Anaheim Healthcare Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 501 South Beach Blvd., Anaheim, California 92804
- CMS Provider Number
- 055984
- Inspections on file
- 40
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Anaheim Healthcare Center, Llc during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter was observed with the drainage bag and tubing touching the floor and not inside a dignity bag, contrary to facility policy and CDC guidelines. Both an LVN and the DON confirmed the improper placement and lack of adherence to catheter care protocols.
A resident with an indwelling urinary catheter was observed with the urinary drainage bag and tubing touching the floor and the drainage bag not placed inside a privacy bag, making the urine contents visible to anyone entering the room. Staff confirmed this was not in accordance with facility policy, which requires catheter drainage bags to be covered at all times to maintain resident dignity and privacy.
A resident on contact precautions for C. diff infection did not have the correct signage posted at their room, and an Activity Assistant entered the room without donning the required PPE (gown and gloves), contrary to facility policy. The Infection Preventionist confirmed the signage should have indicated contact precautions and that all staff must wear PPE when entering the room.
Surveyors observed that food and drink served to residents was not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency for the facility.
A resident on a no salt added diet did not receive the full prescribed breakfast menu, missing both the breakfast meat of choice and seasonal fruit cup due to a late delivery and lack of communication. The dietary staff acknowledged the menu was not followed, and the resident confirmed she did not receive all menu items.
A resident who could not make medical decisions had bilateral bolster pillows in use following a fall, but the medical record lacked a signed provider consent and a physician's order for the intervention. Both an LVN and the DON confirmed these requirements were not met, and facility policy was not followed.
A CNA failed to follow facility policy by pouring hot water into a resident's colostomy bag in an attempt to clean it, resulting in the bag touching the resident's skin and causing a burn injury. The resident experienced pain, redness, and a blister on the thigh, requiring pain medication and wound care. Staff interviews confirmed that the CNA did not adhere to established protocols, and the incident led to a documented wound.
A nurse aide, lacking proper training and competency in colostomy care, attempted to empty a resident's colostomy bag by pouring hot water into it, contrary to facility policy. This action caused the resident to sustain a burn and blister on the thigh and abdomen. The aide had not received formal instruction on the procedure and learned incorrect techniques from other staff, leading to the incident and subsequent injury.
Due to a kitchen equipment malfunction, lunch meals were not served at the scheduled time to the majority of residents. Several residents, including those requiring insulin or medications with meals, experienced significant delays, hunger, and frustration. Staff did not inform residents of the delay, and some required additional monitoring or snacks as a result.
Surveyors found multiple food safety and sanitation deficiencies, including unlabeled and expired food items in refrigerators, dirty surfaces in food storage areas, and improper storage of utensils. The majority of residents received food from the kitchen where these issues were observed, and facility policies requiring proper labeling, dating, and cleaning were not followed.
Several residents, including those lacking decision-making capacity, did not have properly completed informed consent forms for medications and treatments. Required signatures, dates, and witness information were missing or incomplete, and the facility's process for involving the IDT and Ombudsman was not followed as per policy. Staff interviews confirmed that consent documentation was not handled according to established procedures.
A resident with a physician's order for one-to-one feeding assistance due to aspiration precautions was observed eating independently and coughing while swallowing, without staff present. The care plan addressing nutrition was not revised to include the required intervention, as confirmed by the DON.
Several deficiencies were identified, including improper monitoring for orthostatic hypotension due to incomplete BP measurements and lack of notification parameters, failure to provide required one-on-one feeding assistance for a resident at risk of aspiration, and repeated BP measurements taken from the restricted arm of two residents with dialysis access devices, despite clear orders and facility policy. Staff interviews confirmed a lack of understanding and adherence to proper procedures.
A resident with dysphagia and Alzheimer's disease, who had a physician's order for one-to-one feeding assistance due to aspiration precautions, was observed eating lunch alone and unsupervised. The resident's diet slip did not reflect the required supervision, and staff interviews revealed a lack of awareness of the order, resulting in the resident consuming food and drink independently while intermittently coughing.
Surveyors identified multiple failures in respiratory care, including unlabeled and undated nebulizer and suction equipment, improper storage of suction devices, administration of oxygen therapy without proper physician orders or documentation, and failure to date an oxygen humidifier bottle. These deficiencies were confirmed by nursing staff and the DON during observations and record reviews.
The facility did not ensure proper medication administration and documentation for three residents, including failure to accurately sign out and dispose of a narcotic, administering a bowel medication without assessing for loose stool as ordered, and giving an antihypertensive medication despite blood pressure parameters that should have led to the dose being held. Staff and DON confirmed these deficiencies during interviews and record reviews.
Surveyors found that arformoterol was not stored per manufacturer instructions, with both opened and unopened vials kept in medication carts instead of a refrigerator, and staff did not monitor cart temperatures. Expired medical supplies and medications, including povidone-iodine swab sticks, a disinfectant bottle, and COVID-19 test kits, were not properly discarded from medication carts and storage rooms. Medication carts were also observed to be unsanitary, with sticky residues and dried medication present, and staff confirmed these conditions did not meet facility policy.
A resident with decision-making capacity did not receive a requested tuna melt as a replacement for the posted lunch entrée, despite the request being documented. Staff interviews confirmed the special request was missed, and the resident was served the standard menu items instead.
A resident with fluctuating decision-making capacity was not provided with their preferred Vietnamese menu during a meal, despite their care plan and facility policy requiring food preferences to be honored. Instead, the resident was served ice cream and verbally requested the preferred food, which was not provided by staff.
Several residents had inconsistencies in their medical records, including mismatches between documented decision-making capacity and responsible party status, lack of updates to H&P exams after cognitive reassessment, and inaccurate documentation of advance directives. Additionally, a medication order contained an incorrect hold parameter, and urine output was not properly documented after catheter removal for two residents. These issues were confirmed by interviews with nursing staff and the DON, who acknowledged the documentation errors.
The facility did not ensure that arbitration agreements for three residents without decision-making capacity were explained and agreed upon with the full required IDT, including the Ombudsman. Instead, the Administrator signed the agreements as the legal representative without the mandated participation of all Bioethics Committee members, contrary to facility policy.
Staff failed to follow infection control protocols, including improper use of PPE when entering and leaving COVID-19 isolation rooms, not performing hand hygiene, and contaminating clean areas with items from isolation rooms. Environmental lapses included improper storage and labeling of urinals, presence of personal items in clean linen areas, and incorrect placement of meal trays. Infection control surveillance did not include residents with infection symptoms, and staff did not wear proper PPE or sanitize equipment when administering medications via GT.
The facility did not maintain a complete antibiotic stewardship program, as its infection screening evaluation lacked clear criteria for identifying true infections and did not provide an option to indicate when no criteria were met. Additionally, a resident receiving rifaximin for hepatic encephalopathy did not have the duration of antibiotic therapy documented in the medical record, contrary to facility policy. Both the IP and DON confirmed these deficiencies during interviews and record reviews.
Two residents were not properly administered or documented for influenza and pneumococcal vaccinations. One resident's record showed an undated refusal for the pneumococcal vaccine with no further documented attempts, while another resident's record lacked both a date for influenza vaccine refusal and evidence of vaccine administration, despite consent from a responsible party.
A resident who had provided consent for the COVID-19 vaccine did not receive the vaccine, and there was no documentation of administration in the medical record. The Infection Preventionist confirmed that, despite the presence of a signed consent form, the vaccine was not given as required by facility policy.
An inspection revealed that the Blood Glucose Monitoring System Quality Control Record for Medication Cart C was missing the serial number for the Assure Platinum Meter. An RN confirmed the omission, and the DON verified the findings.
A resident's closet drawer was found to be in disrepair, with chipped paint and unpainted areas, during an observation and interview. The resident reported using the drawer and wanting it repaired, indicating the environment was not maintained in a homelike condition.
A resident with a physician's order for continuous supplemental oxygen was documented as receiving daily oxygen therapy, but the MDS assessments for two separate periods were inaccurately coded to indicate no oxygen use. The MDS Coordinator confirmed the discrepancy after reviewing the medical records.
A resident with fluctuating decision-making capacity was not provided a meal tray at the same time as others at her table during lunch, despite facility policy requiring respectful and dignified mealtime practices. This was observed and confirmed by staff and another resident.
A nurse did not fully close the privacy curtain or room door while administering medications via gastrostomy tube to a resident, leaving the resident exposed to the hallway and visible to staff, residents, and visitors. The nurse later acknowledged that privacy should have been ensured during the procedure.
A resident with an indwelling urinary catheter and a physician's order for its use did not have a care plan problem or interventions developed to address the catheter, as confirmed by both medical record review and LVN interview. This failure to include the catheter in the care plan was not consistent with facility policy for comprehensive, individualized care planning.
Surveyors observed that multiple garbage dumpsters had lids left open or missing, with garbage inside preventing proper closure. The Administrator confirmed these findings, which did not meet the FDA Food Code requirement for tight-fitting lids to prevent pest entry.
A facility failed to implement its infection control program when a nurse did not wear a gown during high-contact care for a resident, despite Enhanced Barrier Precautions requiring it. The resident had specific orders for PPE use due to a gastrostomy tube and trachea stoma wound care. The Infection Preventionist confirmed the expectation for staff to follow these protocols.
A resident experienced an unwitnessed fall, and the facility failed to monitor and document the resident's condition for 72 hours as required by policy. Despite the care plan being updated to include monitoring for potential issues, progress notes did not reflect this monitoring. The ADON and DON confirmed the lack of continuous monitoring for negative impacts from the fall.
A facility failed to create a comprehensive care plan for a resident needing IV hydration and with a clogged nephrostomy tube. Despite policies requiring individualized care plans, the resident's records lacked documentation for these issues. Interviews with staff confirmed the absence of necessary care plans, highlighting a failure to address the resident's specific needs.
The facility failed to maintain comfortable temperatures in seven resident rooms, affecting 19 residents. Observations and interviews revealed that residents experienced discomfort due to high temperatures, with some rooms reaching up to 88 degrees Fahrenheit. The Maintenance Supervisor acknowledged issues with two HVAC units that had been under repair for a week, affecting temperature control in six rooms.
A resident's personal property was not adequately protected, leading to the potential for theft or loss. The facility failed to properly document and release the resident's belongings, including a walker, upon discharge to a hospital. The walker was later found in the facility, indicating a lapse in inventory management and adherence to policy.
A resident with COPD and a duodenal ulcer repeatedly refused prescribed medications, but the facility failed to notify the physician as required by policy. Despite the resident's capacity to make decisions, the lack of communication with the physician about the refusals was confirmed by staff interviews, posing a potential risk to the resident's health.
A resident was given the wrong insulin pen by a nurse, who handed a lispro pen instead of the prescribed glargine pen. The resident, capable of self-administering medications, noticed the error and requested a double-check, leading to the correct medication being provided. The incident was confirmed by medical records and staff interviews.
Failure to Maintain Proper Catheter Care and Bag Placement
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate care and services as required by facility policy and CDC guidelines. During an observation, the resident's urinary drainage bag and tubing were found touching the floor, and the drainage bag was not placed inside a dignity bag as specified in the facility's catheter care policy. The policy requires catheter care to be performed every shift, with privacy bags available and drainage bags covered at all times. The CDC guideline also states that urine collection bags should not rest on the floor. The deficiency was confirmed through observation, staff interview, and review of the resident's medical record and facility policies. The LVN present acknowledged that the drainage bag and tubing should not be touching the floor and should be inside a dignity bag. The DON also verified the findings, noting that although the resident was on a low bed, there should have been a measure in place to prevent the drainage bag from contacting the floor. The resident had an order for an indwelling urinary catheter due to obstructive uropathy.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident with an indwelling urinary catheter. During an observation, the resident's urinary drainage bag and tubing were found touching the floor, and the drainage bag was not placed inside the required privacy (dignity) bag. This made the urine contents visible to anyone entering the resident's room. The facility's policy requires that catheter drainage bags be covered at all times with a privacy bag and that catheter care be performed every shift to ensure dignity and privacy for residents with indwelling catheters. A review of the resident's medical record showed an order for an indwelling urinary catheter due to obstructive uropathy. Staff interviews confirmed that the drainage bag and tubing were improperly positioned and not covered, contrary to facility policy and CDC guidelines. The Director of Nursing acknowledged the findings and verified that the drainage bag should not have been touching the floor and should have been inside a dignity bag.
Failure to Follow Contact Precautions for Resident with C. diff Infection
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident who was on contact precautions due to a C. diff infection. According to the facility's policy, staff are required to wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment, and to don personal protective equipment (PPE) upon room entry. During an observation, an Activity Assistant was seen inside the resident's room without wearing the required gown and gloves. When questioned, the Activity Assistant admitted to forgetting to check the signage at the door before entering. Additionally, the signage posted at the resident's door was not updated to reflect the current contact precautions required for C. diff infection. The Infection Preventionist (IP) confirmed that the signage should have indicated contact precautions and acknowledged the oversight. The resident had a physician's order for contact isolation due to C. diff, and the facility's policy specified the necessary infection control measures, which were not followed during the observed incident.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals served to residents.
Failure to Follow Prescribed Breakfast Menu for a Resident
Penalty
Summary
The facility failed to follow the prescribed breakfast menu for one resident who was on a no salt added regular portion diet. According to the menu, the resident was supposed to receive a Belgian waffle, breakfast meat of choice, seasonal fruit cup, and hot or cold cereal. However, the resident was only served two waffles and oatmeal, without the breakfast meat or seasonal fruit cup. The resident's meal ticket indicated a dislike for sausage and milk, but not all dairy products, and the resident stated she would have eaten eggs if they had been provided. The omission of the fruit cup was due to a late delivery, and the dietary manager acknowledged that they were unaware of the shortage until trayline service was underway. Residents were not informed about the missing items until they received their trays. Review of facility documents showed that the menus are required to meet the nutritional needs of residents and be followed as planned. The dietary manager and certified dietary manager confirmed that the menu was not followed for this resident, and the resident confirmed that she did not receive the full menu items for breakfast on that day. This failure had the potential to result in the resident not receiving adequate nutrition and appropriate servings to meet her individual needs.
Incomplete Medical Record and Missing Physician Order for Bolster Pillow
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete regarding the use of bilateral bolster pillows. The resident, who was unable to make medical decisions, had a care plan intervention for bilateral bolster pillows following an unwitnessed fall from bed. However, the medical record review revealed that the informed consent form for the bolster pillow was not signed by the provider who obtained the consent, and there was no physician's order for the use of the bolster pillow documented in the resident's records. During interviews and concurrent medical record reviews, both an LVN and the DON confirmed that a bolster pillow required both a signed consent from the resident or representative and a physician's order, neither of which were present in this case. The facility's policy on informed consent also specified that the healthcare professional proposing the intervention is responsible for providing information and obtaining proper consent, which was not followed in this instance.
Improper Colostomy Care Results in Resident Burn Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to provide necessary care and services to a resident with a colostomy, resulting in a burn injury. The CNA attempted to empty the resident's colostomy bag but was unable to remove all fecal matter. Instead of following facility policy and procedure, which prohibits direct care staff from putting fluids into the colostomy bag, the CNA left the room, obtained a cup of hot water, and poured it into the colostomy bag. During this process, the colostomy bag touched the resident's skin, causing a burning sensation and subsequent injury to the left thigh and abdomen. The resident, who was cognitively intact and able to make decisions, immediately reported pain and burning to the CNA, but the CNA did not promptly respond. The resident had to physically intervene to stop the procedure. The incident resulted in redness and, later, a blister on the resident's left thigh. The medical record documented the development of a burn wound, with measurements and a wound status of open, and the resident required pain medication and wound treatment as a result. Interviews with facility staff, including the CNA, LVN, DSD, and DON, confirmed that the CNA used hot water inappropriately and did not follow established protocols for colostomy care. Facility policy clearly states that CNAs are not permitted to put fluids into colostomy bags and should notify a supervisor if additional care is needed. The CNA admitted to not checking the water temperature and not using appropriate protective measures, such as a towel, which contributed to the resident's injury.
Nurse Aide Lacks Competency in Colostomy Care, Resulting in Resident Burn
Penalty
Summary
The facility failed to ensure that a nurse aide demonstrated competency in the skills and techniques necessary to care for a resident with a colostomy, as identified through the resident's assessment and care plan. The nurse aide, who had been employed for less than three months, was responsible for emptying a resident's colostomy bag but was not properly trained on the procedure during orientation or in CNA school. Instead, the aide learned from other CNAs, one of whom demonstrated pouring water into the colostomy bag, a practice not permitted by facility policy. During the incident, the nurse aide attempted to empty the colostomy bag but was unable to remove all fecal matter. The aide then left the room, obtained a cup of water from a dispenser, and poured it into the colostomy bag without checking the water temperature. The hot water came into contact with the resident's skin, causing a burning sensation and resulting in redness and a blister on the resident's left thigh and abdomen. The resident reported significant pain and had to alert the aide to stop the procedure. The aide acknowledged the error and reported the incident to a nurse, who observed the injury and provided pain medication. Facility policy and lesson plans explicitly state that direct care staff are not permitted to put fluids into a colostomy bag and should notify a supervisor if they encounter care needs beyond their scope. Interviews with facility leadership confirmed that the aide should not have performed the action and that the required competency for emptying an ostomy bag was documented as completed, despite the aide's lack of proper training. The incident resulted in a burn injury to the resident, with documentation of the wound and subsequent treatment.
Failure to Serve Lunch Meals at Scheduled Times Due to Kitchen Malfunction
Penalty
Summary
The facility failed to provide lunch meals to 196 out of 216 residents at the scheduled mealtime, as required by facility policy and posted meal schedules. On the day in question, the kitchen oven thermostat and igniter malfunctioned, causing the kitchen staff to begin plating lunches an hour late. As a result, the first lunch trays did not leave the kitchen until 1257 hours, well after the scheduled lunch period of 1130 to 1230 hours. The Dietary Manager confirmed that all residents receiving kitchen-prepared meals would not receive their lunch within the scheduled timeframe, which was important for those with medications scheduled around meal times. Multiple residents reported not receiving their lunch at the expected time, expressing feelings of hunger, frustration, and aggravation. One resident, who had received six units of insulin at 1130 hours, had not received her lunch by 1320 hours and reported feeling sweaty and hungry, requiring juice and a snack from staff. Nursing documentation confirmed her blood sugar was rechecked due to the late meal. Other residents also reported not being informed about the delay and described significant hunger, with one rating their hunger as a nine out of ten. These observations and interviews confirm that the facility did not meet its obligation to serve meals at scheduled times according to residents' needs and preferences.
Food Safety and Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to meet food safety requirements in the kitchen, as evidenced by several specific deficiencies observed during a survey. Defrosted meat stored in the walk-in refrigerator was not labeled with a pull date or use by date, and several veggie sausage patties were stored past their use by date. Additionally, an unlabeled plastic bin containing meat was found, and the Director of Dining Services confirmed that proper labeling, including type of meat, pull date, and use by date, was required but not followed. The walk-in refrigerator's wall and floor were observed to have dirt, and food debris was found on the bottom of the dairy refrigerator, which contained items such as Jello, milk, and cottage cheese. The dairy refrigerator was reportedly cleaned twice a week and as needed, but was not maintained in a clean condition at the time of observation. Further, the snack refrigerator contained three bags of unlabeled grapes, and the Director of Dining Services confirmed that these should have been labeled with the date received to ensure safe storage times. In the dry storage room, a plastic rice scoop was found lying on top of a plastic bin of rice instead of being stored inside a clean bag as required, creating a risk of contamination. These failures were observed in a facility where the majority of residents received food prepared in the kitchen, and the facility's own policies and procedures required proper labeling, dating, and sanitation practices that were not followed.
Failure to Obtain and Document Complete Informed Consents for Care and Treatment
Penalty
Summary
The facility failed to ensure that accurate and complete informed consents were obtained for several residents, as required by its own policies and procedures. For multiple residents who lacked capacity to make their own medical decisions and had no legal surrogate, the required process involving the facility's Interdisciplinary Team (IDT) and inclusion of an unaffiliated resident representative, such as the Ombudsman, was not followed. In several cases, consent forms were either incomplete, missing required signatures, or improperly filled out, with sections for the resident's legal representative left blank or simply marked as 'IDT' without a signature or date. Interviews with the Administrator and DON confirmed that the Ombudsman had not participated in the Bioethics Committee/IDT meetings for over a year, contrary to facility policy, and that the Administrator should have signed as the responsible party on behalf of the IDT. For residents who were unable to make medical decisions, such as those prescribed psychotropic and antidepressant medications, the documentation of informed consent was inconsistent and incomplete. Forms for these residents often lacked the name and signature of the person who obtained consent, the date, and the required witness information. In some cases, the forms indicated that consent was obtained from the resident, despite documentation showing the resident lacked decision-making capacity. Additionally, for one resident, the consent for advanced wound care services was obtained from the resident, even though the medical record indicated the resident was unable to provide consent. Other deficiencies included missing or incomplete information on consent forms for residents who could make their needs known but not medical decisions. For example, forms were missing the date and signature of the person who placed a consent call, the date and signature of the eligible provider or clinician, the date and name/signature of a witness, and the date and signature of the resident or their power of attorney. In some cases, instructions for distributing copies of the consent forms were not followed, and the required information was not completed. Interviews with nursing staff and the DON confirmed these findings and acknowledged that the informed consents should have been properly signed and dated according to policy.
Failure to Update Care Plan for Aspiration Precautions
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident to reflect a physician's order for one-to-one feeding assistance as an aspiration precaution. Medical record review showed that the resident had a physician's order dated 3/27/25 for one-to-one feeding assistance, but this intervention was not included in the resident's active care plan addressing nutrition. During an observation, the resident was seen eating independently in his room without staff present and was noted to cough intermittently while swallowing. The Director of Nursing confirmed that the care plan had not been updated to include the required intervention in accordance with the physician's order.
Failure to Follow Physician Orders and Proper Monitoring Procedures
Penalty
Summary
The facility failed to provide necessary care and services to several residents as ordered by their physicians and as required by their care plans. For two residents with orders to monitor for orthostatic hypotension, the monitoring was not conducted correctly. Specifically, blood pressure (BP) measurements were not taken in all required positions (lying, sitting, standing) within the appropriate time intervals, and the physician's orders did not specify parameters for when to notify the physician of significant BP changes. Staff, including the DON and LVN, were unsure of the correct procedure and lacked facility policies or resources to guide them in monitoring orthostatic hypotension or determining when to notify the physician. Another resident with a physician's order for one-on-one feeding assistance due to aspiration precautions was not provided with the required assistance during meals. Observations and staff interviews confirmed that the resident was eating independently, contrary to the physician's order and the care plan, which specified one-on-one feeding assistance to prevent aspiration. The DON and LVN verified that the order was not being implemented by the facility staff. Additionally, two residents with orders and care plans specifying that blood pressure should not be taken on their left arms due to the presence of dialysis access devices had multiple BP readings documented as being taken from the restricted arm. Facility policy also prohibited BP measurements on the arm with a dialysis access device. Staff interviews and medical record reviews confirmed that these orders were not followed, and the DON acknowledged that BP should not have been taken on the left upper arm for these residents.
Failure to Provide One-to-One Feeding Assistance for Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia and Alzheimer's disease, who had exhibited coughing or choking during meals and had a physician's order for one-to-one feeding assistance for aspiration precautions, was observed eating lunch independently in his room without staff supervision. The resident was seen consuming soup, juice, and a nutritional drink while intermittently coughing, and was outside the view of facility staff during the meal. The diet slip on the resident's tray did not include the physician's order for one-to-one feeding assistance. Interviews with the assigned CNA, LVN, Dietary Manager, and Director of Rehabilitation confirmed that the physician's order for one-to-one feeding assistance was active and that staff should have maintained visual supervision during meals. The CNA assigned to the resident was unaware of the order and allowed the resident to eat alone, contrary to the documented care plan and physician's instructions. The failure to communicate and implement the required supervision was verified through medical record review and staff interviews.
Deficiencies in Respiratory Care: Labeling, Documentation, and Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies in labeling, storage, and documentation of respiratory equipment and therapy. For one resident, the nebulizer tubing, mask, and canister were found unlabeled and not dated, with no indication of when they were last changed, despite a physician's order for regular nebulizer treatments. An LVN confirmed that these items should have been labeled and changed weekly or as needed. Another resident had a suction canister, tubing, and Yankauer suction tip that were not labeled or stored in a set-up bag, and the canister contained liquid of unknown age. The same resident was observed receiving oxygen at a rate higher than the physician's order, with no documentation of the administration or the reason for the increased flow. The LVN and RN involved confirmed the lack of labeling, improper storage, and missing documentation. A third resident was observed receiving oxygen therapy without a physician's order, and there was no documentation or reason for the administration. The DSD and LVN verified the absence of an order and documentation. Additionally, another resident's oxygen humidifier bottle was not dated as required by physician's order and facility policy. The DON acknowledged all these findings during interviews and record reviews.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration for three residents, as evidenced by direct observations, interviews, and medical record reviews. For one resident, the facility did not accurately document, sign out, or dispose of a narcotic medication (tramadol) according to its own policies and procedures. The medication administration record (MAR) and the controlled drug record did not match, and there was an unidentified, undated, and unlabeled tablet found attached to the narcotic bubble packet. Staff interviews confirmed that the required documentation and proper disposal procedures, including dual signatures for wasting narcotics, were not followed. Another resident with a physician's order for docusate sodium to be held in the presence of loose stool was administered the medication without the nurse assessing for current episodes of loose stool or diarrhea. Medical records showed the resident had a recent history of loose stool, and the nurse acknowledged not checking for this condition prior to administration. The DON confirmed that the medication should have been held as per the physician's order when loose stool was present. A third resident had a physician's order for losartan potassium to be held if the systolic blood pressure (SBP) was below 130 mmHg. Despite this, the MAR showed the medication was administered on multiple occasions when the resident's SBP was below the specified threshold. Both the nurse and the DON verified that the medication was given contrary to the physician's order, and the documentation supported this finding.
Deficient Medication Storage, Expired Supplies, and Unsanitary Medication Carts
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of drugs and biologicals within the facility. Inspections of several medication carts revealed that arformoterol, a medication used to treat chronic obstructive pulmonary disease, was not stored according to the manufacturer's instructions. Both unopened and opened unit dose vials of arformoterol were found in medication carts rather than in a refrigerator, as required. Staff interviews confirmed that the facility did not monitor the temperature of the medication carts to ensure compliance with the specified storage range, and the Director of Nursing acknowledged that the medication should have been refrigerated. Further observations found expired medical supplies and medications in multiple locations, including medication carts and the medication storage room. Items such as a small bore extension set, povidone-iodine swab sticks, a bottle of disinfectant, and COVID-19 antigen self-test kits were all found to be past their expiration dates and had not been properly discarded. Staff verified these findings and stated that expired items should have been removed from use and disposed of according to facility policy. Additionally, medication carts were found to be in unsanitary condition, with sticky residues and dried medication observed on bottles and cart surfaces. Staff confirmed that these carts should have been maintained in a clean and sanitary manner to ensure infection control. The facility's policies and procedures require proper storage, sanitation, and disposal of medications and supplies, but these were not followed as observed during the survey.
Failure to Provide Requested Meal Substitution
Penalty
Summary
The facility failed to ensure that posted meal menus and resident meal requests were followed for a specific resident. Review of facility documentation showed that the resident had submitted a special request for a tuna melt as a replacement for the posted meal entrée on a specific date. Despite this documented request, the resident was served the standard menu items, which included pork, beans, bread, cake with strawberries, and cranberry juice, but not the requested tuna melt. The resident, who was determined to have decision-making capacity, confirmed during an interview that she did not receive the meal she wanted and indicated that this was not a frequent occurrence. Interviews with facility staff, including an LVN and the Dietary Supervisor, confirmed that the resident's special meal request was missed and not provided as planned. The facility's policy required that food preferences and special requests be documented and followed, but this was not adhered to in this instance. The DON also verified the findings during a subsequent interview.
Failure to Honor Resident Food Preferences During Mealtime
Penalty
Summary
The facility failed to honor a resident's food preference as required by its policies and the resident's care plan. Specifically, a review of the resident's care plan indicated that their food preferences should be honored within diet parameters, and substitutes should be offered if meal intake was below 50%. The resident's diet slip specified a soft and bite-size Vietnamese menu with chopped meat, vegetables, noodles, and bread. However, during an observation, the resident was served ice cream and was not provided with the Vietnamese menu as requested. The resident in question had a fluctuating capacity to understand and make decisions, as documented in their medical record. During the observed mealtime, the resident verbally requested Vietnamese food, but the staff member feeding the resident confirmed that the Vietnamese menu was not served. This failure to provide the preferred food was contrary to the facility's policy on promoting and maintaining resident dignity during mealtime and had the potential to negatively impact the resident's meal intake and psychosocial well-being.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as required by its own policies and accepted professional standards. For multiple residents, there were inconsistencies between their capacity to make medical decisions as documented in their History & Physical (H&P) examinations and what was recorded on their admission face sheets. Specifically, some residents who were determined to lack capacity were incorrectly listed as self-responsible on their admission records, and updates to H&P examinations were not made after changes in cognitive assessments. Additionally, a resident's Advance Directive Acknowledgment form did not accurately reflect the existence of a completed POLST, despite one being present in the record. The facility also failed to ensure the accuracy of medication orders and documentation of clinical monitoring. One resident's physician order for metoprolol tartrate included an incorrect hold parameter for systolic blood pressure, which was verified by nursing staff as a documentation error. Furthermore, for two residents who had indwelling urinary catheters removed, the facility did not document urine output or use the bladder scanner to assess for urinary retention as required by facility policy. Instead, only check marks were recorded on the Treatment Administration Records (TARs), without accurate measurements of urine output or post-void residuals. These documentation failures were confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged the discrepancies and lack of accurate record-keeping. The facility's own policies require factual, accurate, and complete documentation, but these standards were not met in the cases reviewed, resulting in incomplete or inaccurate medical records for the affected residents.
Failure to Involve Full IDT in Arbitration Agreement Process for Residents Lacking Capacity
Penalty
Summary
The facility failed to ensure that the arbitration agreement was properly explained and agreed upon with the appropriate Interdisciplinary Team (IDT) members for three residents who lacked decision-making capacity. According to the facility's policies, the Bioethics Committee, which includes the Administrator, DON, Medical Director, Primary Care Physician, Social Services, and Ombudsman, is responsible for making decisions on behalf of residents without capacity or a responsible party. However, in each case reviewed, the Administrator signed the arbitration agreement as the resident's legal representative without the involvement of the full Bioethics Committee, specifically excluding the Ombudsman. For one resident, medical records indicated the resident could make their needs known but was unable to make medical decisions. The arbitration agreement was signed by the Administrator on behalf of the IDT, but interviews confirmed that the Ombudsman was not present or involved in the decision-making process. The Ombudsman stated she had not participated in any Bioethics Committee meetings or meetings regarding arbitration agreements for over a year. Similar findings were noted for two other residents who also lacked decision-making capacity, with the Administrator signing the agreements without the required participation of the Ombudsman or the full Bioethics Committee. These actions were inconsistent with the facility's own policies, which require the arbitration agreement to be explained in a manner understandable to the resident or their representative, and for the Bioethics Committee to be involved in such decisions for residents lacking capacity. The failure to involve the appropriate IDT members, including the Ombudsman, in the arbitration agreement process was confirmed through interviews and record reviews for all three residents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program according to its policies and accepted standards of care. Staff members, including an LVN and a CNA, did not follow proper infection control procedures when entering and leaving rooms under contact/droplet precautions for COVID-19, such as not performing hand hygiene, not wearing required PPE, and contaminating clean meal carts with items from isolation rooms. Additionally, a nurse was observed entering a COVID-19 positive room without an N95 mask, and another staff member left a COVID-19 isolation room without proper PPE and failed to perform hand hygiene. Environmental issues were also identified, including the presence of paper trash and a staff personal item in the clean linen area, and improper storage and labeling of urinals in resident rooms and restrooms. A finished meal tray was placed on a PPE cart instead of a designated meal cart, and a urinal was stored next to a resident's meal tray and drinking liquids. These actions were verified by staff during interviews and were not in accordance with the facility's infection control policies. The facility's infection control surveillance did not include residents with signs or symptoms of infection, and staff failed to wear proper PPE when administering medications via gastrostomy tube (GT) to a resident on enhanced barrier precautions. Additionally, a stethoscope used for checking GT placement was not sanitized after use. These failures were acknowledged by staff and the Director of Nursing during interviews, and the facility was experiencing a COVID-19 outbreak at the time.
Deficient Antibiotic Stewardship Program and Incomplete Documentation of Antibiotic Duration
Penalty
Summary
The facility failed to maintain an accurate and complete antibiotic stewardship program as required by its own policies and procedures. Specifically, the infection screening evaluation component of the antibiotic stewardship review did not include clear guidelines on how many criteria must be met to identify a true infection, nor did it provide an option to indicate when no criteria were met. Both the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed during interviews and document reviews that the evaluation lacked these essential elements, and that assessments were based on subjective judgment rather than standardized criteria. Additionally, the facility did not ensure that a resident's prescribed antibiotic therapy for hepatic encephalopathy included documentation specifying the duration of treatment, as required by the facility's antibiotic stewardship protocols. Medical record review showed that the resident was receiving rifaximin without a documented duration for the therapy, and both the IP and DON verified the absence of this information in the resident's records. This omission was found during concurrent interviews and record reviews with facility staff.
Failure to Document and Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two of five sampled residents received appropriate influenza and pneumococcal immunizations as required by facility policy. For one resident, the medical record indicated a refusal of the pneumococcal vaccine, but the consent/declination form was undated, and there was no documentation of additional attempts to offer the vaccine. The Infection Preventionist (IP) confirmed that the resident's record lacked a date for the refusal and did not show further efforts to administer the vaccine. For another resident, the immunization record documented a refusal of the influenza vaccine, but no date was provided for the refusal. Additionally, the vaccine consent/declination form was signed by the resident's responsible party, but there was no evidence in the medical record that the influenza vaccine was administered. The IP verified the absence of documentation regarding the administration of the influenza vaccine for this resident.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was administered to a resident who had provided consent for vaccination. According to the facility's policy and procedure, all eligible residents are to be offered and administered the COVID-19 vaccine unless medically contraindicated, already given, or refused. Medical record review for the resident showed that the responsible party had signed a consent form for the COVID-19 vaccine, but there was no documentation in the resident's immunization records indicating that the vaccine was administered. During an interview and concurrent medical record review with the Infection Preventionist (IP), it was confirmed that the consent for vaccination was present in the record, but there was no evidence that the vaccine had been given after consent was obtained. The lack of documentation and administration of the vaccine was verified by the IP, indicating a failure to follow the facility's established protocol for COVID-19 immunization.
Incomplete Documentation on Blood Glucose Monitoring System
Penalty
Summary
During an inspection of Medication Cart C, it was observed that the Blood Glucose Monitoring System Quality Control Record was missing the serial number for the Assure Platinum Meter. When questioned, an RN confirmed that the form should have included the serial number to ensure accuracy. The Director of Nursing later verified these findings during an interview. No information about specific residents or their medical conditions was provided in the report.
Failure to Maintain Homelike Environment Due to Damaged Closet Drawer
Penalty
Summary
A deficiency was identified when a resident's room was observed to have a closet drawer in disrepair, with chipped paint and unpainted areas. During an observation and interview, the resident confirmed that he used the closet drawer and expressed a desire for it to be repaired. The condition of the closet drawer was directly observed by surveyors and noted as not meeting the standard for a safe, clean, comfortable, and homelike environment as required for residents. No additional medical history or specific condition of the resident at the time of the deficiency was provided in the report.
Inaccurate MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one resident who was reviewed for respiratory care. Medical record review showed that the resident was readmitted to the facility and had a physician's order for continuous supplemental oxygen at 4 liters per minute, which was administered daily as documented in the resident's monitor records for both November 2024 and February 2025. However, the MDS assessments for the corresponding periods did not reflect the resident's receipt of oxygen therapy during the 14-day look-back periods. During an interview and concurrent record review, the MDS Coordinator confirmed that the MDS assessments were inaccurately coded and did not accurately represent the resident's ongoing oxygen use.
Failure to Serve Meal Tray Promptly During Lunch
Penalty
Summary
The facility failed to provide a meal tray to Resident 173 at the same time as other residents during lunch in the dining room, which did not promote dignity and respect as outlined in the facility's policy. Observation showed that while two other residents at the same table were eating, Resident 173 was left without a meal tray. This was confirmed by both another resident and the Director of Staff Development (DSD) during the observation. Resident 173's medical record indicated a fluctuating capacity to understand and make decisions, but there was no indication that this was the reason for the delay in meal service. The facility's policy requires that all residents be treated with respect and dignity, especially during mealtimes.
Failure to Ensure Resident Privacy During Medication Administration via GT
Penalty
Summary
A deficiency occurred when a licensed nurse failed to provide complete privacy for a resident with a gastrostomy tube (GT) during medication administration. The facility's policy requires privacy to be ensured by pulling the privacy curtain or closing the door to a private room during such procedures. However, during the observation, the privacy curtain in the resident's room was not fully closed, and the room door remained open, exposing the resident to the hallway while the nurse checked GT placement, residual, and administered medications. This lapse resulted in the resident being visible to facility staff, other residents, and visitors passing by. The nurse acknowledged that the privacy curtain should have been drawn to protect the resident's privacy during the procedure. The Director of Nursing was informed of these findings and confirmed the incident.
Failure to Develop Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the use of an indwelling urinary catheter for one resident. According to the facility's policy, a person-centered care plan should be created for each resident, including measurable objectives and timeframes to meet their identified needs. Medical record review showed that the resident had a physician's order for an indwelling urinary catheter with a drainage bag, and direct observation confirmed the presence of the catheter and drainage bag. Despite these findings, the resident's care plan did not include a problem or interventions related to the indwelling urinary catheter. This omission was verified during an interview and concurrent medical record review with an LVN, who confirmed that the care plan lacked documentation addressing the catheter use. The absence of a care plan for this specific medical device constituted a failure to provide individualized and consistent care as required by facility policy.
Improper Storage of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in its six dumpsters, as observed on multiple occasions. Five of six dumpsters were found with lids open and garbage inside, with the lids propped open by the garbage itself, preventing them from fully closing. On another occasion, one dumpster was missing a lid entirely, and garbage was visible inside. These observations were verified by the Administrator, who confirmed the findings through photographs. The 2022 FDA Food Code requires outside garbage receptacles to have tight-fitting lids or covers to prevent the scattering of garbage, breeding of flies, or entry of rodents, but this standard was not met during the survey observations.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to implement its infection control program effectively, as evidenced by the actions of Treatment Nurse 1 during the care of a resident. The nurse was observed providing wound care to the resident's trachea stoma while wearing gloves but not donning a gown, which is a requirement under Enhanced Barrier Precautions (EBP) for high-contact resident care activities. This oversight was confirmed during an interview with the nurse, who acknowledged the necessity of wearing a gown to prevent the spread of infections. The resident in question had specific physician orders for EBP related to the use of a gastrostomy tube and trachea stoma wound care, which required the use of personal protective equipment (PPE) such as gloves and gowns during care activities. Despite the presence of EBP signage on the resident's door, which outlined the need for hand hygiene and PPE use, the nurse did not fully comply with these precautions. The Infection Preventionist (IP) confirmed that staff were expected to adhere to these protocols to prevent disease transmission.
Failure to Monitor Resident After Fall
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable well-being following an unwitnessed fall. The facility's policy required that any change in a resident's condition, such as a fall, be documented and monitored for 72 hours. However, the medical records for the resident did not show evidence of continued monitoring for any negative impact from the fall incident. This lack of documentation and monitoring was confirmed during interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The resident, who had the capacity to understand and make decisions, was found on the floor by a CNA. The care plan was updated to include monitoring for signs and symptoms such as pain, bruises, changes in mental status, and other potential issues following the fall. Despite this, the progress notes from the days following the incident did not reflect the required monitoring. Both the ADON and DON acknowledged the failure to monitor the resident continuously for any negative impact from the fall, as per the facility's policy.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who required IV hydration and had a clogged nephrostomy tube. The facility's policies and procedures for hydration and nephrostomy tube care emphasized the need for individualized care plans reflecting the resident's goals and preferences. However, the resident's medical records did not show any documented care plan addressing the administration of IV hydration for dehydration on 9/19/24 or the clogged nephrostomy tube on 9/20/24. Interviews with facility staff, including an LVN and the DON, confirmed the absence of care plans for these issues. The LVN acknowledged that a change in the resident's condition required contacting the physician and family, conducting an assessment, developing a care plan, documenting in the progress notes, and monitoring the resident. The DON verified that the necessary care plans were not initiated, indicating a failure to provide appropriate individualized care for the resident's needs.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable temperatures in seven resident rooms, affecting 19 residents. Observations and interviews revealed that residents experienced discomfort due to high temperatures, with some rooms reaching up to 88 degrees Fahrenheit. Residents reported feeling warm, uncomfortable, and ignored by staff when they raised concerns about the temperature. The facility's policy stated that temperatures should be maintained between 71 and 81 degrees Fahrenheit, but this was not adhered to, as evidenced by the thermostat readings and resident complaints. The Maintenance Supervisor acknowledged issues with two HVAC units that had been under repair for a week, affecting the temperature control in six rooms. Despite daily checks of thermostats, the actual room temperatures were not monitored, leading to prolonged periods of discomfort for the residents. The Administrator was informed of these findings, and the Maintenance Supervisor later confirmed that the HVAC units were repaired, although the deficiency had already impacted the residents' living conditions.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to protect the personal property of a resident, leading to the potential for theft or loss. The facility's policy required a resident property inventory to be completed upon admission, listing all personal items. However, upon the resident's discharge to an acute care hospital, there was no documented evidence that the inventory was signed off by the resident or responsible party and facility staff. The resident's walker, which was maroon in color and marked with the resident's name, was not included in the items released to the resident's friend, as per the Resident Property Update form. Interviews with facility staff revealed that the resident's belongings were kept in a storage room for safekeeping upon discharge. The Assistant Administrator was unaware of the missing walker until contacted by the hospital's Director of Case Management. The walker was later found in the facility's rehabilitation gym, with the resident's name written on it. The Administrator confirmed that the items should have been cross-referenced with the Inventory of Personal Effects form, which was not done. Further interviews with the Social Services Designee (SSD) and the Director of Nursing (DON) confirmed that the inventory list was not properly managed. The SSD stated that a smaller inventory slip was provided to the responsible party, but it was not itemized or cross-referenced with the original inventory form. The DON verified that the discharge section of the Inventory of Personal Effects form was blank and acknowledged that the walker should have been released to the resident's responsible party upon discharge.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to provide necessary care and services to a resident as ordered by the physician, specifically by not notifying the physician about the resident's continuous refusal of medications. The resident, who had diagnoses of COPD and a duodenal ulcer, was prescribed omeprazole and ipratropium-albuterol inhalation solution. Despite the resident's capacity to understand and make decisions, they repeatedly refused these medications over several days in June 2024. The facility's policy required that any medication refusals be reported and documented, but there was no evidence that the physician was informed of the resident's consecutive refusals. Interviews with facility staff, including an LVN, an RN, and the DON, confirmed that the physician had not been notified, and there was no documentation to indicate otherwise. The failure to notify the physician had the potential to negatively affect the resident's health condition and well-being.
Medication Error: Incorrect Insulin Administration
Penalty
Summary
The facility failed to provide the correct insulin medication to Resident 5 as ordered. On the morning of 4/29/24, the nurse handed Resident 5 a lispro pen insulin injection instead of the prescribed glargine pen. Resident 5, who was capable of self-administering her medications, noticed the error and asked the nurse to check with the supervisor. The supervisor and nurse returned with the correct glargine insulin pen injection. Resident 5 expressed concern about what could have happened if she had been asleep and unable to catch the mistake. Medical records confirmed that Resident 5 had orders for both insulin glargine and insulin lispro, with specific administration times and dosages for each. The incident was documented in the SBAR Communication Form, which showed that the charge nurse initially handed the wrong insulin pen to Resident 5, who then requested a double-check of the medication. The error was acknowledged by the nurse and the supervisor, who verified the correct medication and explained the situation to Resident 5. Interviews with RN 1 and RN 2 confirmed the sequence of events, with RN 1 admitting to holding both insulin pens and mistakenly handing the lispro pen to Resident 5. The DON also verified the error and acknowledged that it should not have occurred.
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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