Arbor Glen Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendora, California.
- Location
- 1033 E. Arrow Highway, Glendora, California 91740
- CMS Provider Number
- 056360
- Inspections on file
- 51
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Arbor Glen Care Center during CMS and state inspections, most recent first.
A resident with muscle weakness, a left femur fracture, moderately impaired cognition, and a Stage 4 pressure ulcer had a care plan and facility policy requiring assistance with turning and repositioning at least every two hours and as needed. Observations showed the resident remained in essentially the same side-lying position with a pillow under one shoulder and down to the waist over several hours. A CNA reported changing the resident’s brief but not repositioning the resident due to the resident’s refusal and did not notify a nurse of this refusal, despite expectations that refusals be reported so licensed staff could follow up. This resulted in a failure to provide pressure ulcer care as planned and required.
A resident with a Stage 4 pressure ulcer, muscle weakness, and a prior femur fracture had a PRN order for hydrocodone-acetaminophen for severe pain but did not receive pain medication before wound care and a subsequent bed bath. During the observed care, the resident repeatedly reported pain at level 7, moaned with repositioning, and cried out in pain multiple times, yet the treatment nurse and CNAs continued the procedures without premedicating or allowing time for analgesia to take effect. The resident later stated they had experienced prolonged pain, and interviews with the TN and DON, along with the facility’s pain management policy, confirmed that pain should have been anticipated and managed prior to these treatments.
Staff failed to follow Enhanced Barrier Precautions when a CNA provided a bed bath to a resident with MDRO and an indwelling urinary catheter, then immediately proceeded to bathe another resident with infection-related cardiac device complications and endocarditis without changing the protective gown or performing hand hygiene. Although facility policy required gown and glove use for high-contact care under EBP and mandated changing gowns and gloves and performing hand hygiene after each resident encounter, the CNA only changed gloves, believing the first resident was not on precautions and that the gown was merely preventive. The IP nurse confirmed the resident was on EBP for a history of MDRO in the urine and that EBP was intended to prevent MDRO transmission.
A resident with DM and a markedly elevated Hgb A1C was admitted on long‑term insulin therapy and had intact cognition and decision‑making capacity. Review of physician orders and MARs showed that scheduled Humalog and Lantus orders expired, and for eight days there were no active orders or administration of any oral or injectable DM medications. Progress notes documented that the resident was not on diabetic medications after hospital insulin orders ended and that the physician could not be reached, while the resident and a home health agency administrator requested delaying discharge until an insulin regimen was established. In interviews, nursing leadership and an RN confirmed the lapse in insulin therapy and acknowledged that nurses were responsible under facility policy and job descriptions to monitor the resident’s condition, recognize abnormal findings, and consult with the physician regarding continuation of insulin management.
Two residents with significant medical needs experienced prolonged waits—ranging from 30 minutes to 2 hours—for staff to respond to call lights, including requests for toileting assistance. Both residents, who required varying levels of assistance with activities of daily living, reported these delays during interviews. The DON confirmed that such wait times are not acceptable, and facility policies require prompt response and respectful treatment.
Two residents expressed concerns about long wait times for staff assistance during shift changes at resident council meetings. Although the AD reported these complaints to the DON, no Plan of Action form was created as required by facility policy, resulting in the concerns not being formally addressed.
Facility staff did not document a resident's visit to a urologist in the medical record, despite facility policy requiring physician visits to be recorded. The omission was confirmed by the DON and resulted in incomplete medical documentation for a resident with multiple diagnoses and care needs.
A resident with significant care needs and frequent incontinence did not receive timely assistance after activating the call light for help with a brief change. Staff were observed walking past the room without responding, and the resident reported repeated delays of 30 minutes or more. CNAs indicated that licensed nurses did not help with call lights, despite facility policy and leadership stating that all staff are responsible for prompt responses.
A resident with significant medical needs and frequent incontinence did not receive timely assistance with ADLs, specifically incontinence care, after activating the call light. Staff were observed walking past the room without responding, and interviews revealed that licensed nurses often did not help answer call lights, leaving the responsibility to CNAs. Facility policy and care plans required prompt assistance, but this was not provided, resulting in the resident waiting extended periods for care.
A resident with a gastrostomy tube for enteral feeding received care from CNAs who operated the tube feeding machine, despite facility policy and staff statements that only licensed nurses are permitted to do so. CNAs reported routinely putting tube feeding machines on hold and resuming them after care, even though they were not trained or authorized for this task. Facility policies, job descriptions, and competency checklists confirmed that tube feeding management is not within the CNA scope of practice.
A resident dependent on tube feeding received care from a CNA who operated the enteral feeding pump, contrary to facility policy and staff training requirements. Staff interviews revealed inconsistent practices and understanding about who is authorized to operate tube feeding machines, with only licensed nurses permitted to do so according to facility policy and competency checklists.
A resident with a gastrostomy tube, dependent on staff for all care, did not receive proper Enhanced Barrier Precautions (EBP) when a CNA provided care without wearing an isolation gown, despite clear signage and facility policy requiring gown and glove use for residents with indwelling devices. Staff interviews confirmed knowledge of EBP requirements, and the deficiency was observed during high-contact care activities.
The facility failed to prevent and manage pressure ulcers for three residents. One resident with a Stage 4 ulcer was not repositioned as required, leading to potential worsening of the condition. Another high-risk resident was not turned regularly, resulting in new pressure injuries. A third resident's low air loss mattress pump was found off, contrary to care plans, risking further skin breakdown.
A facility failed to implement its Infection Prevention and Control Program, leading to potential cross-contamination. Unlabeled personal toiletries were found in a shared restroom, and staff did not adhere to PPE protocols for residents on contact isolation. CNAs did not change gowns and gloves between residents, and a CNA entered a room with residents on contact precautions without PPE. The Infection Preventionist Nurse emphasized the importance of proper PPE use and labeling to prevent infection spread.
The facility failed to implement its antibiotic stewardship program for three residents, leading to unnecessary antibiotic administration. A resident was given Ertapenem Sodium without completing the necessary infection surveillance form. Another resident received Ampicillin Sodium without confirming the criteria for its use, and the IPN did not follow up with the physician. A third resident was administered Zosyn for pneumonia without completing the required documentation. These actions were contrary to the facility's policy on antibiotic stewardship.
A resident's call light was found on the floor and out of reach, potentially delaying necessary care. The resident, with moderate cognitive impairment and requiring substantial assistance, was unable to access the call light. Staff interviews confirmed the importance of accessible call lights for safety, aligning with facility policy.
A facility failed to provide adequate staffing, resulting in delayed incontinence care and loss of dignity for two residents. One resident, with heart failure and diabetes, experienced significant delays in changing soiled briefs, impacting their therapy schedule. Another resident with Alzheimer's disease was observed seeking help in the hallway but was not immediately assisted by busy CNAs. The facility's staffing policy was not followed, leading to these deficiencies.
A resident with Alzheimer's and severe cognitive impairment was not treated with dignity when a CNA dismissed their request for help, stating they were busy. Other CNAs and the DON acknowledged the inappropriate response, emphasizing the need for compassion and respect for all residents.
A resident with Parkinson's disease and hand rigidity was provided with an unsuitable push call light system, despite being dependent on others for daily activities and mobility. An LVN and the DON acknowledged the need for a more appropriate system, such as a tap or mechanical pad, to ensure the resident could effectively alert staff for assistance. The facility's policy on accommodating residents' needs was not followed in this case.
A resident was admitted to the facility without a required PASARR screening, despite having multiple mental disorder diagnoses. The facility's policies mandate this screening to ensure appropriate care, but it was not conducted, leaving the facility without crucial information on the resident's mental health needs.
A facility failed to provide documented activities for a resident, potentially affecting their psychosocial well-being. Observations showed the resident lying in bed without engagement, and interviews revealed a lack of documentation for activities provided. The resident's activity preferences were not assessed, leaving staff without guidance on meaningful activities.
A resident with a history of constipation was not managed according to physician's orders, leading to multiple bowel movements and eventual hospital transfer. The resident refused Milk of Magnesia, and the LVN administered a Dulcolax suppository without consulting the physician, contrary to orders. The DON confirmed the failure to follow protocols, resulting in the resident's condition worsening.
A resident receiving continuous oxygen therapy at 2 LPM via nasal cannula did not have the required oxygen warning signage posted in their room, as per facility policy. This oversight was confirmed during an observation and interview with an LVN, who acknowledged the need for signage to prevent fire risks. The facility's policy mandates NO SMOKING/OXYGEN IN USE signs to ensure safety.
The facility failed to maintain adequate quaternary sanitizing solution levels in one of the kitchen's sanitation buckets, compromising its effectiveness. A test strip showed a concentration of 100 ppm, below the required 200-400 ppm range. The issue was linked to too many washcloths in the bucket, reducing the solution's potency. This deficiency was confirmed through staff interviews and record reviews.
The facility failed to have the Director of Nursing (DON) present at a required QAPI quarterly meeting. The absence was confirmed through a review of the QAPI Sign in Sheet and an interview with the Administrator, who acknowledged the necessity of the DON's attendance for planning and monitoring nursing services. The facility's QAPI Plan identified the DON as the clinical care sub-committee leader, underscoring the importance of their role.
A facility was found to have exceeded the maximum resident occupancy in a room, with six residents accommodated in a space meant for no more than four. This was confirmed through interviews with a Treatment Nurse and the Administrator, who admitted to adding a sixth bed and resident without a policy in place to guide room occupancy limits.
A resident with a history of falls was inaccurately assessed, leading to a change in their fall risk category from high to medium. The LVN admitted to the documentation error, which contradicted the facility's policy for accurate assessments to guide care plans.
The facility failed to update the care plans for two residents after significant health events. One resident experienced falls on two occasions, and the care plan was not revised to address the increased fall risk. Another resident developed a pressure injury and refused repositioning, but the care plan remained generic and did not include specific interventions. The facility's policies require care plan updates to address such changes in condition, but these were not followed, potentially impacting the residents' well-being.
Two residents in an LTC facility experienced falls due to inadequate supervision and failure to maintain a safe environment. One resident's bed was not kept in the lowest position as required, increasing fall risk. Another resident, at high risk for falls, fell after attempting to get out of bed without assistance. Despite being informed, an LVN did not intervene, citing it was not her responsibility, highlighting a lack of teamwork and communication among staff.
A facility failed to follow its policy for controlled medication administration for five residents. An LVN did not sign the controlled medication count sheets or the MAR after administering medications, risking medication errors and accountability issues. The DON highlighted the importance of accurate documentation to prevent medication diversion and ensure resident safety.
A resident with significant medical needs, including a gastrostomy tube, was observed with an abdominal binder, but the facility failed to implement a care plan for its use despite a physician's order. Staff interviews revealed a lack of awareness and adherence to the facility's policy requiring comprehensive care planning, leading to potential inconsistent care.
The facility failed to ensure proper hand hygiene practices, as observed with an LVN and a CNA who did not wash hands or use sanitizer after resident contact and before handling meal trays. This non-compliance with the facility's hand hygiene policy was confirmed by staff interviews and the Interim Director of Nursing.
A facility failed to provide proper care for a resident's PICC site, leading to potential infection risks. The resident, with cellulitis and diabetes, had orders for regular monitoring and IV antibiotics. However, the PICC site was not cleaned or the dressing changed as required. Observations showed dried blood and a loose dressing, and interviews revealed that nurses did not assess the site during medication administration. The facility's policy emphasized the need for regular dressing changes to prevent infections.
A resident with a high fall risk was not provided with bilateral floor mats as per their care plan and physician's orders, leading to a fall and skin tear. Staff interviews revealed a lack of communication and adherence to fall prevention protocols, with no fall precaution indicators present. The facility's policy on implementing physician orders was not followed, potentially placing the resident at risk for further falls.
A resident with a history of multiple sclerosis and cerebral palsy developed a breast lump that was not promptly addressed by the facility. Despite the resident's requests, staff failed to notify the primary care provider or schedule a mammogram, leading to a delayed cancer diagnosis. The resident experienced severe pain and was eventually transferred to a hospital, where a biopsy confirmed breast cancer. Interviews revealed lapses in communication and adherence to care policies.
CNAs failed to respect a resident's request on how to be turned in bed, leading to a fracture in her right arm. Despite the resident's intact cognition and existing medical conditions, including a broken left arm and severe osteoporosis, the CNAs insisted on turning her their way, resulting in severe pain and a displaced fracture. The incident highlighted a disregard for the resident's dignity and rights, as acknowledged by the DON.
A resident with a history of multiple sclerosis and cerebral palsy experienced a delay in care due to the facility's failure to promptly notify the physician of a lump in the resident's breast. Despite the resident's repeated requests for medical attention, the facility staff did not follow up with the physician to obtain necessary orders for a mammogram. This delay resulted in the resident being transferred to an emergency department months later, where a mass suspicious for malignancy was discovered.
A resident with a noted breast lump and subsequent cancer diagnosis did not have a care plan developed by the facility. Despite a physician's recommendation for a mammogram and the resident's severe pain leading to an emergency department visit, no care plan was created to address the resident's condition. This oversight was confirmed by facility staff, highlighting a failure to adhere to the facility's care planning policy.
A resident with severe cognitive impairment was involved in an alleged abuse incident where an Activities Supervisor and an LVN were accused of inappropriate actions. The facility failed to report these allegations to the California Department of Public Health as required by their policy, potentially compromising the resident's safety.
A long-term care facility failed to provide adequate nursing staff during a night shift, leaving one LVN to care for 86 residents, contrary to the required two LVNs. This staffing shortage affected four residents, who reported feeling unsafe and experienced delays in care. Interviews with staff and residents confirmed the deficiency, highlighting the facility's failure to adhere to its staffing policy.
A resident with an indwelling Foley catheter was found to have urine sediments in the tubing, indicating a potential infection. Despite physician orders to monitor for infection signs and notify the physician, the facility failed to address the issue promptly. The resident, with severe cognitive impairment and a history of UTI and sepsis, required substantial assistance, yet the facility did not adhere to its catheter care policy.
Failure to Reposition Resident With Stage 4 Pressure Ulcer and Report Refusals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a Stage 4 pressure ulcer was turned and repositioned in accordance with the resident’s care plan. The resident had diagnoses including muscle weakness and a displaced subtrochanteric fracture of the left femur, moderately impaired cognitive skills, and required assistance with mobility and activities of daily living. The care plan identified the resident as having a pressure ulcer or risk for pressure ulcer development related to weakness, pain, impaired mobility, incontinence, and risk for impaired circulation, and directed staff to monitor, remind, and assist the resident to turn and reposition every two hours and as needed. A separate care plan also documented that the resident was resistive to care related to non-compliance with turning and repositioning, with interventions to educate the resident on possible outcomes of not complying with treatment or care. Surveyor observations showed that after wound care and a bed bath, CNAs turned and positioned the resident slightly toward the right side with a pillow placed lengthwise from the left side of the neck under the left shoulder down to the waistline, and this same positioning was observed at multiple times later that day. During an interview, a CNA stated they had changed the resident’s diaper but did not reposition the resident because the resident refused to turn, and the CNA did not inform the charge nurse or any licensed nurse of this refusal. The Treatment Nurse and DON both stated that CNAs are expected to follow the repositioning schedule and report refusals to the charge nurse so that licensed staff can provide education, encouragement, and follow-up. The facility’s policy on Prevention and Management of Pressure Injuries indicated that residents should be encouraged to reposition and that the facility will promote a turning schedule and reposition frequently as needed.
Failure to Provide Premedication for Pain Before Wound Care and Bed Bath
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pain management before performing wound care and a bed bath for a resident with a Stage 4 pressure ulcer. The resident was originally admitted with diagnoses including muscle weakness and a displaced subtrochanteric fracture of the left femur and had moderately impaired cognitive skills, requiring significant assistance with activities of daily living. The physician’s orders included a pain management consult and hydrocodone-acetaminophen 5-325 mg every six hours as needed for severe pain rated 7–10. During an observed wound care session, the treatment nurse asked the resident for a pain rating, and the resident reported a pain level of 7. As certified nursing assistants repositioned the resident and removed a pillow from under the heels, the resident moaned and verbalized pain in the groin and back, stating, "You're doing everything else to hurt me." Despite this, the treatment nurse proceeded with wound care without administering pain medication or allowing time for any pain medication to take effect. Later in the same session, while wound care was ongoing, the treatment nurse again asked the resident for a pain rating, and the resident continued to report a pain level of 7. The nurse asked if the resident wanted them to stop and return after pain medication, but the resident responded, "Let's get this done," and the procedure continued without premedication. After wound care, a bed bath was provided by certified nursing staff, during which the resident cried out in pain three times. By the end of the observation period, the resident stated having experienced 45 minutes of pain. Interviews with the treatment nurse and the DON confirmed that pain management prior to treatment is considered important to promote comfort and prevent suffering, and the facility’s pain management policy states that the facility will identify circumstances when pain can be anticipated and implement pharmacologic and/or non-pharmacologic interventions to manage or prevent pain, which did not occur in this instance.
Failure to Follow Enhanced Barrier Precautions Between Residents During Bed Baths
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control procedures, specifically Enhanced Barrier Precautions (EBP), when providing care to a resident with a multidrug-resistant organism (MDRO) and then to another resident. One resident had been admitted with diagnoses including UTI and DM and had an active diagnosis of MDRO per the MDS, with a physician’s order placing the resident on EBP due to an indwelling urinary catheter and MDRO. Facility policy required gown and glove use for high-contact care activities such as bathing, hygiene, and changing linens for residents on EBP, and further required changing gloves and gowns after each resident encounter and performing hand hygiene. Surveyors observed a CNA providing a bed bath to the MDRO-positive resident while wearing a protective gown. After completing the bed bath, the CNA did not remove the gown or perform hand hygiene, but instead only changed gloves and then prepared and proceeded to provide a bed bath to another resident who was dependent on staff for showering/bathing and had diagnoses including infection and inflammatory reaction due to cardiac and vascular devices and endocarditis. During interview, the CNA stated they wore the same gown and only changed gloves between the two residents because they believed the first resident was not on any precautions and that the gown was “just for prevention.” The Infection Prevention Nurse later confirmed that the first resident was on EBP for a history of MDRO in the urine and that EBP was intended to protect that resident and others from acquiring MDRO, consistent with the facility’s written policies.
Failure to Ensure Ongoing Physician Management of Insulin Therapy for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician assessment and continued management of a high‑risk medication regimen for a resident with diabetes mellitus. The resident was admitted with diagnoses including diabetes mellitus with ketoacidosis and long‑term use of insulin, and had documented decision‑making capacity and intact cognitive skills. A Hemoglobin A1C result showed a level of 13.6%, and the resident had clear speech and was usually understood and able to understand others. Review of the physician orders and Medication Administration Records showed that the resident had orders for Humalog insulin before meals and Lantus insulin every 12 hours beginning in October, with those orders ending on 11/20/2025. The records indicated there were no physician orders for any oral or injectable diabetes medications from 11/20/2025 through 11/27/2025, and the MAR confirmed that no diabetes medications were administered during that eight‑day period. Subsequent insulin orders were not written until 11/28/2025. Progress notes dated 11/27/2025 documented that the resident was not on any diabetic medications because the hospital insulin orders had ended on 11/20/2025, and that the physician could not be reached. The note also indicated that the resident and a home health agency administrator requested that discharge be held until an insulin regimen was established. In interviews, an RN and the DON acknowledged that the resident did not receive insulin for eight days, that nursing staff should have clarified the discontinuation of insulin with the physician, and that it was facility policy and part of the nursing job responsibilities to monitor residents, recognize abnormalities, and consult with the physician regarding resident evaluation and care needs.
Delayed Response to Call Lights and Toileting Requests
Penalty
Summary
Facility staff failed to promptly respond to call lights and requests for toileting assistance for two residents. One resident, admitted with peripheral vascular disease, sickle-cell disease, and muscle wasting, reported waiting 30 minutes to 1 hour for staff to answer the call light, particularly in the afternoon. This resident required supervision or touch assistance for personal and oral hygiene, bathing, and dressing, and had no cognitive impairment. Another resident, with diagnoses including lymphoma, urinary tract infection, and muscle weakness, required substantial to maximal assistance for bathing and supervision or touch assist for dressing and toileting hygiene. This resident reported waiting 2 hours for staff to respond to a call light when needing to use the bathroom, timing the delay by watching the clock in the room. Interviews with both residents confirmed repeated delays in staff response to call lights, with one resident specifically noting the need for toileting assistance during the prolonged wait. The Director of Nursing acknowledged that residents should not have to wait 30 minutes for call lights to be answered. Facility policies reviewed indicated that staff are expected to answer call lights within a reasonable time and treat residents with dignity and respect, allowing flexibility in daily activities and choices.
Failure to Create Plan of Action for Resident Council Concerns
Penalty
Summary
The facility failed to ensure that a Plan of Action form was created in response to concerns raised by residents during resident council meetings, as required by the facility's own policy and procedure. Specifically, meeting minutes from two separate resident council meetings documented complaints from residents about long wait times for staff assistance during shift changes. Although the Activities Director reported these complaints to the Director of Nursing, no Plan of Action form was submitted as mandated by the facility's policy. The facility's policy states that the Activities Director is responsible for referring resident concerns to appropriate personnel and that a Plan of Action form should be submitted to address these concerns or suggestions. The lack of a Plan of Action form for the complaints about wait times meant that the concerns raised by residents were not formally addressed or tracked according to established procedures.
Failure to Document Physician Visit in Resident Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident when they did not document the resident's visit to a urologist in the medical record. The resident, who had diagnoses including urinary tract infection, type 2 diabetes mellitus, and hypertension, was admitted and later readmitted to the facility. According to the Minimum Data Set, the resident had no cognitive impairment and was dependent on staff for lower body dressing, bathing, and toileting hygiene. The resident's granddaughter confirmed accompanying the resident to a urologist appointment, but there was no documentation of this visit in the resident's progress notes. During a review of the facility's policy and procedure on charting and documentation, it was found that physician visits and orders are required to be documented in the resident's record. The Director of Nursing confirmed that the appointment was not documented as required. This omission resulted in the resident's medical record lacking a summary of the physician visit, leading to incomplete information in the resident's chart.
Failure to Promptly Respond to Call Light Compromises Resident Dignity
Penalty
Summary
Staff failed to promptly respond to a resident's call light, resulting in a lack of timely assistance for personal care needs. The resident, who had diagnoses including end stage renal disease, hypoglycemia, muscle weakness, and mobility issues, required substantial to maximal assistance with toileting, bathing, and dressing, and was frequently incontinent. The care plan directed staff to anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. During observations, the resident activated the call light for a brief change and reported that staff typically took 30 minutes or longer to respond, sometimes making the resident wait up to an hour. The resident also stated that staff would sometimes defer assistance until their rounds were complete or would instruct the resident to wait for the assigned staff member, even if another staff member was available. Multiple staff were observed walking past the resident's room while the call light was on, and the call light remained unanswered for at least 10 minutes during the surveyor's observation. Interviews with CNAs revealed that licensed nurses generally did not assist with answering call lights or simple resident requests, leaving the responsibility to CNAs. Both the LVN and DON stated that all staff were responsible for answering call lights and emphasized the importance of prompt responses to meet residents' needs. The facility's policy required staff to answer call lights within a reasonable time, listen to the resident's request, and respond appropriately, but these procedures were not followed in this instance.
Delayed Response to Call Light and Incontinence Care for Resident Needing ADL Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs), including toileting and incontinence care, did not receive timely help from facility staff. The resident, who had diagnoses such as end stage renal disease, hypoglycemia, muscle weakness, and mobility issues, was assessed as needing substantial to maximal assistance with toileting and other ADLs and was frequently incontinent. The care plan specified that staff should anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. On the day of the incident, the resident activated the call light to request a brief change but reported that staff typically took 30 minutes or longer to respond, sometimes making the resident wait up to an hour for assistance. Observations confirmed that the call light remained unanswered for at least 11 minutes while multiple staff members walked by the room. The resident also reported that if the assigned staff member was unavailable, other staff would instruct the resident to wait for the assigned staff, further delaying care. Interviews with CNAs revealed that licensed nurses generally did not assist with answering call lights or simple resident requests, leaving the responsibility to CNAs. However, both the LVN and DON stated that all staff were responsible for answering call lights promptly, emphasizing the importance of meeting residents' needs quickly. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain their abilities, but this was not followed in the observed case.
Untrained Staff Operate Tube Feeding Machines Against Policy
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received care from staff who were trained and competent in feeding tube management according to facility policies and procedures. The resident in question was admitted with diagnoses including dysphagia and failure to thrive, and had a gastrostomy tube for nutrition. The resident was dependent on staff for all activities of daily living and received tube feeding as ordered by a physician. During observations, a Certified Nursing Assistant (CNA) was seen turning the resident's tube feeding machine from 'hold' to 'run' after providing care, despite facility policy and staff statements indicating that only licensed nurses are permitted to operate tube feeding machines. Interviews with CNAs revealed that it was common practice for them to put tube feeding machines on hold and then resume feeding after care, even though they were not trained or authorized to do so. The Director of Staff Development and the Director of Nursing both confirmed that CNAs are not allowed to operate tube feeding machines, and that this task falls outside their scope of practice. A review of the facility's policies and procedures, as well as CNA job descriptions and competency checklists, confirmed that tube feeding management is not included in CNA training or competencies. The facility's policy specifies that only licensed nurses are to provide care and maintenance of gastrostomy tubes. This failure to follow policy and ensure staff competency had the potential to affect not only the resident observed but all residents receiving tube feeding in the facility.
Untrained Staff Operated Tube Feeding Equipment
Penalty
Summary
The facility failed to ensure that only appropriately trained and licensed staff operated enteral feeding equipment for a resident who required tube feeding. The resident, who was dependent on others for all activities of daily living and had a gastrostomy tube due to dysphagia and failure to thrive, was observed receiving care from a CNA who operated the tube feeding machine. Specifically, the CNA turned the tube feeding machine from 'hold' to 'run' after providing care, despite facility policy and scope of practice limitations. Interviews with staff revealed inconsistent practices and understanding regarding the operation of tube feeding machines. One CNA admitted to turning the machine on to avoid disturbing residents with alarms, while another CNA stated it was common practice to put the machine on hold and then resume feeding after care. However, both the LVN and the Director of Staff Development confirmed that only licensed nurses were permitted to operate tube feeding machines, and that CNAs were neither trained nor authorized to do so. A review of the facility's policies, CNA job descriptions, and competency checklists confirmed that tube feeding machine operation was not included in CNA training or competencies. The facility's policy specified that gastrostomy tube care and maintenance were licensed nurse procedures. The deficiency was identified through direct observation, staff interviews, and review of facility documentation, demonstrating a failure to ensure that only competent, authorized staff provided care related to enteral feeding equipment.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for one resident who had a gastrostomy tube and was dependent on staff for all activities of daily living. The resident's medical records indicated diagnoses of dysphagia and failure to thrive, and the resident was receiving tube feeding for nutrition. During an early morning observation, a CNA provided care to the resident without wearing an isolation gown, despite a posted sign indicating the resident was on EBP. The CNA later acknowledged forgetting to put on the gown, even though facility policy and staff interviews confirmed that EBP, including the use of gown and gloves, was required for residents with indwelling medical devices such as G-tubes. Interviews with the Director of Staff Development, Infection Prevention Nurse, and Director of Nursing all confirmed that staff were expected to follow EBP protocols, including wearing masks, gowns, and gloves when providing care to residents with tubes, wounds, or other devices. The facility's policy specified that EBP should be used during high-contact care activities to prevent the indirect transfer of multidrug-resistant organisms. The failure to follow these precautions was directly observed and confirmed through staff interviews and policy review.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent and manage pressure ulcers for three residents. Resident 62, who had a Stage 4 pressure ulcer, was not turned and repositioned by CNA 1 as required. Despite being assessed as moderate risk for pressure ulcers, Resident 62 was observed lying on her back for extended periods without repositioning. CNA 1 did not seek assistance from other staff to reposition Resident 62, even when the resident became agitated and resistant to care. The care plan for Resident 62 indicated the need for regular repositioning, but this was not consistently followed, and the interdisciplinary team did not address the resident's refusal of care. Resident 183, assessed as high risk for pressure ulcers, was also not repositioned adequately. CNA 2 failed to turn Resident 183 every two hours as required, and the resident was observed lying on her back for extended periods. When CNA 2 attempted to reposition Resident 183, the resident resisted, and CNA 2 did not seek further assistance. The care plan for Resident 183 was generic and did not include specific interventions for the new pressure injury. The facility's policy required regular turning and repositioning, but this was not adhered to, leading to the development of pressure injuries on Resident 183's buttocks. Resident 32, who had a Stage 3 pressure ulcer, was found with the low air loss mattress pump turned off, contrary to the care plan and facility policy. The LAL mattress was intended to prevent further skin breakdown, but CNA 2 was unaware of how long the pump had been off. This oversight could have contributed to the worsening of Resident 32's pressure ulcer. The facility's policy required the LAL mattress to be plugged in and functioning to prevent skin breakdown, but this was not followed, compromising the resident's care.
Infection Control Deficiencies in PPE Use and Personal Item Labeling
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program (IPCP) for nine sampled residents, leading to potential cross-contamination and transmission of infections. Unlabeled personal toiletries were found stored in a shared restroom used by four residents, contrary to the facility's policy that requires personal items to be labeled and kept at the resident's bedside. This oversight was confirmed during an observation and interview with a Certified Nursing Assistant (CNA) and the Infection Preventionist Nurse (IPN), who emphasized the importance of labeling and proper storage for infection control. Additionally, staff failed to adhere to proper personal protective equipment (PPE) protocols while caring for residents on contact isolation. Observations revealed that CNAs did not change gowns and gloves between assisting different residents in a cohorted room, despite the presence of contact precautions signage. The IPN confirmed that staff should change PPE between residents to prevent cross-contamination, especially when dealing with residents on contact isolation for infections like Vancomycin-resistant enterococci (VRE). Furthermore, a CNA entered a room with residents on contact precautions for Candida Auris without wearing the required gown and gloves. The CNA only wore PPE when providing direct care, contrary to the facility's policy that mandates PPE use upon entering the room of residents on contact precautions. The IPN reiterated the necessity of wearing PPE to prevent the spread of C. auris, a highly transmissible fungus, and to ensure the safety of both residents and staff.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for three residents, leading to the unnecessary administration of antibiotics. Resident 10 was readmitted with diagnoses including sepsis and dementia. Despite being administered Ertapenem Sodium, there was no Infection Surveillance - V2 Form (ISV2F) completed to determine if the resident met McGreer's criteria for antibiotic use. The Infection Prevention Nurse (IPN) acknowledged the oversight and the absence of necessary documentation to justify the antibiotic administration. Resident 72, admitted with sepsis and muscle weakness, was prescribed Ampicillin Sodium. However, the ISV2 form was not completed to confirm if the resident met the criteria for antibiotic treatment for cellulitis or other infections. The IPN admitted to not following up with the resident's physician regarding the antibiotic use, which is crucial to ensure the criteria are met and to prevent antibiotic resistance. Resident 134, diagnosed with acute respiratory failure and diabetes, was given Zosyn for pneumonia. Similar to the other cases, the ISV2 form was incomplete, and there was no indication that the resident met McGreer's criteria for antibiotic use. The facility's policy on antibiotic stewardship, which aims to promote appropriate antibiotic use and reduce resistance, was not adhered to in these cases, leading to potential risks of antibiotic resistance.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 283, which could potentially delay or prevent the resident from obtaining necessary care and services. Resident 283 was admitted to the facility with diagnoses including an unspecified head injury, muscle weakness, and epilepsy. The resident's Minimum Data Set (MDS) indicated that their cognition was moderately impaired, and they required substantial to maximal assistance with activities of daily living and mobility. During an observation, the call light for Resident 283 was found on the floor and underneath the bed, making it inaccessible to the resident. Interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that call lights should be within reach to enhance resident safety and well-being. The facility's policy and procedure on call lights emphasized the importance of leaving the call device within the resident's reach before leaving the room.
Inadequate Staffing Leads to Delayed Care and Loss of Dignity
Penalty
Summary
The facility failed to provide sufficient staffing to ensure timely incontinence care and maintain the dignity of two residents, Resident 233 and Resident 39. Resident 233, who was admitted with diagnoses including heart failure and type 2 diabetes, required substantial assistance for toileting hygiene. On multiple occasions, Resident 233's family member observed delays of 30 minutes to an hour for changing soiled briefs. On one occasion, Resident 233 was left in a soiled diaper for two hours, causing a missed physical therapy session. Interviews with staff revealed that the facility was short-staffed, particularly during evening and night shifts, with CNAs responsible for an unusually high number of residents. Resident 39, diagnosed with Alzheimer's disease and requiring maximal assistance for personal hygiene, was observed following CNAs in the hallway, asking for help. The CNAs, busy with other tasks, did not immediately assist Resident 39, with one CNA acknowledging that they should have asked another staff member to help. The Director of Nursing confirmed that all residents should be treated with dignity and respect, as per the facility's policy. The facility's staffing policy indicated that adequate staff should be maintained to meet residents' needs, which was not adhered to in this instance.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity when a Certified Nursing Assistant (CNA) was observed dismissing the resident's request for assistance. The incident involved a resident diagnosed with Alzheimer's disease, generalized muscle weakness, and abnormal posture, who was admitted to the facility with severely impaired cognition and required maximal assistance with personal hygiene and transfers. During an observation, the resident, while sitting in a wheelchair, followed CNAs in the hallway, asking for help. One CNA responded by saying, 'not right now, I am busy,' and turned away to continue passing water to other residents. Interviews with other CNAs and the Director of Nursing (DON) revealed that the response to the resident's request was inappropriate. Another CNA expressed that they would not have turned their back on the resident and acknowledged the resident's confusion and need for assistance. The DON emphasized that all residents, including those who are confused, should be treated with compassion, empathy, and dignity. The facility's policy on resident rights, revised in January 2025, mandates that all residents be treated with kindness, dignity, and respect.
Inadequate Call Light System for Resident with Parkinson's
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the resident's call light system was accessible and functional. The resident, who was admitted and readmitted with diagnoses including metabolic encephalopathy, Parkinson's disease, and muscle weakness, was observed to have rigid hands and was dependent on others for activities of daily living and mobility. Despite these conditions, the resident was provided with a push call light system, which was not suitable given the resident's hand rigidity. During interviews, both an LVN and the DON acknowledged the inadequacy of the call light system for the resident's needs. The LVN noted that a tap or mechanical pad call system would be more appropriate, allowing the resident to alert staff for assistance effectively. The DON emphasized the importance of assessing residents' needs for suitable call systems at admission and periodically thereafter to ensure effective care and a safe environment. The facility's policy on accommodating residents' needs included providing appropriate call lights, but this was not adhered to in the case of the resident.
Failure to Conduct PASARR Screening for New Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident 45, was pre-screened for PASARR (Preadmission Screening and Resident Review) prior to admission. This screening is a federal requirement to ensure that individuals with mental disorders or intellectual disabilities are placed in facilities that can provide appropriate care. Resident 45 was admitted with multiple diagnoses, including unspecified dementia, psychosis, depression, and schizophrenia, which are considered mental disorders. Despite these diagnoses, there was no record of a PASARR in Resident 45's medical record, as confirmed by both the Admission Coordinator and the Director of Nursing during interviews and record reviews. The absence of a PASARR meant that the facility lacked critical information to determine if Resident 45 required specialized care or rehabilitative services for their mental disorder. The facility's policy and procedure documents, including the Admission Practice and PASARR policies, clearly state the requirement for a PASARR to be completed upon admission. However, this was not adhered to in the case of Resident 45, as the necessary screening was not conducted, and the documentation was not retained in the resident's medical record. This oversight had the potential to impact the quality of care provided to Resident 45, as the facility was not fully informed of the resident's mental health needs.
Failure to Provide Documented Activities for a Resident
Penalty
Summary
The facility failed to provide adequate activities for Resident 62, which could potentially affect the resident's psychosocial well-being. During observations, Resident 62 was seen lying in bed for extended periods without engagement in activities. Interviews with the Activities Director (AD) revealed that the facility offers one-to-one (1:1) activities for residents who do not participate in group activities. However, the AD was unable to provide documentation of any activities provided to Resident 62, as the Activities Staff (AS) do not document activities in general. Further investigation showed that there was no Admission Activities Assessment for Resident 62, and the Minimum Data Set (MDS) assessment of daily and activity preferences was left blank. This lack of documentation meant that the AS had no guidance on what activities would be meaningful for Resident 62. The facility's policy and procedure on Quality of Life, Activities Program, emphasizes the importance of a resident-centered activities program to maintain or improve residents' well-being, but this was not implemented for Resident 62.
Failure to Follow Bowel Management Orders
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident, identified as Resident 42, who was experiencing bowel management issues. The resident, who had a history of occasional constipation, was not properly managed as per the physician's orders. The orders included the administration of Milk of Magnesia (MOM) and Dulcolax suppository for constipation management. However, the resident refused MOM, and the facility staff did not notify the physician of this refusal or the resident's multiple bowel movements. The Licensed Vocational Nurse (LVN) administered a Dulcolax suppository without verifying the frequency of the resident's bowel movements or consulting the physician, which was against the physician's orders. This action was taken despite the resident having multiple bowel movements and expressing discomfort. The resident reported feeling anxious and miserable due to the bowel issues and was eventually transferred to a General Acute Care Hospital for further evaluation after experiencing blood in the stool. The Director of Nursing (DON) confirmed that the LVN did not follow the physician's orders and failed to document the resident's refusal of MOM or notify the physician of the resident's condition. The facility's policies required any change in a resident's condition to be communicated to the physician, and medications to be administered as prescribed. The failure to adhere to these protocols resulted in the resident's condition worsening and necessitating hospital transfer.
Failure to Post Oxygen Signage for Resident on Continuous Oxygen Therapy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the posting of oxygen signage for a resident receiving supplemental continuous oxygen. Resident 233, who was admitted with multiple diagnoses including respiratory failure and COPD, was receiving continuous oxygen therapy at 2 liters per minute via nasal cannula. Despite the ongoing oxygen therapy, there was no oxygen warning signage posted in Resident 233's room, which is a requirement per the facility's policy to ensure safety and alert residents and visitors to the presence of oxygen. During an observation, it was noted that Resident 233 was awake and alert in bed with the oxygen therapy in place, yet the necessary signage was absent. An interview with an LVN confirmed that the signage should have been posted to prevent the use of flammable materials, such as cigarettes, which could pose a fire risk. The facility's policy, as reviewed, clearly indicated the need for NO SMOKING/OXYGEN IN USE signs as part of the equipment for administering oxygen safely.
Inadequate Sanitizing Solution in Kitchen
Penalty
Summary
The facility failed to ensure that one of the two sanitation buckets in the kitchen contained an adequate amount of quaternary sanitizing solution, which is essential for disinfecting key areas used in food preparation for residents. During an observation, a staff member checked the quaternary sanitizing solution in two buckets using a test strip. The test strip indicated that bucket 1 had a concentration of 100 ppm, which is below the required range of 200 ppm to 400 ppm for effective disinfection. This deficiency was confirmed through interviews and record reviews, where it was noted that the solution's effectiveness was compromised due to an insufficient concentration. Further investigation revealed that the reduced effectiveness of the sanitizing solution in bucket 1 was due to an excessive number of washcloths in the bucket, which absorbed the disinfectant and reduced its potency. The Registered Dietician confirmed that the presence of too many or heavily soiled washcloths could compromise the solution's efficacy. The Director of Dining Services emphasized the importance of maintaining proper quaternary solution levels to prevent cross-contamination and ensure a safe environment for residents. The facility's policy required the solution to be tested every shift or when cloudy and replaced if below 200 ppm, which was not adhered to in this instance.
Absence of DON at QAPI Meeting
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) attended the Quality Assurance Performance Improvement (QAPI) quarterly meeting, as required. During a review of the QAPI Sign in Sheet and an interview conducted on February 6, 2025, it was confirmed that the DON was not present at the QAPI meeting held on January 24, 2025. The Administrator acknowledged that the DON's presence was necessary for planning and monitoring nursing-related services, as the DON is the head of the nursing department. The Administrator admitted that an acting DON should have attended the meeting when the previous DON left. The facility's 2025 QAPI Plan specified that the DON was designated as the clinical care sub-committee leader, highlighting the importance of their role in the QAPI leadership team.
Excessive Resident Occupancy in Room
Penalty
Summary
The facility failed to comply with regulations by accommodating more than the allowed number of residents in a single room. Specifically, room [ROOM NUMBER] was observed to have six residents, exceeding the maximum limit of four residents per room. This was confirmed during an observation and interview with Treatment Nurse 1, who stated that there were six residents in the room. The Administrator, during an interview, acknowledged that the room initially had five beds and residents when they were hired in August 2024. However, a sixth bed was added on January 20, 2025, and a sixth resident was admitted the following day. The Administrator also admitted that the facility lacked a policy specifying the maximum number of residents per room, contributing to this oversight.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's fall history, which is crucial for developing an effective care plan. The resident, who was admitted and readmitted with diagnoses including psychosis, muscle weakness, gait abnormalities, and dementia, had a documented history of falls. However, discrepancies were found in the fall risk assessments conducted on different dates. On January 22, 2025, the resident was assessed as high risk for falls, having experienced three or more falls in the past three months. Yet, a subsequent assessment on January 31, 2025, inaccurately documented the resident as having only one or two falls, changing the risk category from high to medium. The inaccuracy was acknowledged by an LVN during a review, who admitted to documenting the fall history incorrectly. This error was significant as it altered the resident's fall risk category, potentially impacting the care and interventions provided. The facility's policy emphasizes the importance of accurate and comprehensive assessments to inform care plans, but this was not adhered to in this instance, as evidenced by the inaccurate documentation of the resident's fall history.
Failure to Revise Care Plans for Fall and Pressure Injury
Penalty
Summary
The facility failed to revise the care plan for Resident 59 after the resident sustained a fall on two separate occasions, on 12/23/2024 and 12/31/2024. Despite the falls, the care plan, which was created on 10/22/2024, was not updated to address the resident's increased risk for falls. Interviews with the Licensed Vocational Nurse and Registered Nurse revealed that the care plan should have been updated after each fall to reassess the resident's needs and address any contributing factors to prevent future incidents. The facility's policy on fall prevention also indicated that a care plan update should be generated following a fall. The facility also failed to revise the care plan for Resident 183 after the resident developed a pressure injury and refused to turn and reposition. The care plan, initiated on 2/5/2025, included generic interventions that were not specific to the resident's new pressure injury. Observations showed that the resident was resistant to repositioning, and the care plan did not include specific interventions to address this refusal. The Registered Nurse acknowledged that the care plan needed to be more specific to encourage the resident to turn and reposition. The facility's policy on comprehensive person-centered care planning requires the interdisciplinary team to develop a care plan with measurable objectives and timeframes to meet the resident's needs identified in the comprehensive assessment. The failure to update the care plans for both residents resulted in unmet individualized needs and had the potential to affect their physical well-being.
Failure to Prevent Falls Due to Inadequate Supervision and Bed Positioning
Penalty
Summary
The facility failed to maintain a safe environment for two residents, leading to potential and actual falls. Resident 233, who was at medium risk for falls due to muscle weakness and mobility issues, had an order for their bed to remain in the lowest position as a safety precaution. However, during an observation, the bed was found in a high position, contrary to the care plan and facility policy, which increased the risk of injury in the event of a fall. Resident 59, diagnosed with psychosis, muscle weakness, and dementia, was identified as high risk for falls. On a specific date, Resident 59 attempted to get out of bed without assistance, leading to a fall. Despite the presence of a Licensed Vocational Nurse (LVN) who was informed of the resident's need for assistance, the LVN did not intervene, stating it was not her responsibility. This lack of teamwork and communication among staff members contributed to the fall, as the LVN prioritized medication administration over immediate resident safety. Interviews with staff and residents highlighted a pattern of inadequate collaboration and communication, particularly involving the LVN's reluctance to perform basic care tasks. The Director of Nursing and other staff emphasized the importance of teamwork and the LVN's role in ensuring resident safety, even in situations requiring immediate intervention. The facility's policies on fall management and resident safety were not effectively implemented, resulting in a failure to prevent falls and ensure a hazard-free environment.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to adhere to its policy and procedure for medication administration, specifically concerning controlled medications, for five residents. Licensed Vocational Nurse 1 (LVN 1) did not sign the controlled medication count sheets after administering medications to these residents, which is a critical step in ensuring proper medication management and accountability. Additionally, LVN 1 did not sign the Medication Administration Record (MAR) for two residents after administering their controlled medications, further compounding the issue of inadequate documentation. During interviews, LVN 1 acknowledged the importance of signing the controlled medication count sheet to prevent potential medication errors, such as double dosing or underdosing, and to ensure accountability in case of medication diversion. The Director of Nursing (DON) emphasized the necessity of following the MAR and accurately documenting medication administration to maintain resident safety and prevent medication diversion. The facility's policy, revised in January 2025, clearly outlines the requirement for immediate documentation of controlled medication administration, including the date, time, amount, and nurse's signature, which was not followed in these instances.
Failure to Implement Care Plan for Abdominal Binder
Penalty
Summary
The facility failed to implement a care plan for the use of an abdominal binder for a resident, which was necessary to prevent the dislodgement of the resident's gastrostomy tube. The resident, who was admitted with diagnoses including cerebral infarction, malignant neoplasm of the colon, and gastrostomy status, was observed wearing an abdominal binder. However, there was no care plan in place for its use, despite a physician's order being obtained on 1/21/2025. The resident's Minimum Data Set indicated significant communication and self-care dependencies, highlighting the need for consistent care planning. Interviews with facility staff revealed a lack of awareness and implementation of a care plan for the abdominal binder. The Case Manager was unsure if a care plan existed, and the Director of Nursing acknowledged that a care plan should be created with any new physician's order. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes, which was not adhered to in this case, leading to the potential for inconsistent care for the resident.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the spread of infections among residents, staff, and visitors. This deficiency was observed in the actions of a Licensed Vocational Nurse (LVN 1) and a Certified Nursing Assistant (CNA 3) who did not adhere to the facility's hand hygiene policy. LVN 1 was seen fist bumping with a resident in the dining room and then proceeded to handle meal trays without performing hand hygiene. Similarly, CNA 3 assisted a resident with their lunch tray and touched various surfaces in the resident's room, but did not wash hands or use hand sanitizer before delivering a meal tray to another resident. Interviews with LVN 1 and CNA 3 revealed that both staff members were aware of the importance of hand hygiene in preventing infection spread but failed to comply with the protocol. The Interim Director of Nursing confirmed that staff are required to perform hand hygiene before and after handling meal trays, touching residents, or interacting with equipment in resident rooms. The facility's failure to ensure proper hand hygiene practices was corroborated by the Centers for Disease Control and Prevention's guidelines, which emphasize the necessity of cleaning hands before and after patient contact and after touching contaminated surfaces.
Failure to Provide Proper PICC Site Care
Penalty
Summary
The facility failed to provide appropriate care for a resident's peripherally inserted central catheter (PICC) site, as per the physician's orders and facility policy. The resident, who was admitted with cellulitis and diabetes mellitus, had orders to monitor the PICC site every 8 hours and administer specific IV antibiotics. However, the IV Medication Administration Record indicated that the PICC site was not cleaned, and the dressing was not changed until a day after the medication administration. Observations revealed that the PICC site had dried blood, and the dressing was falling off, which was not addressed by the nursing staff. Interviews with the resident and nursing staff revealed that the nurses did not check or change the dressing on the PICC site as required. The resident mentioned that the nurses would take care of the dressing later, and the nurses admitted to not assessing the PICC site during medication administration. The Interim Director of Nursing confirmed that PICC site dressings should be changed every 7 days or as needed if soiled, and that RNs must check the site during medication administration to prevent infections. The facility's policy also emphasized the importance of regular dressing changes to minimize infection risks.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate fall prevention measures for a resident who was at high risk for falls, as indicated by their care plan and physician's orders. The resident, who had a history of metabolic encephalopathy, muscle weakness, multiple sclerosis, and contractures, experienced a fall resulting in a skin tear. Despite a physician's order and care plan intervention to provide bilateral floor mats, these were not present at the resident's bedside during an observation. Interviews with staff revealed a lack of communication and adherence to fall prevention protocols, as there was no fall precaution sticker or floor mats to indicate the resident's fall risk. The facility's policy required physician orders to be reviewed and implemented accurately, yet this was not followed in the case of the resident's floor mats. Staff interviews highlighted inconsistencies in communication about fall risks during shift changes and huddles. A family member noted that the mats had been removed due to tripping hazards, but could not recall when this occurred. The absence of floor mats, despite the resident's high fall risk score, demonstrated a failure to adhere to the care plan and physician's orders, potentially placing the resident at risk for further falls and injuries.
Failure to Provide Timely Care for Breast Lump
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who developed a lump in her left breast. On April 17, 2024, a Licensed Vocational Nurse (LVN) noted the lump but did not promptly notify the resident's Primary Care Provider (MD 1) or develop a care plan to address the issue. Despite the resident's repeated requests for medical attention, the facility staff did not follow up with the necessary interventions, including scheduling a mammogram as recommended by MD 1. The resident, who had a history of multiple sclerosis, hydronephrosis, and cerebral palsy, experienced severe pain under her left breast and rib cage on July 1, 2024, leading to her transfer to a General Acute Care Hospital (GACH). At the hospital, a mass suspicious for malignancy was discovered, and a subsequent biopsy confirmed infiltrating ductal carcinoma. The facility's failure to reassess the resident's condition and communicate effectively with MD 1 resulted in a significant delay in diagnosis and treatment. Interviews with facility staff, including LVNs and the Director of Nursing (DON), revealed a lack of adherence to the facility's policies and procedures regarding change of condition reporting and care planning. The staff did not document or carry out the physician's orders for a mammogram, and the Social Services Director was not informed to schedule the necessary appointment. This oversight contributed to the resident's prolonged distress and delayed cancer diagnosis.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
Certified Nursing Assistants (CNAs) 2 and 3 failed to respect and honor the rights of a resident, referred to as Resident 2, by not listening to her request regarding how she wished to be turned in bed. Resident 2, who had intact cognition and was dependent on staff for various activities, including turning in bed, had requested to be turned a certain way due to her existing medical conditions, including a broken left arm. Despite her request, the CNAs insisted on turning her in a manner they deemed appropriate, disregarding her instructions and leading to a physical altercation. During the incident, Resident 2 experienced severe pain in her right elbow after being turned by the CNAs, which resulted in a displaced oblique fracture of the mid humeral diaphysis. The fracture was suspected to be exacerbated by Resident 2's severe osteoporosis, a condition that was not being treated with medication at the time. The incident led to Resident 2 being transferred to a General Acute Care Hospital for further evaluation and treatment, including surgery to repair the fracture. Interviews with Resident 2 and her roommate, as well as a review of the facility's policies, highlighted the failure of the CNAs to treat Resident 2 with dignity and respect. The Director of Nursing acknowledged that staff should listen to residents and respect their rights, emphasizing the importance of treating residents with dignity as a basic human right. The facility's policy on Resident Rights mandates that residents be treated with consideration and respect, which was not adhered to in this case.
Failure to Promptly Notify Physician of Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician of a change in condition for a resident who experienced a significant health issue. On April 17, 2024, a Licensed Vocational Nurse (LVN) noted a lump in the resident's left breast but did not promptly notify the resident's primary care provider. The facility's policy required immediate notification of the physician for significant changes in a resident's condition, but this was not adhered to, leading to a delay in obtaining necessary medical orders and assessments. The resident, who had a history of multiple sclerosis, hydronephrosis, and cerebral palsy, expressed concerns about the lump and experienced severe pain, but the facility staff did not take timely action. Despite the resident's repeated requests for medical attention, the facility staff failed to follow up with the physician to clarify and obtain orders for a mammogram. The delay in addressing the resident's condition resulted in the resident being transferred to an emergency department months later, where a mass suspicious for malignancy was discovered. Interviews with facility staff and the Director of Nursing revealed a lack of communication and follow-up regarding the resident's condition. The facility's policy required reassessment and monitoring of the resident's condition, but this was not done. The resident's physician was not informed of the lump until much later, and the necessary diagnostic procedures were delayed, potentially impacting the resident's health outcome. The facility's failure to adhere to its policies and procedures for change of condition reporting led to a significant delay in care for the resident.
Failure to Develop Care Plan for Resident with Breast Lump and Cancer Diagnosis
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who experienced a significant change in condition. On April 17, 2024, a Licensed Vocational Nurse (LVN) noted a lump in the resident's left breast and notified the resident's physician, who recommended a mammogram. However, there was no documented order for the mammogram, and no care plan was developed to address the lump. The situation escalated when the resident complained of severe pain under the left breast and rib cage on July 1, 2024, leading to a transfer to an emergency department. An ultrasound revealed a suspicious mass in the left breast, highly indicative of malignancy, yet a mammogram could not be performed due to the resident's inability to position themselves. Despite these findings, a care plan was still not developed to address the resident's condition or the subsequent diagnosis of infiltrating ductal carcinoma on July 31, 2024. Interviews with facility staff, including the Director of Nursing and another LVN, confirmed that a care plan should have been developed following the resident's change in condition. The absence of a care plan meant that staff were not informed of the necessary interventions to manage the resident's condition, potentially leading to a decline in the resident's health. The facility's policy required the interdisciplinary team to develop a comprehensive care plan for each resident, especially upon significant changes in condition, which was not adhered to in this case.
Failure to Report Alleged Abuse in LTC Facility
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health, as required by their policy and procedure. The resident, who was admitted with conditions including cervical disc degeneration, dysphagia, and severe cognitive impairment, was involved in an incident where it was alleged that the Activities Supervisor placed hands on the resident's shoulders and a Licensed Vocational Nurse force-fed medications. Despite these allegations, there was no documentation in the resident's medical chart regarding the incident. The facility's Administrator acknowledged that the allegations were considered accusations of abuse and that the facility's policy required such allegations to be reported within two hours if they involved abuse or serious bodily injury. However, the allegations were not reported to the appropriate authorities, including the State Survey Agency and Adult Protective Services, as stipulated in the facility's policy. This oversight had the potential to compromise the resident's safety and violated the resident's rights.
Inadequate Night Shift Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff during the nocturnal shift on August 24, 2024, from 3 am to 7 am, which affected four residents. The staffing shortage left only one Licensed Vocational Nurse (LVN) to care for 86 residents, contrary to the facility's standard staffing requirement of two LVNs for the night shift. This staffing inadequacy was confirmed through interviews with staff and residents, who expressed concerns about safety and the timely provision of care. Resident 1, who was cognitively intact and had conditions such as peripheral vascular disease and muscle wasting, reported feeling unsafe due to the reduced staffing. Similarly, Resident 3, with acute respiratory failure and dysphagia, and Resident 4, with metabolic encephalopathy and end-stage renal disease, also expressed concerns about the safety and timeliness of care. Resident 5, diagnosed with Parkinson's Disease and anemia, noted that medication administration was affected, with some medications being given early and others late. Interviews with staff, including LVN 1, LVN 2, the Director of Staff Development, and the Director of Nursing, confirmed that the facility did not adhere to its staffing policy, which required two LVNs for the night shift. The Director of Nursing and the Administrator acknowledged that having only one LVN was unsafe for both the residents and the staff. The facility's policy and procedure on staffing, as well as the Facility Assessment, emphasized the need for adequate staffing to meet residents' needs, which was not met during the incident.
Failure in Catheter Care Monitoring
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling Foley catheter, as evidenced by the presence of urine sediments in the catheter tubing. The resident, who was admitted with diagnoses including metabolic encephalopathy, UTI, and sepsis, was noted to have severely impaired cognition and required substantial assistance with personal hygiene. The physician orders required staff to monitor for signs of infection, including increased sediments in the urine, and notify the physician if such signs were present. However, during an observation, a white, cloudy substance was found in the resident's catheter tubing, which was identified by LVN 3 as a potential sign of infection. Despite the facility's policy requiring monitoring of catheter care every shift, the presence of sediments was not addressed in a timely manner. LVN 5 confirmed the presence of sediments and acknowledged the need to notify the physician, yet the documentation on the Treatment Administration Record indicated that the catheter was monitored every shift. The Director of Nursing also confirmed that sediments could indicate an infection, highlighting a lapse in the facility's adherence to its own catheter care policy and procedure.
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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