Antelope Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, California.
- Location
- 44567 North 15th St. West, Lancaster, California 93534
- CMS Provider Number
- 555456
- Inspections on file
- 117
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 65
Citation history
Health deficiencies cited at Antelope Valley Care Center during CMS and state inspections, most recent first.
A resident with COPD, pneumonia, and asthma was receiving continuous oxygen via nasal cannula, with a care plan and internal procedures requiring weekly changes and labeling of oxygen tubing and humidifier equipment. During observation, the resident’s oxygen tubing and humidifier solution container had no dates indicating when they were last changed. The unit clerk acknowledged that these items must be dated to verify they were changed and reported they are changed weekly, while the DON confirmed an internal policy requiring dating and weekly changes to reduce infection and bacterial growth. Review of the written oxygen administration policy showed supplies should be replaced every 7–14 days or per manufacturer guidelines, but the lack of dating on the resident’s equipment demonstrated noncompliance with the facility’s own procedures.
A resident with DM and ESRD on hemodialysis, who was dependent on staff for eating and at risk for malnutrition, did not have a person-centered care plan addressing breakfast and meal provision in relation to an early dialysis schedule. Although the care plan noted feeding assistance and general malnutrition interventions, there was no specific plan to ensure the resident received breakfast before early-morning transport or a sack lunch for dialysis days. On one dialysis day, the resident was picked up before eating, the time of last meal was left blank on the pre-dialysis assessment, and a sack lunch was prepared and sent only after the resident had already left, with the ADON acknowledging that required nutritional interventions were not implemented and that the care plan failed to address these dialysis-related nutritional needs.
A resident with DM and ESRD on a scheduled early-morning dialysis regimen, who was cognitively intact but dependent for all ADLs and required feeding assistance, was picked up for dialysis without having received breakfast and without a prepared sack lunch. Nursing and dietary staff reported that the dialysis schedule and early pick-up time were not communicated to the kitchen, so no early meal or sack lunch was ready despite the kitchen being open. The resident, who had necrotic hands and needed to be fed, left for dialysis upset and without food, and leadership acknowledged that this lack of breakfast and sack lunch could have led to hypoglycemia.
A resident with ESRD on dialysis, DM, and metabolic encephalopathy, who was cognitively intact but dependent for all ADLs and required feeding assistance, was picked up early by transportation for dialysis before receiving breakfast and without a sack lunch in hand. A progress note later indicated that dietary staff were informed and a sack lunch was made and sent, but the Dietary Supervisor reported the lunch was not ready at pick-up and was delivered late. The assigned RN stated that the resident, who had necrotic hands and needed to be fed, was already gone when she went to the room, and that she notified the DON and a family member about the situation but did not document these events or her interventions in the medical record. The ADON confirmed there was no RN documentation for that day, despite facility policy requiring complete, accurate charting of services, events, and changes in condition.
A resident with heart failure, COPD, dementia, and palliative care needs, who required moderate assistance with ADLs and had severely impaired cognition, was discharged to a board and care home without the facility verifying that the destination could meet care needs or documenting communication with the receiving provider. Staff relied on information from a palliative care provider instead of performing their own assessment, and the POA was initially told the resident would return to a prior SNF but was not informed when the discharge plan changed. Required discharge notices and summaries were not documented as provided to the POA, despite the resident’s inability to sign or make decisions, contrary to the facility’s discharge policy requiring representative involvement and an individualized post-discharge plan.
Surveyors found that nursing staff failed to follow medication orders and complete MAR documentation for two residents. One resident with DM and hypertensive heart disease received metoprolol despite an SBP below the ordered hold parameter, and the same resident did not receive ordered pantoprazole and insulin lispro as shown by blank MAR entries and a later elevated blood glucose. Another resident with GERD, neuropathy, and hypothyroidism had blank MAR entries for scheduled famotidine, gabapentin, and levothyroxine, indicating they were not administered. Interviews with the DON, DSD, QAN, and LVNs confirmed that medications were either given contrary to orders or not given at all, contrary to facility policy requiring medications to be administered as prescribed and within the appropriate time frame.
A resident with intact decision-making capacity and chronic pain had PRN Percocet orders specifying 5-325 mg for moderate pain (4–6/10) and 10-325 mg for severe pain (7–10/10). On one occasion, an LVN documented the resident’s pain as 4/10 but administered the higher 10-325 mg dose instead of the ordered 5-325 mg dose. During interviews, the QAN and DON confirmed that the nurse did not follow the physician’s pain management parameters, contrary to facility policy requiring that medication regimens be implemented as ordered.
A resident with anxiety disorder and other medical conditions repeatedly refused prescribed buspirone, but the physician was not notified as required by facility policy. Nursing staff did not complete the necessary change in condition documentation, and the resident reported the medication was ineffective despite informing staff.
A resident with anxiety disorder and other medical conditions repeatedly refused prescribed antianxiety medication, but staff did not develop or implement a care plan to address the refusal. Despite documentation of the refusals and the resident's communication that the medication was ineffective, there was no guidance for staff on follow-up actions, contrary to facility policy.
Licensed nurses did not monitor three residents after each experienced a change of condition, including respiratory and gastrointestinal issues, as required by facility policy. Documentation was missing for several shifts, and both nursing staff and leadership confirmed that monitoring was not completed every shift for 72 hours following the events.
A resident with chronic respiratory conditions who required continuous oxygen therapy did not have their oxygen tubing and humidifier dated to indicate when they were last changed, and their oxygen mask was left on the bedside table instead of being stored in a supplies bag. Facility staff confirmed that these actions were not in line with policy, which requires dating and proper storage of oxygen supplies.
A Restorative Nurse Assistant did not wear a gown while assisting a resident with passive range of motion exercises, despite the resident being on enhanced barrier precautions due to a chronic wound and indwelling catheter. Facility policy and physician orders required gown and glove use during such high-contact care, but the staff member believed PPE was only needed for wound or catheter care, not restorative care. This failure to follow infection control protocols was confirmed by interviews with the Infection Preventionist and DON.
The facility failed to ensure that two residents were not prescribed duplicate psychotropic medications without a documented clinical rationale and did not monitor one resident's antidepressant for adverse effects. Additionally, the behavior manifestations for the use of antianxiety medications in another resident were not specific or measurable, hindering proper monitoring and assessment.
The facility did not ensure that services provided met professional standards of quality, as observed through practices that did not align with established guidelines. No further details about the specific actions, staff, or residents involved were provided.
Two residents did not receive timely care as required: one experienced a delay in physician follow-up and antibiotic initiation after reporting painful urination, and another missed a scheduled antibiotic dose due to incomplete medication reconciliation at admission, despite the medication being available in the e-kit. Facility staff did not follow policies for change of condition notification, documentation, and medication reconciliation, resulting in delayed treatment.
Three residents with pressure ulcers or at high risk for skin breakdown did not receive care as ordered by their physicians. Staff failed to apply prescribed protective devices, did not obtain or clarify wound care orders before applying dressings, and did not specify dressing types in orders. These actions were confirmed by nursing leadership and observed during care, with facility policies requiring adherence to physician orders for wound care.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility failed to ensure safe and appropriate pain management for several residents by not consistently assessing and documenting pain levels, pain locations, or non-pharmacological interventions before administering opioid medications. In multiple cases, PRN oxycodone was given outside of physician orders, and discrepancies in medication orders were not clarified, resulting in improper pain management and lack of adherence to facility policy.
A medication error rate of 5 percent or greater was identified, showing that the facility did not maintain medication administration accuracy within regulatory limits.
Surveyors found that licensed staff failed to rotate insulin injection sites for multiple residents with diabetes, did not prepare or administer medications such as Lokelma, sevelamer, metformin, and potassium chloride according to physician orders, and missed doses of pain medication. These actions were confirmed by facility leadership as medication errors and were not in accordance with professional standards or facility policy.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility failed to have a policy in place for the use and storage of foods brought in by family and other visitors for a resident, as identified during the survey.
The facility failed to maintain accurate and complete medical records for two residents by documenting conflicting code statuses on a POLST and physician order, omitting nursing notes after a resident was found unresponsive and CPR was initiated, and not documenting a resident's hospital leave or related communications. These actions resulted in incomplete and inaccurate records, as confirmed by facility staff and policy.
Staff failed to follow infection control protocols by not wearing required PPE during high-contact care for two residents on Enhanced Barrier Precautions, allowed personal items in the clean laundry area, and did not properly store a resident's BiPAP/CPAP tubing, resulting in multiple breaches of facility infection prevention policies.
Multiple residents receiving antibiotics were not monitored or had no documentation of monitoring for adverse effects as required by facility policy and care plans. Staff failed to document monitoring during and after antibiotic therapy for various antibiotics, including levofloxacin, amoxicillin-potassium clavulanate, Avycaz, and cefdinir. Facility policies required such monitoring and documentation, but staff and leadership confirmed these actions were not completed.
The facility did not designate a qualified infection preventionist to oversee the infection prevention and control program, as required.
Multiple residents did not have timely or comprehensive care plans developed or implemented for critical needs, including pressure ulcer prevention, behavioral management, antibiotic use, pain management, and psychotropic medication therapy. Staff failed to update or create care plans in response to physician orders or changes in condition, resulting in missed interventions and delays in necessary care.
Several residents at high risk for falls had equipment or furniture placed on top of their fall mats, contrary to facility policy and manufacturer instructions, which compromised the effectiveness of the mats. Additionally, after a resident experienced a fall, the required interdisciplinary team root cause analysis was not conducted. These deficiencies were confirmed through staff interviews, record reviews, and direct observation.
A resident with severe cognitive impairment and high fall risk did not have the call light within reach, as staff kept it out of reach due to the resident's behavior of putting objects in her mouth. Multiple staff confirmed this practice, despite the care plan and facility policy requiring the call light to be accessible and the need for increased monitoring.
A resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored, resulting in a deficiency related to resident autonomy and informed consent.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
Two residents experienced deficiencies in their living environment when staff failed to replace torn fall mats for one resident and did not ensure a clean floor free of sticky, yellow stains beneath a urinal for another. Both residents were cognitively intact and able to express their needs, and staff acknowledged the issues but did not take timely action to address them, contrary to facility policy requiring a safe, clean, and homelike environment.
A resident admitted with a Foley catheter did not have a baseline care plan developed or implemented within 48 hours of admission, and there was no documented indication for the catheter's use. Staff confirmed the absence of both the required care plan and the medical justification, despite facility policy mandating timely creation of a baseline care plan for new admissions.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and were linked to failures in following established protocols.
A resident received a feeding tube without documented medical necessity or agreement, and did not receive appropriate care for the feeding tube, resulting in a deficiency.
A resident receiving IV antibiotics for a pressure ulcer did not have the IV antibiotic bag labeled with the date and time of administration, as required by facility policy and standard practice. The RN indicated the date and time only on the IV tubing, and both the RN and DON confirmed that the bag itself should have been labeled to ensure proper medication administration and prevent confusion.
Two residents requiring respiratory care did not have their suction and oxygen equipment changed and labeled according to facility policy and professional standards. One resident's suction canister was not dated and the tubing had not been replaced within the required interval, while another resident's oxygen tubing lacked a label indicating when it was last changed. Staff confirmed that equipment should be changed and labeled weekly, but these protocols were not followed.
A resident requiring dialysis did not receive care and services that met established safety and appropriateness standards.
Staff did not deliver care or services in a manner that was trauma informed or culturally competent, failing to consider residents' trauma histories or cultural backgrounds as required.
A resident did not receive the necessary behavioral health care and services required, as observed and documented by surveyors. The facility did not provide the appropriate behavioral health interventions and supports needed to meet the resident's needs.
A nurse failed to properly document the administration of a controlled pain medication, resulting in a discrepancy between the medication record and the actual doses available. Additionally, a resident with a history of musculoskeletal pain did not receive a prescribed lidocaine patch as ordered, and the required assessment for self-administration was not completed, leading to inaccurate documentation in the eMAR.
An opened Humulin 70/30 insulin pen intended for a resident was found stored at room temperature in a medication cart without an open date label, contrary to manufacturer requirements and facility policy. An LVN confirmed the insulin was open and unlabeled, and acknowledged the need for labeling to track expiration.
Surveyors found that the facility did not have established or implemented policies and procedures for administering flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
A resident with multiple medical conditions was not administered the COVID-19 vaccine despite having provided informed consent and being eligible. Staff interviews and documentation confirmed that the required steps to obtain a physician's order, notify the pharmacy, and administer the vaccine were not completed, resulting in the vaccine remaining pending in the resident's record.
A topical pain medication was left at a resident's bedside without proper assessment for self-administration. The resident, who required supervision for daily activities, had not been evaluated by the interdisciplinary team as required by facility policy. Staff discovered the medication in the resident's room and confirmed that it should not have been left accessible, as no assessment for self-administration had been completed.
A resident with a history of falls and severe cognitive impairment was found to have their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. Staff confirmed the importance of keeping the call light within reach to ensure timely assistance.
A resident with complex medical needs did not receive prescribed pain medications as ordered, including morphine sulfate and oxycodone with acetaminophen, due to medication unavailability and administration errors. Nursing staff documented multiple instances where the resident reported moderate to severe pain but did not receive the appropriate medication, resulting in unmanaged pain during daily activities.
A resident with respiratory failure, asthma, and COPD was found with a vaping device, but staff did not document this or update the care plan to address the associated risks. The care plan for oxygen use was also incomplete, lacking specific and measurable interventions, and overall care planning and documentation did not meet facility policy requirements.
Failure to Date and Change Oxygen Tubing and Humidifier per Facility Procedures
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of oxygen equipment for one resident. The resident was admitted with COPD, pneumonia, and asthma and had an order for continuous oxygen at 2 L/min via nasal cannula. The resident’s care plan required continuous oxygen use with interventions that included changing humidification and oxygen tubing as indicated, changing and labeling oxygen tubing weekly or as needed if damaged or soiled, and observing oxygen precautions. During observation, the resident was seen in bed on oxygen via nasal cannula with oxygen tubing and a humidifier solution container that had no dates indicating when they were last changed. In a concurrent interview, the unit clerk stated that oxygen tubing and the humidifier solution container did not have dates and acknowledged that they must be dated to verify they were changed, adding that these items are changed every Friday and that dirty tubing can pose an infection risk. The DON stated that, although the written policy did not specify labeling, an internal policy required that oxygen tubing and humidifiers be labeled with the date changed on the tubing, concentrator, and the bag the tubing comes in, and that they are to be changed weekly to decrease infection and bacterial growth. The DON further stated that if the equipment is not dated, staff cannot confirm it was changed. Review of the facility’s oxygen administration policy indicated oxygen supplies and tubing should be replaced typically every 7 to 14 days or per manufacturer guidelines, but the observed lack of dating on the resident’s oxygen tubing and humidifier solution container showed the facility did not follow its own internal procedures for labeling and tracking changes.
Failure to Care Plan Dialysis-Related Nutritional Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan addressing a resident’s nutritional needs in relation to an early hemodialysis schedule. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and end stage renal disease requiring renal dialysis. The care plan dated 2/25/2026 documented that the resident was dependent on staff for eating and included a hemodialysis care plan that only indicated dietary consultation for meal planning as indicated. A separate care plan dated 2/26/2026 identified risk of malnutrition with interventions such as allowing adequate time for meal consumption, assisting with meals and fluids as needed, monitoring meal intake, and providing diet as ordered, and an order for feeding assistance was in place. On 2/27/2026, the resident’s dialysis schedule required pickup from the SNF at 8:00 a.m. for an 8:45 a.m. treatment, as documented on the Order Recapitulation Report. The Pre-Hemodialysis Communication Observation/Assessment for that date showed the resident was picked up at 7:50 a.m., but the section for time of last meal was left blank. Progress notes from 8:30 a.m. the same day indicated that transportation had picked up the resident before she had eaten breakfast. The notes further indicated that the Dietary Supervisor was informed and a sack lunch was prepared and sent to the dialysis center, but this occurred after the resident had already left the facility. During interviews, the Dietary Supervisor confirmed that the resident was picked up for dialysis without a sack lunch and that the meal sent later was delayed. In a concurrent interview and record review, the ADON acknowledged that there was no care plan developed to address the resident’s breakfast intake in relation to the early dialysis schedule and that the existing malnutrition interventions (allowing adequate time for meals, assisting with meals/fluids, and providing diet as ordered) were not implemented. The ADON stated the resident should have been fed by the outgoing shift before pickup and should have had a sack lunch to take to dialysis, and noted that without breakfast and a sack lunch the resident could have developed hypoglycemia. The facility’s Nutritional Assessment and Care Planning policy required that nutritional assessments be used to develop individualized care plans addressing causes of impaired nutrition, resident preferences, goals, benchmarks, and time frames, but this was not done for the resident’s dialysis-related nutritional needs.
Failure to Provide Breakfast and Sack Lunch to Dialysis Resident Requiring Feeding Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with professional standards for a newly admitted resident with diabetes mellitus and end stage renal disease (ESRD) who required hemodialysis three times weekly. The resident’s admission record showed diagnoses including metabolic encephalopathy, diabetes, and ESRD with dependence on dialysis, and the order recapitulation documented a dialysis schedule on Monday, Wednesday, and Friday at 8:45 a.m., with an 8:00 a.m. pick-up time from the SNF. The resident’s orders also included a need for feeding assistance, and the MDS indicated intact cognitive skills but dependence on staff for all ADLs. On the morning in question, progress notes documented that transportation picked up the resident for dialysis at 8:30 a.m. before the resident had eaten breakfast. The notes further indicated that the dietary supervisor was informed after the resident had already left, and a sack lunch was then prepared and sent to the dialysis center. Interviews with the dietary supervisor and assistant dietary supervisor confirmed that no sack lunch had been prepared or provided to the resident before departure, and that the kitchen had not been informed of the resident’s early dialysis schedule, despite the kitchen opening at 5:00 a.m. daily. Nursing staff interviews corroborated that the resident, who had necrotic hands and required feeding assistance, was not fed prior to pick-up. A registered nurse stated that a CNA reported transportation arrived at 7:30 a.m., the resident had not yet been fed breakfast, and the resident became upset. The RN and ADON both stated that the resident should have received an early breakfast and a prepared sack lunch before leaving for dialysis, and that the admission nurse had failed to notify dietary/kitchen staff of the early dialysis schedule. The ADON stated that without breakfast and a sack lunch, the resident could have experienced hypoglycemia while at the dialysis center. Review of facility policies on nutritional assessment and care of residents with ESRD showed requirements for identifying clinical conditions affecting nutrition and for staff training on the nutritional needs of residents with ESRD.
Failure to Document Nursing Interventions Related to Missed Meal Before Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one resident by not documenting nursing interventions related to a missed meal and sack lunch prior to dialysis. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and end stage renal disease requiring dialysis three times weekly, with a scheduled pick-up time from the facility at 8:00 a.m. The resident’s orders also indicated a need for feeding assistance and the Minimum Data Set documented that the resident was cognitively intact but dependent on staff for all activities of daily living. On the morning in question, transportation arrived at approximately 7:30 a.m. to take the resident to the dialysis center before the resident had received breakfast. A progress note timed at 8:30 a.m. documented that transportation picked up the resident before breakfast and that the Dietary Supervisor was informed, made a sack lunch, and sent it to the dialysis center. However, during interview, the Dietary Supervisor stated that the resident was picked up with no sack lunch provided at the time of pick-up and that the sack lunch was delivered later to the dialysis center. During interviews, the RN assigned to the resident stated that the resident had necrotic hands and required feeding, and that a CNA reported transportation had arrived before the resident was fed. The RN stated that when she went to the resident’s room, the resident had already been picked up, and that the CNA reported the resident was upset. The RN reported that she notified the DON and a family member, who was also upset, but acknowledged she did not document what happened that day, including her notifications to the family member and DON. The ADON confirmed there was no documentation from the RN on that date and stated the medical record was not complete. The facility’s charting and documentation policy required that all services, changes in condition, events, and incidents be documented in the medical record, and that documentation be objective, complete, and accurate.
Failure to Ensure Safe, Coordinated Discharge and Representative Involvement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident with multiple serious medical conditions. The resident was admitted with diagnoses including heart failure, palliative care needs, unspecified dementia, and COPD. An MDS dated 5/15/2025 documented that the resident’s cognitive functioning was severely impaired and that the resident required moderate assistance with oral hygiene, toileting hygiene, dressing, and personal hygiene. A physician’s order dated 5/15/2025 directed transfer of the resident to a specific board and care home. The DON reported there was no documented evidence that facility staff evaluated the board and care facility or communicated with it prior to the resident’s discharge. The DON stated staff did not verify that the receiving facility met required standards or could provide necessary care and services, and that staff relied solely on information from the palliative care provider without completing their own assessment and evaluation. The DON acknowledged the resident was inappropriately discharged and placed at risk of not receiving necessary care, including correct medications and pain assessment and management. The facility also failed to involve the resident’s representative in the discharge planning process and to inform him of the final discharge destination. The resident’s POA stated he was initially told the resident would be transferred back to a previous SNF, and that he was not informed when the discharge plan changed and the resident was instead discharged to a board and care home. The POA learned of the actual discharge location two days later after contacting the former administrator. Review of the Notice of Transfer or Discharge and the Discharge Summary, both dated 5/15/2025, showed the resident was unable to sign, and the DON confirmed there was no documentation that the POA received these documents. The DON stated the resident could not make decisions, that risks and benefits of the discharge plan should have been discussed with the POA, and that the facility’s own discharge policy required resident/representative involvement and an individualized post-discharge plan, which did not occur in this case.
Failure to Follow Medication Orders and Complete MAR Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for two residents. For one resident with osteomyelitis, diabetes mellitus, and hypertensive heart disease with heart failure, the physician’s order dated 11/11/2025 directed metoprolol succinate 50 mg by mouth daily for hypertension, to be held if systolic blood pressure (SBP) was less than 110 mmHg or heart rate less than 60 beats per minute. The January 2026 MAR showed that on 1/9/2026 at 9 a.m., LVN 4 administered metoprolol when the resident’s blood pressure was 104/76 mmHg. In interviews, LVN 1, the DSD, and the DON each stated that the metoprolol should have been held and that the nurse should have checked the physician order prior to administration. The same resident also had orders for pantoprazole 40 mg by mouth in the morning on an empty stomach for GERD and insulin lispro per sliding scale subcutaneously before meals for diabetes. Review of the January 2026 MAR showed that on 1/8/2026 at 6:30 a.m., both pantoprazole and insulin lispro entries were blank. The QAN confirmed that the pantoprazole and insulin lispro were left blank on the MAR and that there was no recorded blood sugar at the time the insulin was due; the next recorded blood sugar at 8:10 a.m. was 221 mg/dl. The DON stated that the resident could experience hyperglycemia and GERD because LVN 3 did not administer the pantoprazole and insulin. A second resident, admitted with metabolic encephalopathy, unspecified hereditary and idiopathic neuropathy, and unspecified hypothyroid, had physician orders dated 8/22/2025 for famotidine 20 mg by mouth in the morning before meals for GERD, gabapentin 300 mg by mouth in the morning for neuropathy, and levothyroxine 50 mcg by mouth in the morning before breakfast for hypothyroidism. The January 2026 MAR showed that on 1/8/2026 at 6 a.m., gabapentin and levothyroxine entries were blank, and at 6:30 a.m., famotidine was blank. The QAN and DON both stated that blank MAR entries indicated the medications were not administered and that the resident could experience GERD, increased neuropathic pain, and uncontrolled hypothyroidism. The facility’s “Administering Medications” policy dated 5/2024 required medications to be administered safely, timely, and as prescribed, within one hour of the prescribed time, and in accordance with prescriber orders, including checking vital signs when necessary.
Failure to Follow Ordered PRN Pain Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication according to the physician’s ordered parameters for one resident. The resident was admitted with diagnoses including COPD, left knee pain, and shortness of breath, and had documented capacity to understand and make decisions, with intact cognitive skills for daily decisions. Physician orders dated 12/19/2025 specified Percocet 5-325 mg by mouth every four hours as needed for moderate pain rated 4–6/10, and Percocet 10-325 mg by mouth every four hours as needed for severe pain rated 7–10/10. Review of the resident’s MAR for January 2026 showed that on 1/2/2026 at 8:16 p.m., LVN 1 administered Percocet 10-325 mg when the resident’s documented pain level was four. During a concurrent interview and record review with the Quality Assurance Nurse, it was confirmed that the resident’s pain level at that time was four out of ten and that LVN 1 administered the higher 10-325 mg dose instead of the ordered 5-325 mg dose for that pain level. The QAN stated that LVN 1 should have looked at and followed the physician’s order. In a separate interview, the DON also stated that LVN 1 should have reviewed and followed the physician order and that, based on the pain level of four, the 5 mg dose should have been administered. The facility’s Pain Assessment and Management policy indicated that the medication regimen is to be implemented as ordered, with results documented and communicated as appropriate. The failure to follow the ordered pain medication parameters for this resident constituted the cited deficiency.
Failure to Notify Physician of Repeated Medication Refusal
Penalty
Summary
The facility failed to notify a resident's physician of the resident's repeated refusal of buspirone hydrochloride, a medication prescribed for generalized anxiety disorder. The resident, who had diagnoses including recurrent enterocolitis due to C. diff, generalized muscle weakness, essential hypertension, and anxiety disorder, was admitted with intact cognitive skills and was dependent on staff for certain activities of daily living. According to the Medication Administration Record, the resident refused the prescribed buspirone on ten occasions over several days before the medication was discontinued. Despite the facility's policy requiring physician notification after two or more consecutive refusals of medication, there was no documented evidence that the physician was informed of these refusals. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the nurses should have completed a Change in Condition Evaluation form and notified the physician regarding the resident's medication refusal. The resident reported refusing the medication because it was not effective and stated that this was communicated to the nursing staff, but the medication continued to be offered. The facility's policy also required documentation of changes in the resident's medical or mental condition, which was not completed in this case.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop and implement a person-centered care plan to address a resident's repeated refusal of prescribed antianxiety medication, buspirone. The resident, who was admitted with diagnoses including recurrent enterocolitis due to C. diff, generalized muscle weakness, essential hypertension, and anxiety disorder, had intact cognitive skills and was dependent on staff for certain activities of daily living. Despite the resident's ongoing refusal of buspirone over several days, as documented in the Medication Administration Record, there was no care plan created to address this behavior or to guide staff in managing the refusal. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that a care plan should have been developed to ensure appropriate follow-up, including informing the physician and considering a psychiatry consult. The resident reported refusing the medication because it was not effective and had communicated this to nursing staff, but the medication continued to be offered without adjustment to the care plan. Review of facility policy indicated that care plans should include measurable objectives and describe services not provided due to resident refusal, but this was not done in this case.
Failure to Monitor Residents After Change of Condition
Penalty
Summary
Licensed nurses failed to follow professional standards of practice by not monitoring three residents after each experienced a change of condition (COC). For one resident with end stage renal disease, type 2 diabetes mellitus, and COPD, there was no documented evidence of respiratory monitoring for two consecutive shifts following episodes of shortness of breath. Both the registered nurse and interim director of nursing confirmed that monitoring was not completed as required, and acknowledged that the resident's respiratory status was not assessed every shift for 72 hours after the COC. Another resident, admitted with pleural effusion, asthma, and chronic respiratory failure, experienced shortness of breath and was not monitored on several shifts following the COC. Documentation was missing for specific shifts, and both the registered nurse and interim director of nursing confirmed that the resident was not monitored every shift for 72 hours as per protocol. The lack of monitoring was acknowledged as a failure to assess the effectiveness of interventions and to detect any worsening of the resident's respiratory condition. A third resident, with a history of diabetes, foot ulcer, and gastro-esophageal reflux disease, had a COC involving nausea, multiple episodes of vomiting, and abdominal pain. There was no documented monitoring for one shift after the COC, and both the registered nurse and interim director of nursing confirmed the lapse. Facility policy required monitoring and documentation of residents' progress and responses to treatment after a COC, but this was not followed for these residents.
Failure to Date and Properly Store Oxygen Supplies for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident with chronic respiratory conditions, including pleural effusion, asthma, and chronic respiratory failure. The resident required continuous oxygen therapy at two liters per minute via nasal cannula, as ordered by the physician. During observation, it was found that the resident's oxygen tubing and humidifier were not dated to indicate when they were last changed, and the oxygen mask used for respiratory treatment was left on top of the bedside table rather than stored properly. Additionally, there was no oxygen supplies bag available in the resident's room for storing the oxygen tubing when not in use. Interviews with facility staff, including an LVN and the Interim Director of Nursing, confirmed that facility policy required oxygen supplies and tubing to be dated and changed every seven to fourteen days, and that supplies not in use should be kept in a dated and labeled oxygen supplies bag. The staff acknowledged that the lack of dating and improper storage of oxygen supplies meant they could not determine how long the supplies had been in use, and that this practice was not in accordance with facility policy. The failure to follow these procedures was directly observed and confirmed through staff interviews and policy review.
Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection control program by not ensuring that a Restorative Nurse Assistant (RNA) used proper personal protective equipment (PPE) during high-contact care for a resident on enhanced barrier precautions (EBP). Specifically, the RNA assisted a resident with passive range of motion (PROM) exercises for the lower extremities without wearing an isolation gown, despite the resident having a chronic stage four pressure ulcer and an indwelling catheter, both of which require EBP during high-contact activities. The resident's care plan and physician's orders clearly indicated the need for EBP, including gown and glove use during such activities, to prevent the spread of multidrug-resistant organisms (MDROs). Interviews with the RNA, Infection Preventionist (IP), and Director of Nursing (DON) confirmed that the RNA did not follow the facility's EBP policy, which mandates gown and glove use during high-contact care for residents with wounds or indwelling devices. The RNA incorrectly believed that gowns were only necessary for wound or catheter care, not for restorative care activities. The facility's policy, last reviewed in May 2025, explicitly lists restorative care as a high-contact activity requiring EBP. This failure to adhere to established infection control protocols had the potential to contribute to the spread of MDROs among residents.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to prevent the concurrent use of two antidepressant medications, Celexa and Wellbutrin, for a resident diagnosed with major depressive disorder. There was no documented clinical rationale for using both medications simultaneously, and the care plan did not specify Wellbutrin as a targeted intervention. Additionally, staff did not monitor the use of Wellbutrin for adverse effects in the Medication Administration Record (MAR), and psychiatric progress notes lacked any discussion or justification for the dual therapy. Another resident with schizoaffective disorder was prescribed two antipsychotic medications, Seroquel and Abilify, at the same time, again without a documented clinical rationale. The psychiatric nurse practitioner confirmed there was no clinical justification for this duplicate therapy, other than historical use, and acknowledged that such practice is uncommon without dose optimization. The facility's documentation and care planning did not address the need for or appropriateness of using both antipsychotics together. For a third resident with generalized anxiety disorder, the facility did not ensure that the behavior manifestations for the use of buspirone and clonazepam were specific and measurable. The care plan and physician's orders described the behaviors in vague terms, such as "feeling of anxiety" and "restlessness as evidenced by negative vocalizations," which staff and quality assurance personnel agreed were not sufficiently specific or person-centered. This lack of specificity hindered proper monitoring of the medications' effectiveness and appropriateness, as well as the ability to track adverse effects.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. Specific details regarding the actions or inactions of staff, the nature of the services provided, or the impact on residents were not included in the report. No information was provided about the medical history or condition of any residents involved at the time of the deficiency.
Failure to Provide Timely Physician Follow-Up and Medication Reconciliation
Penalty
Summary
The facility failed to provide timely and appropriate treatment and care in accordance with physician orders and professional standards for two residents. For one resident with end stage renal disease and a history of urinary tract infection, the resident complained of burning pain on urination. Although the physician was notified of this change of condition, there was no documentation that nursing staff made follow-up calls to the physician when a response was not received, nor was there timely documentation in the progress notes. The physician's order for an antibiotic was not obtained until more than 48 hours after the initial complaint, and there was no evidence that any diagnostic tests were ordered to confirm the infection. Facility policy required prompt notification and documentation of changes in condition, but these steps were not followed. Another resident, admitted with a diagnosis of pneumonia and requiring antibiotics, did not receive a scheduled dose of amoxicillin-clavulanate as ordered upon admission. The discharge instructions from the hospital specified the timing for the next antibiotic dose, but the medication was not started until the following morning, resulting in a missed dose. The medication was available in the facility's emergency kit, but the admitting nurse did not transcribe the order correctly, causing a delay in administration. Facility policy required accurate medication reconciliation upon admission to ensure continuity of care, but this process was not completed as required. Interviews with facility staff, including the Infection Preventionist, Director of Nursing, and Medical Records Director, confirmed that the required follow-up actions and documentation were not performed in both cases. The failures to follow up with the physician and to reconcile and administer medications as ordered resulted in delays in treatment for both residents. Facility policies on change of condition, documentation, and medication reconciliation were not adhered to, as evidenced by the lack of timely communication, documentation, and medication administration.
Failure to Provide Pressure Ulcer Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. For one resident with a stage three sacral pressure ulcer and high risk for further skin breakdown, staff did not apply bilateral cushion boots as ordered by the physician while the resident was in bed. The boots, intended to protect the heels from pressure injuries, were observed unused in a plastic bag, and both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that staff should have ensured the boots were applied per the physician's order. Another resident with a history of pressure-induced deep tissue injuries (DTI) to the sacral region and left heel did not have a physician's order prior to the application of a wound dressing on the right heel. Additionally, the wound treatment for the left heel DTI was not followed as specified in the physician's order, and the type of dressing used was not specified in the order. The treatment nurse acknowledged that orders should have been clarified and obtained before applying any wound dressing, including for preventative measures, and that failure to do so could result in improper care. A third resident with a stage three sacral coccyx pressure ulcer received wound treatment without a physician's order on a specific date. The treatment nurse applied a dressing after zinc oxide ointment had already been applied, which was not included in the physician's order. The nurse admitted that the order should have been clarified before proceeding with the treatment. Facility policies reviewed indicated that wound care orders should specify the treatment, frequency, and type of dressing, and that all wound care should be performed according to physician orders and protocols.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for multiple residents. For one resident with diagnoses including cirrhosis of the liver, ankylosing spondylitis, diverticulitis, generalized abdominal pain, and osteoarthritis, the facility did not ensure that licensed nurses assessed and documented the resident's pain level using a numeric pain rating scale, the location of pain, or the use of non-pharmacological interventions prior to administering oxycodone as ordered. Review of the Medication Administration Record (MAR) and progress notes revealed numerous instances where these required assessments and interventions were not documented, despite facility policy and physician orders mandating such documentation. The resident reported ongoing abdominal pain and dissatisfaction with the effectiveness of the pain medication provided. Another resident with a history of spinal fusion, rheumatoid arthritis, and pain due to internal orthopedic prosthetic devices was not administered PRN oxycodone 10 mg according to the physician's orders, which specified its use for severe pain (pain scale 7-10). Instead, the medication was given for pain levels below the threshold indicated in the order. Additionally, there was a discrepancy in the orders for oxycodone 5 mg, which was also prescribed for pain levels 7-10, a range typically associated with severe rather than moderate pain. This order was not clarified with the physician prior to administration, and the medication was given for pain levels that did not match the intended severity, as documented in the MAR. A third resident with new onset bilateral shoulder pain did not receive a timely assessment of the pain or administration of a lidocaine patch as ordered. The facility's policies and procedures, which require consistent pain assessment, documentation, and implementation of both pharmacological and non-pharmacological interventions, were not followed. Interviews with nursing staff and the Director of Nursing confirmed that these lapses in documentation and order clarification occurred, and that the facility's pain management protocols were not adhered to during the period reviewed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a medication error rate that exceeded the regulatory threshold.
Failure to Prevent Significant Medication Errors in Insulin and Oral Medication Administration
Penalty
Summary
Surveyors identified that licensed staff failed to rotate subcutaneous insulin injection sites for three residents with diabetes, despite physician orders and facility policy requiring site rotation. Documentation showed repeated administration of insulin in the same anatomical areas over extended periods. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed during interviews that this practice did not comply with professional standards, facility policy, or prescriber orders, and constituted a medication error. Additionally, surveyors observed medication administration errors involving the preparation and timing of medications for residents with kidney disease and diabetes. One nurse prepared Lokelma for a resident using significantly more water than prescribed, based on the resident's preference, without obtaining a physician order or updating the care plan. The same nurse also administered sevelamer outside of mealtime, contrary to the prescription and pharmacy label instructions. The nurse acknowledged these deviations and the potential for incomplete dosing or reduced medication effectiveness. Further observations revealed that metformin and potassium chloride were administered to residents without food, despite explicit physician orders to give these medications with meals. There were also missed doses of hydrocodone/APAP for two residents. These actions were confirmed by staff interviews and record reviews as not being in accordance with physician orders or accepted professional standards, and were recognized by facility leadership as medication errors.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Lack of Policy for Outside Food Brought by Visitors
Penalty
Summary
The facility did not have a policy regarding the use and storage of foods brought to residents by family members and other visitors. This lack of policy was identified during the survey, indicating that the facility had not established procedures or guidelines to address how outside food should be managed for residents.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two of three sampled residents. For one resident, there was a discrepancy between the code status documented by an LVN on the Physician Orders for Life-Sustaining Treatment (POLST) form and the physician's order. The POLST indicated that resuscitation/CPR should be attempted, while the physician's order documented a Do Not Resuscitate (DNR) status. The LVN acknowledged mistakenly documenting DNR in the physician's order instead of full code, despite the resident and family requesting full code and the POLST being signed accordingly. This inconsistency was confirmed by the Social Service Designee, Assistant Director of Nursing (ADON), and Director of Nursing (DON), all of whom noted the importance of accurate code status documentation for proper care delivery. Additionally, the same resident experienced an unresponsive episode during which the LVN who first discovered the resident did not document her observations or interventions in the medical record. Although the LVN initiated CPR and called for emergency assistance, there was no nursing note from her detailing the events from the start of her shift until the resident was found unresponsive. The DON and RN involved confirmed that the LVN should have documented her findings and actions, as required by facility policy, to ensure a complete and accurate account of the resident's condition and care provided. For another resident, the facility failed to document the events surrounding the resident's hospital leave. The electronic health record indicated the resident was on hospital leave on two occasions, but there were no progress notes or SBAR-Change of Condition forms documenting the transfer to the hospital or the reason for the leave. The ADON and DON both stated that there should have been documentation of the resident's status, the transfer, and communication with the physician and family. Facility policy requires that all changes in a resident's condition, treatments, and events be documented in the medical record to facilitate communication and continuity of care.
Failure to Implement Infection Control Practices and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for three of ten sampled residents. In one instance, a Licensed Vocational Nurse (LVN) did not wear a gown while conducting a gastrostomy tube (G-tube) assessment on a resident who was under Enhanced Barrier Precautions (EBP) due to the presence of a G-tube. The resident had severe cognitive impairment and required family involvement in care planning. The LVN acknowledged awareness of the EBP sign and the requirement to wear a gown during high-contact care but did not follow the procedure, as confirmed by the Director of Nursing (DON). In another case, a Certified Nursing Assistant (CNA) did not wear a gown while providing incontinence care to a resident on EBP for a wound. The resident had intact cognition and participated in care planning. The CNA admitted to not checking the EBP sign and not wearing the required gown during high-contact care, which was also confirmed as a lapse by the DON and another LVN. Facility policy required the use of PPE, including gowns, during such care activities for residents on EBP. Additional deficiencies were observed in the facility's laundry and respiratory therapy practices. Personal water bottles and drinking containers were found in the clean laundry room, contrary to facility policy prohibiting personal items in laundry areas to prevent cross contamination. Staff interviews confirmed a lack of adherence to this policy. Furthermore, a resident's BiPAP/CPAP tubing was observed touching the floor instead of being stored in a plastic bag as required by facility policy, with staff acknowledging the tubing should have been kept clean and off the floor to prevent contamination.
Failure to Monitor and Document Adverse Effects of Antibiotic Therapy
Penalty
Summary
The facility failed to implement and follow its Infection Prevention and Control Program and Antibiotic Stewardship Program for multiple residents receiving antibiotic therapy. Specifically, staff did not monitor or document monitoring for adverse effects of antibiotics for several residents, despite facility policies and care plans requiring such monitoring every shift during and after antibiotic administration. For example, one resident with pneumonia received levofloxacin for five days without any documented monitoring for side effects, and another resident with pneumonia received amoxicillin-potassium clavulanate for seven days with no documentation of monitoring for adverse reactions, even though care plans specified this intervention. Additional residents were affected by similar lapses. One resident with a history of ESBL resistance and severe septic shock received Avycaz intravenously, but there was no documentation of monitoring for adverse effects for fifteen shifts. Another resident with pneumonia received amoxicillin via gastrostomy tube, but staff failed to document monitoring for adverse effects for nine shifts. Two residents with UTIs who received cefdinir also lacked documentation of monitoring for adverse effects during and after antibiotic therapy, except for isolated instances. In each case, staff interviews confirmed that monitoring should have occurred and been documented, but it was not done as required by facility policy. Facility policies reviewed during the survey clearly outlined the need for monitoring and documenting adverse effects of antibiotics, including the use of an antibiotic surveillance tracking form to record relevant data such as start and stop dates, adverse events, and outcomes. Despite these policies, the survey found consistent failures in both monitoring and documentation across multiple residents and antibiotic regimens. Staff and leadership interviews acknowledged these deficiencies and the lack of adherence to established protocols.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a qualified infection preventionist to be responsible for the infection prevention and control program. This omission was observed during the survey and directly relates to the facility's infection prevention and control practices. No additional details regarding specific residents, staff, or events were provided in the report.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in deficiencies related to the timely and appropriate delivery of care. For one resident with a history of pressure ulcers and high risk for further skin breakdown, there was a physician's order for bilateral cushion boots to be used while in bed for wound management and prevention. However, the boots were observed not to be applied, and the care plan did not include this intervention. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the care plan was missing this critical intervention, and staff were not following the physician's order. Another resident with severe cognitive impairment and behavioral issues, specifically a tendency to put objects in their mouth, did not have a care plan addressing this behavior for an extended period. Staff interviews revealed that the behavior had been ongoing for at least a year, but a care plan was only developed after surveyor inquiry. The lack of a timely care plan meant that interventions to address the behavior, such as increased monitoring or physician notification, were not implemented, potentially delaying necessary care and services. Additional deficiencies included the absence of care plans for the use of antibiotics, new onset of pain, and psychotropic medication management. For example, a resident prescribed cefdinir for a urinary tract infection did not have a care plan documenting the antibiotic use, and another resident with new bilateral shoulder pain did not have a care plan or pain assessment reflecting the new pain site or the use of lidocaine patches. Staff interviews confirmed that care plans were not updated or created in response to new orders or changes in condition, leading to gaps in communication and care delivery among the interdisciplinary team.
Failure to Maintain Hazard-Free Environment and Conduct Post-Fall Analysis
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards for four residents reviewed for accidents. Specifically, three residents who were at high risk for falls and had orders for bilateral floor mats were found to have equipment or furniture, such as side tables and trash cans, placed on top of their fall mats. Observations confirmed that these objects were present on the mats in the residents' rooms, and interviews with nursing staff, including the ADON and DON, confirmed that this practice was contrary to both manufacturer instructions and facility policy. Staff acknowledged that placing heavy objects on the mats could damage them and reduce their effectiveness in absorbing the impact of a fall, potentially leading to injury if a resident were to fall onto the mat. Additionally, the facility failed to conduct an interdisciplinary team (IDT) root cause analysis after one resident experienced a fall. The resident, who had a history of Alzheimer's disease and was at high risk for falls, was found sitting on a landing mat after an unwitnessed fall. Record review and staff interviews revealed that no IDT post-fall conference or analysis was conducted for this incident, despite facility policy requiring such a review to identify potential hazards and evaluate risks following a fall. Staff, including the ADON, Quality Assurance Nurse, and DON, confirmed that the IDT review was missed and should have been completed to ensure appropriate interventions were in place. Facility policies reviewed indicated a commitment to maintaining a hazard-free environment and required that environmental hazards, such as obstacles in the footpath and improper use of fall mats, be addressed through ongoing staff training, monitoring, and QAPI processes. The policies also specified that the IDT should analyze assessment and observation data to identify accident hazards and develop individualized care plans. Despite these policies, the facility did not adhere to its own procedures in the cases identified, resulting in increased risk of accidents and injuries for the residents involved.
Failure to Ensure Call Light Accessibility for Resident with Impaired Cognition
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the call light was within the resident's reach, as required by the care plan and facility policy. The resident, who had diagnoses including generalized anxiety disorder, PTSD, psychosis, and severely impaired cognition, was unable to understand or make her needs known and required extensive assistance with activities of daily living. Multiple fall risk assessments identified the resident as high risk for falls, and the care plan specifically directed staff to keep the call light within easy reach and provide reminders to ask for assistance. During several observations, the call light was found hanging on the side of the bed rail, nearly touching the floor and not accessible to the resident. Interviews with CNAs and the MDS nurse revealed that staff intentionally kept the call light out of reach due to the resident's behavior of putting objects in her mouth and biting them. Despite this, the MDS nurse and DON confirmed that the call light should have been within reach, with increased monitoring to ensure safety. The facility's policy also required call lights to be accessible to residents in bed and other locations.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulation. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, but the deficiency centers on the lack of compliance with resident autonomy and informed consent requirements.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting their care or well-being.
Failure to Maintain Safe and Homelike Environment for Two Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. For one resident, who had diagnoses including pneumonia, COPD, and type 2 diabetes mellitus, and was cognitively intact and able to express needs, the facility did not ensure that bilateral fall mats were in good repair. Observations revealed that both floor mats had multiple tears, and the resident stated the mats were old and needed replacement. A CNA confirmed the mats were torn and acknowledged that staff should notify maintenance for replacement, as torn mats do not look good and do not provide a homelike environment. The DON also confirmed that staff are required to report such issues for prompt replacement, and that failure to do so does not provide a clean and homelike environment for the resident. For another resident, who had diagnoses including C. diff enterocolitis, hemiplegia, and hemiparesis, and was cognitively intact with impaired vision, the facility failed to maintain cleanliness in the resident's room. The resident preferred to keep urinals on the bedside table and have the room cleaned later in the day. During observation, a sticky yellowish substance, possibly urine, was found on the floor beneath the urinal. A treatment nurse confirmed the floor was sticky and stated it was the responsibility of all staff to ensure the room was clean and homelike. The DON also stated the floor should be clean and free of stains, and that failure to maintain cleanliness does not promote a homelike environment. The facility's policy on providing a homelike environment, last reviewed in May 2025, requires staff to provide a safe, clean, comfortable, and homelike setting, emphasizing person-centered care and a sanitary, orderly environment. Both incidents demonstrated a failure to adhere to this policy, as staff did not ensure the prompt replacement of damaged equipment or maintain cleanliness in resident living spaces.
Failure to Develop Baseline Care Plan for Urinary Catheter Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with a Foley catheter. Upon review of the resident's admission record, history and physical, and order summary report, it was found that while there was an order for the Foley catheter, there was no documented indication for its use. Additionally, there was no baseline care plan created to address the use of the urinary catheter, as confirmed by both the LVN and the Director of Nursing during interviews. The lack of a baseline care plan meant that essential, person-centered care instructions for the safe use of the catheter were not provided to staff. The resident in question was admitted with diagnoses including muscle weakness, difficulty walking, and acute kidney failure, and was observed to have a Foley catheter in place. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, this was not done for the resident's urinary catheter. The deficiency was identified through observation, interviews with staff, and review of the resident's records, which confirmed the absence of both an indication for the catheter and a baseline care plan.
Failure to Timely Develop and Review Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the facility's failure to follow established protocols for continence care, catheter management, and infection prevention.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services related to the feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes.
Failure to Label IV Antibiotic Bag with Date and Time
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to label an intravenous (IV) antibiotic bag with the date and time it was administered for a resident receiving IV therapy. During an observation, the RN was seen disconnecting the IV antibiotic bag from the resident's peripherally inserted central catheter (PICC) and confirmed that the date and time were only indicated on the IV tubing, not on the IV bag itself. Both the RN and the Director of Nursing (DON) acknowledged that standard practice and facility policy require the date and time to be labeled directly on the IV bag to ensure proper tracking and administration. The resident involved had a history of chronic osteomyelitis, incomplete paraplegia, and type 2 diabetes mellitus, and was receiving IV antibiotics for an infected decubitus ulcer. The resident was alert, oriented, and had intact cognition, requiring varying levels of assistance with activities of daily living. The facility's policy specified that all medication bags must be labeled, but this was not followed in this instance, leading to the identified deficiency.
Failure to Change and Label Respiratory Equipment as Required
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents requiring respiratory support. For one resident with a history of pericardial effusion, COVID-19, and dysphagia, the suction canister was not labeled with the date it was last changed, and the suction tubing in use was dated several months prior, indicating it had not been replaced within the required seven-day interval. Both the Director of Staff Development and the Assistant Director of Nursing confirmed that respiratory supplies should be changed and dated weekly, but the supplies in the resident's room did not meet these requirements. The facility's policy also required weekly changes and proper labeling of suction equipment to minimize infection risk. For another resident with chronic respiratory failure and dependence on supplemental oxygen, the oxygen tubing in use was not labeled with the date and time it was last changed. Observations and interviews with facility staff, including the Director of Rehabilitation and the DON, confirmed that the tubing lacked proper labeling and that staff are responsible for weekly changes and labeling. The facility's policy specified that oxygen cannula and tubing should be changed every seven days or as needed, and that staff should check labels to ensure compliance. These deficiencies were identified through observation, interview, and record review, and were confirmed by multiple staff members who acknowledged the requirements for changing and labeling respiratory equipment. The lack of adherence to these protocols was directly observed in both residents' rooms, and facility policies reviewed by surveyors supported the need for weekly changes and proper documentation.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that a resident in need of dialysis received care and services that met safety and appropriateness standards. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or address the trauma histories or cultural backgrounds of residents when delivering care or services, as required. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents as needed. The lack of appropriate behavioral health care and services was directly observed and documented by surveyors, demonstrating that the facility did not meet the regulatory requirement to address residents' behavioral health needs.
Failure to Accurately Document and Administer Pain Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse failed to accurately document the administration of a controlled medication, oxycodone/APAP 10/325 mg, for a resident. During an inspection of the medication cart, it was found that the narcotic and hypnotic record indicated seven doses remaining, while the medication card contained only six. The nurse admitted to dispensing the missing dose earlier in the day but did not sign the narcotic record at the time of administration, contrary to facility policy which requires immediate documentation upon removal of the medication from the bubble pack. Another deficiency was identified in the administration of a lidocaine patch for pain management for a different resident. The resident, who had a history of cauda equina syndrome, generalized muscle weakness, and polyosteoarthritis, reported not receiving her prescribed lidocaine patch for shoulder pain. Upon review, it was found that the patch had not been applied as ordered, and the electronic medication administration record (eMAR) incorrectly indicated that the medication had been administered. The nurse responsible had not completed the required self-administration assessment for the resident, which is necessary before a resident can self-administer medication. Interviews with nursing staff and review of facility policies confirmed that medications are to be administered and documented as prescribed, and that pain management interventions should be consistent with the resident's care plan and physician orders. The failure to follow these procedures resulted in the resident not receiving timely pain management and the lack of proper documentation and assessment for self-administration of medication.
Unlabeled Open Insulin Pen Found During Medication Cart Inspection
Penalty
Summary
Surveyors observed that an opened Humulin 70/30 insulin pen, used to control high blood sugar, was stored at room temperature in a medication cart without being labeled with an open date. This insulin pen was designated for a specific resident and was found during an inspection of one of the medication carts. According to the manufacturer's specifications, once opened or stored at room temperature, Humulin 70/30 insulin pens must be used or discarded within 31 days, and the open date must be clearly labeled to ensure compliance. The Licensed Vocational Nurse (LVN) present confirmed that the insulin pen was open, stored at room temperature, and not labeled with an open date, acknowledging that this labeling is required to track expiration based on manufacturer guidelines. A review of the facility's medication storage policy, revised in May 2024, indicated that all drugs and biologicals must be stored in a safe, secure, and orderly manner, with proper temperature controls and labeling as required. The policy also specifies that medications requiring refrigeration should be stored in a designated refrigerator. The failure to label the opened insulin pen with the date it was opened was contrary to both the manufacturer's requirements and the facility's own policy.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed. The absence of these policies and procedures was directly observed and documented by surveyors.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident who had provided informed consent through their responsible party. The resident was admitted with multiple diagnoses, including hemiplegia, hemiparesis following cerebral infarction, unspecified pneumonia, and generalized muscle weakness. Documentation showed that the responsible party consented to the COVID-19 vaccine, and the resident was found eligible for vaccination. However, the immunization report indicated the vaccine was still pending, and interviews with staff confirmed that the vaccine was not administered as required. Staff interviews revealed that after obtaining consent, the process should have included obtaining a physician's order, notifying the pharmacy, and administering the vaccine upon delivery. The infection preventionist, RN, ADON, and DON all acknowledged that the vaccine should have been given and that the process was missed. Facility policy required offering and documenting COVID-19 vaccination for all eligible residents, and the failure to follow up resulted in the resident not receiving the vaccine despite consent and eligibility.
Failure to Secure Topical Medication and Assess for Self-Administration
Penalty
Summary
A deficiency occurred when a topical pain medication, Diclofenac Sodium, was left in a resident's bedside drawer without proper assessment for self-administration. The resident, who had a history of malignant neoplasm of the rectum and hypotension, was cognitively intact but required supervision for activities of daily living. The medication was ordered to be applied topically as needed for pain, and records showed it was last administered early in the morning. During an observation later that day, two medication cups containing the cream were found above the resident's bedside drawer. Staff present were unaware of who had left the medication there. Further review revealed that there was no documented assessment to determine if the resident was capable of safely self-administering the medication. Facility policy required an interdisciplinary team assessment before allowing self-administration, but this had not been completed. Staff interviews confirmed that the medication should not have been left at the bedside, as it could be accessed by other residents, and that the required assessment for self-administration was missing.
Call Light Not Kept Within Reach for Resident with Fall Risk
Penalty
Summary
A deficiency was identified when a resident's call light was found on the floor, out of reach, during an observation in the resident's room. The resident had a history of hypertension, falls, and severe cognitive impairment, requiring substantial assistance with activities of daily living. The resident's care plan specifically indicated that the call light should be kept within reach. During the observation, the Director of Staff Development confirmed that the call light was not accessible to the resident and acknowledged the importance of keeping it within reach to ensure the resident could request assistance as needed. Interviews with facility staff, including the Director of Nursing, further confirmed the necessity of maintaining the call light within easy reach for residents, especially those at risk for falls or with impaired cognition. A review of the facility's policy on answering call lights also stated that the call light should always be within easy reach when a resident is in bed or confined to a chair. The failure to ensure the call light was accessible constituted a breach of both the resident's care plan and facility policy.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with significant medical conditions, including a fistula of the vagina to the large intestine, malignant neoplasm of the rectum, and a cutaneous abscess of the buttock. The resident had physician orders for multiple pain medications, including morphine sulfate extended release, oxycodone with acetaminophen in two strengths for varying pain levels, and acetaminophen for mild pain. Despite these orders, the resident did not consistently receive the prescribed medications as scheduled or as needed. On several occasions, the medications were not administered because they were not available, and in some instances, the wrong medication or dosage was given in response to the resident's reported pain levels. Interviews with nursing staff and review of the Medication Administration Record (MAR) and Pain Level Summary revealed that the resident experienced moderate to severe pain, as indicated by pain scores ranging from five to eight out of ten, without receiving the appropriate pain medication. The Assistant Director of Nursing confirmed that the pain medications were not readily available, resulting in the resident experiencing unnecessary pain during daily activities. The facility's actions were not consistent with their Pain Assessment and Management policy, which required staff to identify and address pain according to the resident's needs and physician orders.
Failure to Develop and Document Comprehensive Care Plan for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with significant respiratory diagnoses, including respiratory failure, asthma, and COPD. The resident was found in possession of a vaping device, but this was not addressed in the care plan. Interviews revealed that staff members, including a Quality Assurance Nurse and a Certified Nursing Assistant, were aware of the resident's possession of the vaping device, but there was no documentation or communication to the assigned nurse, and no care plan was initiated to address the risk associated with the vaping device. Additionally, the existing care plan for oxygen use was incomplete, lacking specific and measurable goals and interventions. Record reviews and staff interviews confirmed that the care plans were not individualized or specific to the resident's needs, particularly regarding the risk posed by the vaping device and the management of the resident's respiratory conditions. Facility policies required comprehensive, person-centered care plans and complete, accurate documentation of services and changes in resident condition, but these were not followed. As a result, the resident's needs related to respiratory care and safety were not fully addressed.
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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