failure to adhere to prescribed dietary restrictions for residents requiring NAS diets.
Incomplete Medical Records and Informed Consent Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident with depressive disorder, dementia, and psychosis, the informed consent for a psychotropic medication did not document the method used to verify that the physician discussed the risks and benefits with the resident or their representative. Both the LVN and RN confirmed that the consent form was incomplete, as the section indicating how the consent was verified was left blank. The Director of Nursing also acknowledged that the consent was not complete due to missing documentation on the verification method. For another resident with depression, dementia, and anxiety disorder, the informed consent for a mood-stabilizing medication was also incomplete. The consent form lacked the date beside the physician's signature and did not indicate how the informed consent was verified by the licensed nurse. Both the LVN and RN identified these omissions during their review, and the DON confirmed that the consent was not complete because the physician's signature was not dated and the verification method was not documented. Additionally, for a resident with cerebral infarction, dementia, and a urinary tract infection, the administration of an antibiotic (Augmentin) was not documented in the Medication Administration Record (MAR) as having been given at the prescribed time. Although the Emergency Kit Pharmacy Log showed that the medication was administered, this was not reflected in the resident's MAR. The Infection Preventionist and DON both confirmed that the lack of documentation in the MAR resulted in inaccurate medical records, as it was unclear whether the resident received the medication as ordered.
Personal Belongings Found in Clean Laundry Room Violating Infection Control Policy
Penalty
Summary
A deficiency was identified when personal belongings, including two bags, a sweater, a cellphone, and a pair of sunglasses, were observed inside the clean laundry room. These items belonged to a laundry staff member and were found hanging by the door and placed under the air-conditioning unit near a table with folded clean linens. The Housekeeping Manager confirmed that the items belonged to the staff member, and the Infection Preventionist stated that personal belongings are not permitted in the clean laundry area, as this area is designated for washed linens and clothes and must remain clean. Further interviews revealed that laundry staff are provided with lockers in the janitor room for storing personal items, and facility policy prohibits employee personal belongings from being left in the laundry area. The Director of Nursing acknowledged that the facility failed to keep the laundry area clean and free from potential infection related to the placement of personal belongings, which could result in cross contamination. Facility policies reviewed also indicated that clean linen must be protected from environmental contamination.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the administration of antibiotics to residents. The absence of such a program was identified during the survey, indicating that the facility did not take necessary actions to ensure appropriate antibiotic stewardship.
Failure to Maintain Safe Condition of Essential Equipment
Penalty
Summary
The facility failed to maintain essential electrical and patient care equipment in safe operating condition for five residents. Observations and interviews revealed that one resident's fall mat had peeling covers, compromising its integrity and the homelike environment. The fall mat was intended as an intervention for a resident with severe cognitive impairment, high fall risk, and a history of falls, as documented in the care plan and medical records. Both the LVN and DON confirmed that the mat's condition was unacceptable and did not meet facility standards for safety or environment. Additionally, four residents were found to have bed remote controls with frayed or exposed wires. These residents had varying degrees of cognitive impairment and physical dependency, with some at high risk for falls. Staff, including CNAs and the DON, acknowledged during interviews that exposed or frayed wires on bed controls posed a risk of electrocution and should have been reported immediately to the maintenance department for replacement. Observations confirmed the presence of these hazards in resident rooms, and staff admitted to not noticing or reporting the issues in a timely manner. Review of facility policies and procedures indicated that maintenance services are responsible for ensuring all equipment is safe and operable, and that staff are expected to identify and report hazards. The policies also emphasized the importance of providing a safe, clean, and homelike environment, and specifically addressed the need for electrical safety and the prevention of accident hazards. Despite these policies, the facility did not ensure that equipment such as fall mats and bed controls were maintained in safe condition, resulting in the identified deficiencies.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved. No additional information about the medical history or condition of any resident at the time of the deficiency is provided in the report.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed or did not fully understand their health status, care, and treatments. The deficiency was identified based on findings that residents were not provided with adequate information regarding their medical condition and the care or treatments they were receiving. This lack of communication resulted in residents not being able to make informed decisions about their care.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were administered psychotropic drugs without adequate justification or in a manner that could limit their functional abilities. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for two residents. For one resident with a history of stage three sacral pressure ulcer, contractures, and severe cognitive impairment, there was a physician's order to apply heel protectors to both feet at all times, both in bed and in a wheelchair. Observations revealed that the resident was not wearing heel protectors, and both the CNA and LVN assigned to the resident confirmed that the heel protectors were not applied. The CNA was unaware of the order, and the LVN acknowledged responsibility for ensuring the use of pressure-relieving devices but confirmed the protectors were not in place. The RN also confirmed the order and stated that staff should have ensured the heel protectors were applied as the resident was at high risk for pressure ulcers due to fragile skin, contractures, and poor nutrition. For another resident with a stage four right gluteal pressure injury, dementia, diabetes, and severe cognitive impairment, there was a physician's order for a low air loss mattress (LALM) to be set according to the resident's current weight. The resident's weight was documented as 114 lbs, but the LALM was observed to be set at 160 lbs. The Infection Preventionist and DON both confirmed that the mattress should have been set to 120 lbs, the closest available setting to the resident's weight. The incorrect setting was not in accordance with the physician's order or the facility's care plan, which specified that the LALM should be set based on the resident's current weight to minimize the risk of skin breakdown. Facility policy and procedures required staff to review care plans, identify risk factors, and implement appropriate interventions, including the use of pressure-relieving devices and support surfaces. The operations manual for the LALM also specified that the mattress should be adjusted according to the patient's weight. Despite these guidelines, staff failed to ensure that the prescribed interventions were implemented for both residents, as evidenced by the lack of heel protectors and the incorrect LALM setting.
Failure to Ensure Required Physician and Psychiatrist Visits
Penalty
Summary
The facility failed to ensure that a resident received required face-to-face visits from both the attending physician (AP) and the psychiatrist (Psych MD) as mandated. Specifically, the AP did not make an initial face-to-face visit within 30 days of admission during the first 90 days, and the Psych MD did not conduct a required visit as per physician orders. Instead, nurse practitioners (NPs) conducted all visits for both the AP and the Psych MD, with no documentation of direct visits from the physicians themselves. Review of the resident's medical record confirmed the absence of progress notes or history and physical documentation from either the AP or the Psych MD. The resident involved had diagnoses including cerebral ischemia, unspecified dementia, and insomnia, with documentation indicating severely impaired cognitive skills and lack of capacity to make decisions. Despite orders for psychiatric consultation and follow-up, only NPs performed these visits. Interviews with nursing staff and the DON confirmed that the AP and Psych MD did not see the resident, and the facility's policy requiring physician visits was not followed. The DON acknowledged the failure to ensure required physician visits occurred.
Failure to Ensure Resident Access to Survey Results
Penalty
Summary
The facility failed to ensure that two residents who attended a Resident Council Meeting were aware of the availability and location of the facility's latest survey results. During interviews, both residents stated they did not know where to find the survey results or how the facility addressed previously identified deficiencies. The residents expressed a desire to be informed about the facility's most recent survey inspection results and the corrective actions taken. Observation and interviews with staff revealed that the survey result binder was stored under a cabinet in the dining room, with a label too small for residents to read. Although the facility maintained two survey binders—one in the front lobby and one in the dining room—residents were only informed that they could ask staff to access the binder. Staff acknowledged that the binder should be easily accessible to residents without staff assistance. Review of facility policies confirmed that survey results should be maintained in an area frequented by residents and be readily accessible for examination.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to meet the required room size of at least 80 square feet per resident in multiple resident bedrooms, affecting 19 out of 34 rooms. Observations, interviews, and record reviews confirmed that these rooms, each housing three residents, ranged from 195 to 238 square feet, which is below the minimum standard of 240 square feet for three-bed rooms. The facility had submitted a variance request acknowledging the deficiency, and documentation indicated that the rooms did not meet federal and state requirements for space per resident. During the survey, staff and residents reported no issues with space, and observations showed that residents and staff could move freely within the rooms, with sufficient space for beds, dressers, and care equipment. The administrator confirmed the deficiency and stated that no complaints had been received from residents regarding room size. The facility's policy also requires bedrooms to meet the 80 square feet per resident standard, which was not met in the identified rooms.
Failure to Maintain Resident Dignity During Staff Interaction
Penalty
Summary
A deficiency occurred when a staff member failed to respect a resident's right to dignity during a lunch service. The resident, who had diagnoses including unspecified dementia, schizoaffective disorder bipolar type, and other persistent mood disorders, was noted to be severely impaired in thought process and judgment. During the incident, the resident became aggressive and threw a spoon at a certified nursing assistant (CNA). In response, the CNA threw the spoon back toward the resident and raised her voice at the resident. Another CNA present confirmed witnessing the staff member raise her voice and return the spoon, stating that these actions did not provide a dignified existence for the resident. The facility's policy on dignity, last revised in 2021, requires that residents be treated with dignity and respect at all times, with special sensitivity toward cognitively impaired residents. The policy specifically instructs staff to address the underlying causes of resident behavior and to avoid challenging or contradicting residents' beliefs or statements. The actions of the CNA in this incident were inconsistent with these policy requirements, resulting in a failure to honor the resident's rights and dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, leading to a potential delay in care. Resident 2, admitted with Alzheimer's Disease, hypertension, and cognitive communication deficit, was observed with the call light on the floor by the right side of the bed, out of reach. The resident's care plan, which was last revised in March 2025, indicated that the call light should be within reach to attend to needs promptly. Similarly, Resident 3, who has chronic obstructive pulmonary disease, muscle weakness, and Alzheimer's Disease, was observed with the call light tangled with another resident's call light and on the floor, making it inaccessible. The care plan for Resident 3 also required the call light to be within reach. During observations, staff members, including a Certified Nursing Assistant (CNA) and a Restorative Nursing Assistant (RNA), failed to notice or rectify the situation, leaving the call lights out of reach. The Director of Nursing (DON) acknowledged the failure to ensure the call lights were accessible, which is crucial for residents to call for assistance. The facility's policy, reviewed in January 2025, mandates that residents have a means to call staff for assistance from their bed, toileting, or bathing facilities, and the floor, emphasizing the importance of having the call light within reach.
Failure to Notify Physician of Residents' Skin Condition Changes
Penalty
Summary
The facility failed to notify the physician when two residents experienced changes in their skin condition, specifically rashes and itchiness. Resident 1, who was admitted with conditions including hypertension and dysphagia, was observed with raised, open, and red skin rashes while moaning and itching her arms. Despite these observations, the nursing notes did not document any notification to the physician or family. The MDS coordinator confirmed the absence of documentation indicating physician notification. Resident 2, admitted with Alzheimer's disease and unspecified dermatitis, was observed scratching her neck, chest, and back, reporting that the itchiness had persisted for weeks and was severe enough to disrupt her sleep. The LVN admitted to not notifying the physician about the changes in condition for both residents. The facility's policy requires prompt physician notification for any change in a resident's condition, which was not adhered to in these cases. The physician was unaware of these changes and planned to visit the facility to assess the situation.
Failure to Notify Physician of Residents' Skin Conditions
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in managing their skin conditions. Resident 1, who was admitted with diagnoses including hypertension, angina pectoris, and dysphagia, was observed with a skin rash and itchiness on both upper and lower extremities. Despite the presence of raised, open, and red rashes, the Licensed Vocational Nurse (LVN) did not inform the Medical Doctor (MD) of the change in condition, as required by the facility's policy. The nursing notes also failed to document any notification to the physician or family, placing Resident 1 at risk for further skin irritation and delayed care. Similarly, Resident 2, admitted with Alzheimer's disease, metabolic encephalopathy, and unspecified dermatitis, experienced severe skin itchiness that disrupted her sleep. Despite her complaints and the application of cream by the staff, the itchiness persisted, and there was no documented evidence of physician notification. The Registered Nurse (RN) confirmed the lack of documentation, and the Director of Nursing (DON) acknowledged the policy to report changes in condition but could not explain the oversight. The MD was unaware of the residents' conditions and planned to visit the facility to assess the situation.
Inadequate Disinfection During IGAS Outbreak
Penalty
Summary
The facility failed to implement and maintain an effective infection control program during an outbreak of invasive group A streptococcus (IGAS). The deficiency was identified through interviews and record reviews, which revealed that high touch areas at Nursing Station 1 and Nursing Station 2 were not routinely disinfected as required. The facility's disinfection logs for high touch areas indicated that licensed nurses (LNs) were responsible for disinfecting these areas during specific shifts when housekeeping staff were not present. However, the logs showed multiple instances where LNs did not document their disinfection activities, suggesting that the disinfection may not have been performed. Interviews with the Director of Staff Development (DSD) and the Infection Preventionist (IP) confirmed the presence of an IGAS outbreak in the facility and highlighted the importance of regular disinfection to prevent the spread of the infection. The IP reviewed the disinfection logs and noted several dates where LNs failed to initial the logs, indicating a lack of compliance with the disinfection protocol. The IP emphasized that the logs were created to ensure disinfection was carried out during the outbreak, and the absence of documentation implied that the disinfection was not done. The Director of Nursing (DON) acknowledged awareness of the incomplete disinfection logs and stressed the importance of LNs completing them to confirm that disinfection was performed, especially during hours when housekeeping staff were unavailable. The facility's policies on infection control and communicable diseases, as well as cleaning and disinfection procedures, were reviewed, indicating that the facility had established protocols for maintaining a safe and sanitary environment. However, the failure to adhere to these protocols during the IGAS outbreak resulted in a deficiency in the infection control program.
Delay in STAT X-ray for Resident After Fall
Penalty
Summary
The facility failed to ensure a STAT X-ray was implemented in a timely manner for a resident who had a fall and was suspected to have a fracture. The resident, who had Alzheimer's Disease and severe cognitive impairment, was admitted with a displaced left proximal humerus fracture. After a fall, a STAT X-ray was ordered to assess the resident's left humerus, but it was not conducted within the required four to six-hour window. The delay in obtaining the X-ray results led to a delay in necessary medical care for the resident. Interviews with the Director of Nursing and nursing staff revealed that the STAT X-ray order was not followed promptly due to staff being busy and not following up with the radiology provider. The facility's policy and contract with the radiology provider indicated that STAT X-rays should be completed within four hours, but this was not adhered to. As a result, the resident was eventually transferred to a general acute hospital for further evaluation, where the X-ray confirmed an acute displaced and angulated midshaft humeral fracture.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility was found to have multiple deficiencies in its food storage and preparation practices, which were observed during a survey. The walk-in refrigerator had shelves that were chipped and cracked, which the Dietary Supervisor acknowledged could harbor bacteria and lead to cross-contamination. Additionally, the freezers had dried up pink liquid, dust buildup, and tape debris on the bottom shelves, which were not cleaned as per the facility's policy. These conditions were noted to potentially attract germs and cause foodborne illnesses among the residents. In the dry storage area, a dented can was found stored with non-dented cans, which the Dietary Supervisor stated could lead to botulism if consumed. The knife container and a scoop with a sticky residue were also found to be unclean, posing a risk of cross-contamination. Furthermore, the storage of scoops was disorganized, with handles facing different directions, which was not in line with sanitary practices. The clean storage area for pots and pans was found to have dust, crumbs, and food residues, and the mixer had dirt and food buildup, indicating a lack of proper cleaning after use. Food carts used for lunch service had dried milk spills and tape residues, which were not cleaned after each meal, as required by the facility's cleaning schedule. Additionally, a resident's food from home in the refrigerator was not labeled with a name or received date, which the Director of Nursing admitted was a mistake. This lack of labeling could lead to incorrect diet administration and potential allergic reactions. These deficiencies in food storage and preparation practices posed a risk of harmful bacteria growth and cross-contamination, potentially leading to foodborne illnesses among the residents.
Deficient Policy on Storage of Outside Food
Penalty
Summary
The facility failed to have a comprehensive policy regarding the use and storage of food brought to residents by family and other visitors, which could ensure safe and sanitary storage, handling, and consumption. The existing policy discouraged bringing outside food due to concerns with food safety and infection control but allowed it as a resident's right, especially if the resident was eating poorly. The policy did not clearly outline the facility's responsibility for storing food beyond one mealtime, nor did it provide specific guidelines for safe food storage. The Registered Dietitian (RD) and Director of Nursing (DON) acknowledged that the policy was general and lacked guidance for food storage, which could lead to emotional changes in behavior and potential weight loss among residents. During interviews, the RD stated that food brought from outside was labeled, dated, and stored in the resident's refrigerator, with a practice of discarding any food after 72 hours. However, the policy did not explicitly mention these storage guidelines, leading to potential non-compliance by residents if unexpired food was discarded. The DON also noted that the policy needed revision as it was too general and did not provide adequate guidance for food storage. The lack of a clear policy had the potential to cause decreased food intake, unintentional weight loss, frustrations, and psychosocial harm to all 78 residents in the facility.
Improper Garbage Disposal and Cleanliness in Trash Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in the trash area outside the facility. The dumpster area was found to be littered with soiled plastic utensils, trash, and liquid drippings, which were not adequately cleaned. During an observation and interview with the Dietary Supervisor, it was confirmed that the trash surroundings were not clean. The Maintenance Supervisor, responsible for cleaning the area, admitted to using a blower to clear leaves but did not use water pressure for cleaning. He acknowledged the importance of maintaining cleanliness to prevent infection spread but was unsure of the current state of cleanliness. The Housekeeping Supervisor also confirmed that the trash area had trash and liquid drippings, despite having cleaned the surroundings earlier that morning. The facility's policies and procedures on waste control and disposal, dated January 2024, require that outside garbage bins be kept closed and the surrounding area kept clean. Additionally, the Food Code 2017 mandates that outside receptacles for refuse be designed with tight-fitting lids and kept covered to prevent contamination. The failure to adhere to these guidelines posed a potential risk of attracting pests and spreading infection to all 78 residents of the facility.
Sanitation Deficiency in Food Services Due to Fly Presence
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of a fly in the kitchen. During an observation and interview with the Registered Dietitian (RD) and the Dietary Supervisor (DS), a fly was seen landing on a can opener and later on a baked good in the trayline area. The DS acknowledged that the fly could have entered from the breakroom or office when staff opened the door and expressed concern about the potential for germs to be transmitted to food, which could lead to residents getting sick. The facility's Pest Control Policy, dated earlier in the year, indicated that the facility should maintain an effective pest control program to keep the building free of insects and rodents.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were available and within reach for five residents, leading to a deficiency in accommodating resident needs and preferences. Resident 25, who was admitted with severe cognitive impairments and was dependent on staff for daily activities, did not have a call light available for use. This was confirmed during an observation by a Certified Nursing Assistant (CNA), who acknowledged the importance of having a call light to prevent accidents. The Director of Nursing (DON) also stated that the absence of a call light could delay care, and the facility's policy required call lights to be within reach of all residents. Resident 52, who had a history of falling and cognitive impairments, was observed with a call light that was not within reach while lying in bed. A CNA had to move the call light to make it accessible, emphasizing the necessity of having it within reach. Similarly, Resident 31, who required assistance for mobility and had a history of falls, was found in a wheelchair with the call light clipped to the bed, out of reach. The CNA and a Registered Nurse (RN) both highlighted the importance of having the call light accessible to prevent residents from attempting to move unassisted, which could lead to falls and injuries. Residents 57 and 35 also experienced similar issues with call lights being out of reach. Resident 57, who was dependent on staff for daily activities, was observed in a wheelchair with the call light clipped to the bed, inaccessible. Resident 35, with severe cognitive impairments and a high risk for falls, had the call light placed on top of the bed, out of reach while in a wheelchair. The DON reiterated that the facility's policy required call lights to be within reach to ensure prompt assistance and prevent accidents. The consistent failure to adhere to this policy across multiple residents highlights a significant deficiency in the facility's accommodation of resident needs.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to reflect documented evidence of discussions regarding advance directives (ADs) and to maintain a current copy of the AD in the clinical records for three of four sampled residents. This deficiency was identified during interviews and record reviews for Residents 21, 52, and 57. The absence of ADs in the residents' charts violated their rights to have their healthcare wishes documented and respected, potentially leading to conflicts with their healthcare preferences. Resident 21 was admitted with diagnoses including Alzheimer's disease, unspecified dementia, and schizoaffective disorder. The resident's Minimum Data Set (MDS) indicated limited ability to understand and communicate, requiring substantial assistance for daily activities. Despite an Advance Directive Acknowledgment form indicating the execution of an AD, the document was missing from the resident's chart. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed the absence of the AD in the chart, contrary to facility policy. Similarly, Resident 52, with diagnoses of psychosis and unspecified dementia, had an executed AD according to the History and Physical (H&P) records, but it was not present in the chart. Resident 57, diagnosed with Alzheimer's disease and unspecified dementia, also lacked a completed AD Acknowledgment form, with no documentation indicating the resident's representative was informed of their rights. Interviews with the DSD and DON highlighted the failure to follow facility policy, which mandates the documentation and accessibility of ADs in residents' medical records to ensure their healthcare wishes are known and respected.
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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