Broadway By The Sea
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 2725 E. Broadway, Long Beach, California 90803
- CMS Provider Number
- 055894
- Inspections on file
- 44
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Broadway By The Sea during CMS and state inspections, most recent first.
A resident with impaired cognition and multiple medical conditions developed a documented fever that met criteria for a PRN acetaminophen order, but nursing staff did not administer the medication or document ongoing temperature monitoring and reassessment. An LVN acknowledged taking the resident’s temperature but did not document it, and the DON confirmed that staff failed to give the ordered acetaminophen and to continue monitoring the fever, contrary to the facility’s change-of-condition policy requiring assessment, documentation, and ongoing observation.
Two residents with cognitive impairment and multiple medical conditions did not receive their scheduled 9 a.m. medications within the facility’s required one-hour administration window. One resident’s ordered morning medications, including cardiovascular, diuretic, antiviral, and supplement therapies, were all given more than an hour and a half late. Another resident’s ordered Tamiflu dose was also administered more than an hour and a half after the scheduled time. An LVN reported being behind on the med pass due to multiple tasks, and another LVN cited delayed pharmacy delivery and acknowledged the duty to follow up. The DON and facility policy both specified that medications must be administered within 60 minutes of the scheduled time to ensure effectiveness and minimize side effects.
A resident with diabetes, rheumatoid arthritis, moderate cognitive impairment, and documented bilateral foot infection had a physician’s order for daily Ciclopirox cream to both feet for tinea pedis. Over multiple days, nursing staff documented repeated refusals of the ordered foot treatment in progress notes and on the TAR, but the physician and the resident’s POA were not notified after these ongoing refusals. The treatment nurse later acknowledged that notification should have occurred after the third refusal, and the DON confirmed that a change of condition process and notifications were required under facility policy. This failure resulted in the resident not receiving the ordered antifungal treatment for several days and, per the report, had the potential to cause infection, inflammation, and hospitalization.
A resident with diabetes and cognitive impairment did not receive prescribed Ciclopirox 8% for toenail fungus for two months due to the facility's failure to follow a podiatrist's orders. The medication was not administered because the orders were not transcribed or implemented, and delays in obtaining office visit notes contributed to the oversight. Staff confirmed the resident had not received the treatment as directed.
A resident with diabetes and cognitive impairment did not receive prescribed antifungal treatment for toenail fungus due to the facility's failure to obtain and act on physician visit summaries, resulting in a two-month lapse in care. Staff interviews revealed confusion about the process for securing and implementing physician orders, and the resident's condition persisted without appropriate treatment.
A resident with a history of mental and behavioral disorders exhibited ongoing depressive symptoms and had multiple physician orders for psychiatric evaluation, but was not seen by a psychiatrist for several months. Despite care plan interventions and repeated requests from the resident, staff failed to arrange timely psychiatric consults or monitor and document behavioral health status as required, resulting in worsening symptoms.
A resident with severe cognitive impairment and a history of falls was unable to access her call light, which was found out of reach during an observation. Facility staff, including the ADON and DON, confirmed that the call light should have been accessible as per the resident's care plan and facility policy.
A Licensed Vocational Nurse worked 61 shifts with an inactive license after mistakenly selecting the wrong renewal option and failing to verify her license status. The facility's HR department did not detect the lapse during required monthly verifications, allowing the nurse to continue working without a valid license until the issue was reported by the state licensing board.
Two residents with severe cognitive impairment and skin integrity issues did not receive timely or properly documented wound care. For one, daily wound treatments ordered by a physician were not recorded on the TAR for specific days. For the other, MASD was identified on admission but wound measurements were not documented and a barrier cream order was delayed by three days. Nursing staff and the DON confirmed these lapses, which were not in accordance with facility policy.
A resident at high risk for falls, with a history of atrial fibrillation and dementia, experienced significant injuries due to inadequate fall prevention measures. The care plan lacked specific interventions and was not updated after previous falls. Despite being on anticoagulant therapy, the resident was not provided with necessary supervision or monitoring, leading to a fall that resulted in a subdural hematoma and spinal fracture.
A resident with a history of cerebral infarction, dementia, and atrial fibrillation experienced three unwitnessed falls due to inadequate supervision in an LTC facility. Despite being identified as a high fall risk and requiring assistance for daily activities, the resident was not consistently monitored, particularly in the restroom. The care plan's interventions, such as frequent visual checks and assistance with transfers, were not effectively implemented, leading to repeated falls.
A facility failed to document and monitor the effectiveness of a 1:1 sitter intervention for a resident at high risk for falls, who had multiple diagnoses including dementia and atrial fibrillation. Despite requiring supervision for daily activities, there was no care plan or physician's order for the sitter, and staff did not document the resident's behaviors or the intervention's effectiveness. Interviews with staff revealed the resident frequently attempted to get up unassisted, highlighting the need for proper documentation and monitoring.
The facility failed to implement its Infection Prevention and Control Program by not ensuring all staff, including registry staff, were tested for COVID-19 according to local health department guidance. Registry staff did not perform COVID-19 tests before shifts, and only day shift staff received COVID-19 protocol in-services. The Infection Prevention Nurse was unaware of registry staff testing, and the Director of Nursing acknowledged the need for all staff to receive infection control training.
A resident with intact cognition and moderate assistance needs filed repeated grievances about lengthy call light response times, particularly during night shifts. Despite in-service training for staff, the issue persisted due to reliance on registry CNAs. The facility's grievance policy was not effectively implemented, and the recurring issue was not included in the QAPI plan for monitoring and prevention.
A resident with severe cognitive impairment and diagnoses of hydronephrosis and obstructive uropathy did not receive proper monitoring and treatment for their nephrostomy tube and suprapubic catheter. Physician orders required daily cleansing and monitoring for signs of infection, but these were not completed over a three-day period. Interviews with staff confirmed the oversight, and the facility's policy for placing treatment orders was not followed.
A resident at moderate risk for skin injury developed a Stage III pressure ulcer due to the facility's failure to implement a care plan intervention for repositioning every two hours. Despite the resident's medical history and risk factors, the facility did not adhere to its skin and wound management policy, leading to the development of the ulcer. Interviews and documentation revealed that the resident was not repositioned as required, and the care plan was not updated with necessary interventions.
Two residents' RNA programs were improperly modified by unqualified staff. One resident received unauthorized motorized exercises, while another had a splint applied without a physician's order. The facility's policies require licensed therapists to establish and modify RNA programs, but the RNAs acted independently, risking resident safety.
The facility failed to update informed consent for a resident receiving Seroquel and did not ensure a medical diagnosis for another resident prescribed Haloperidol. The first resident's informed consent did not match the current medication order, potentially leading to unnecessary medication. The second resident was prescribed Haloperidol without a documented diagnosis of schizophrenia, as required by facility policy.
A medication pass in an LTC facility resulted in a 22.58% error rate. Two residents were given chewable aspirin to swallow instead of chewing, and a resident with a G-tube received five medications mixed together, contrary to policy. The errors were acknowledged by an LPN and the DON, highlighting a failure to follow medication administration protocols.
A resident with a G-tube was administered five medications crushed and mixed together by an LVN, contrary to the facility's policy requiring separate administration. The medications were for hypertension, psychotic features, depression, and mood disorders. The DON confirmed the need for individual administration to ensure safety.
The facility failed to ensure safe medication handling and storage for two residents. A resident with severe cognitive impairment had an unidentified medication left at their bedside, which was deemed unsafe by staff. Additionally, an opened Budesonide Inhalation envelope lacked an open date, risking ineffective dosing for a resident with COPD. The facility's policy requires secure storage and adherence to manufacturer guidelines.
The facility failed to label open dates on seven seasoning containers and did not ensure proper hair net usage by a Dietary Aid, potentially risking food contamination.
An OTA, also serving as the DOR, independently conducted Joint Mobility Assessments for three residents, despite lacking the qualifications to do so without supervision from a licensed OT or PT. This practice was against the facility's policy and state regulations, which require such assessments to be performed by licensed therapists.
The facility failed to accurately document Restorative Nursing Aide services for two residents, leading to a deficiency in care. One resident did not receive documented passive range of motion exercises as ordered, while another had no documentation for splint application despite wearing it. The Director of Nursing acknowledged the importance of accurate documentation, but grouped orders led to confusion and inaccuracies.
The facility failed to document the annual review of their Infection Prevention and Control Program policies and procedures. Additionally, staff did not wear required PPE, such as isolation gowns, while providing care to residents on Enhanced Barrier Precautions. This included a resident with an indwelling medical device and another with a stage 3 pressure injury. Interviews confirmed the oversight, and the importance of following infection control protocols was acknowledged by staff.
A facility failed to conduct a quarterly IDT care conference for a resident with severe cognitive impairment, involving the resident's family member. The last documented conference was overdue, violating the resident and family's rights to be informed and participate in the care plan. The facility's policy required family involvement in care plan development, but this was not adhered to.
A resident with asthma and allergic rhinitis was observed self-administering medications without an assessment by the facility's interdisciplinary team. The facility's policy requires such an assessment to ensure safe medication practices, but no documentation was found to support the resident's capability to self-administer. Interviews with staff confirmed the lack of assessment and documentation.
A facility failed to assess and obtain informed consent and a physician's order for the use of bolsters as restraints for a resident with severe cognitive impairment. The oversight was identified during an observation, revealing that while side rails had the necessary documentation, the bolsters did not, violating the resident's rights.
A resident with severe cognitive impairment and multiple medical conditions was observed with a possible fracture in their left lower leg, but the facility failed to report this unknown injury to the CDPH. The administrator did not consider the incident reportable, despite the facility's policy requiring such injuries to be reported. The resident was taken to a hospital where the injury was noted, and a social work consult was conducted due to its unexplained nature.
A resident with advanced dementia was found with a potentially fractured leg, but the facility failed to investigate or report the injury to CDPH within the required timeframe. The administrator did not consider the incident reportable, and no investigation was documented by the previous DON. The interim DON acknowledged the reporting requirement, but the lack of timely action prevented CDPH from investigating the incident promptly.
A resident with schizoaffective disorder and bipolar disorder was readmitted to the facility without the required PASARR screening. The resident's MDS indicated moderate cognitive impairment, necessitating a Level II PASARR. Interviews with the ADON and DON confirmed the oversight, and the facility's policy mandates PASARR completion upon admission.
A resident with hemiplegia and contracture was observed wearing a splint without a documented care plan or order for its application. The RNA applied the splint daily, but both the RNA and OT confirmed the absence of necessary documentation. The interim DON highlighted the importance of care plans to prevent risks like skin breakdown, as per the facility's policy.
A facility failed to monitor and document the condition of a suprapubic catheter stoma site for a resident, as ordered by the physician. The resident had a history of urinary tract infection and obstructive reflux uropathy. A nurse observed redness, discharge, and blood clots around the catheter site but was unsure of their significance. The Director of Nursing confirmed that the Treatment Administration Record did not show monitoring for signs of infection or injury, which is crucial after surgical procedures.
A resident with rheumatoid arthritis and osteoarthritis did not receive the ordered passive ROM exercises due to RNAs being unaware of the order. Instead, they only applied splints, potentially leading to a decline in the resident's physical functioning. The facility's policies required adherence to RNA orders to maintain residents' ROM and mobility.
A facility failed to implement a dietician's recommendation to increase a resident's tube feeding rate, risking the resident's nutritional status. Despite the recommendation to increase the rate to 60 cc/hr, the feeding was observed at 50 cc/hr. The Dietary Supervisor and DON acknowledged the need to follow the dietician's recommendations, as per the facility's policy on nutritional status management.
A facility failed to provide trauma-informed care for a resident with PTSD, as there were no care plans or assessments addressing the resident's condition. Despite the facility's policy requiring individualized care to prevent re-traumatization, the necessary measures were not implemented, leaving the resident without appropriate support for their mental health needs.
The facility did not meet the required space standards for resident rooms, with several rooms accommodating more residents than the space allowed. Rooms for three residents measured only 223 square feet, and rooms for two residents measured 144 square feet. The Administrator requested a waiver for these rooms, claiming no adverse effects on residents' health or safety. Observations did not show immediate issues, and the Department recommended continuing the waiver.
A resident in a facility was over-sedated due to the administration of unnecessary psychotropic medications, including Ativan, Seroquel, and Risperdal, without proper documentation or indication. The resident experienced multiple falls and injuries, and the facility failed to monitor the resident's condition or obtain informed consent for medication changes.
A facility failed to inform and obtain consent from a resident's responsible party for a change in the dosage and frequency of Ativan, a psychotropic medication. The resident, with severe cognitive impairment, was initially prescribed Ativan 0.5 mg every four hours PRN, which was later increased to 1 mg every four hours without proper consent. The responsible party noticed excessive sedation during a visit and expressed concerns about overmedication. Staff interviews revealed confusion about consent responsibilities, contrary to the facility's policy requiring consent for medication changes.
A resident with a history of chronic conditions was found with unexplained bruising, which was not reported to CDPH as required. Despite the resident's ability to make decisions, they were unaware of the cause. Staff interviews revealed an incident involving scissors, but the Director of Nursing attributed the bruising to medical history and did not report it, violating facility policy.
A resident reported being attacked by nursing staff and showed unexplained discoloration on the arm and rib area. Despite the resident's medical history of conditions that could cause easy bruising, the facility did not investigate the allegations or the injuries, contrary to its policy requiring prompt investigation of such incidents.
A facility failed to account for a resident's belongings upon discharge, as the inventory list was not reviewed or signed with the resident's POA. The resident, with a fluctuating capacity to make decisions, was discharged without verifying their belongings, leading to a missing cell phone. The facility's policy required a signed receipt for personal effects, which was not followed.
A resident's missing debit card was not reported to the necessary authorities within the required 24-hour timeframe, leading to unauthorized transactions totaling approximately $11,254.00. The resident, with fluctuating decision-making capacity due to mental health conditions, was not at the facility when the misuse was reported by the POA to the SSD. The SSD delayed reporting the issue to the administration and authorities, resulting in a lack of timely investigation.
The facility did not ensure the safety of residents assessed as high risk for falls, resulting in serious injuries. One resident with a history of falls suffered head trauma and intracranial hemorrhage due to the lack of preventative measures like landing mats and bed alarms. Staff, including an LVN, were unaware of the resident's fall risk and care plan interventions, indicating communication and training issues. Another resident with a history of seizures did not have their bed in the lowest position as care planned, and a third high-risk resident also had their bed in an elevated position. The facility lacked a clear protocol for identifying high fall risk residents and ensuring appropriate interventions, leading to inadequate supervision and preventative measures.
The facility's QAA and QAPI committee failed to identify and address falls as a current issue, despite multiple fall incidents over three months. The Administrator stated that the facility compared its fall incidents to surrounding facilities and determined that their numbers were lower, thus not warranting inclusion in the QAPI plan. This oversight had the potential to affect all 21 residents assessed as high fall risks.
A facility failed to hold an Interdisciplinary (IDT) Care Conference within seven days of a resident's readmission from a General Acute Care Hospital (GACH). The resident, who had multiple diagnoses and was a high fall risk, did not have the requested fall prevention interventions implemented. The Social Services Director acknowledged the oversight, which violated the resident and their responsible party's right to participate in the care plan.
A resident with multiple diagnoses, including cancer and aphasia, did not receive prescribed treatment for skin scratches due to a lack of awareness and follow-through by facility staff. Despite treatment orders being placed, the treatment administration records showed no treatments were provided, and staff interviews revealed a failure to transcribe and carry out the orders.
Failure to Administer PRN Antipyretic and Monitor Fever
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered care and monitoring for a resident who developed a fever. The resident was admitted with diagnoses including lack of coordination, dysphagia in the oropharyngeal phase, and urinary retention, and had moderately impaired cognitive skills for daily decision-making, requiring setup or cleanup assistance with eating, oral hygiene, and personal hygiene. The resident’s vital sign record showed a documented temperature of 100.1°F late in the evening, which met the threshold for a PRN order for acetaminophen 325 mg, two tablets by mouth every six hours as needed for fever greater than 100°F. However, there was no documentation that the resident’s temperature was monitored or reassessed after this elevated reading. Interview and record review revealed that the nurse on duty acknowledged the resident’s temperature was elevated from the previous shift and stated it was the licensed nurse’s responsibility to monitor any change of condition and elevated temperatures, to see if the temperature decreased, and to administer medication as ordered. The nurse reported taking the resident’s temperature but not having time to document it. The DON confirmed that licensed staff failed to administer the ordered acetaminophen for the fever and stated that licensed staff should assess, give medication as ordered, and continue monitoring for fever. Review of the facility’s change of condition/quality of care policy indicated that nurses are required to perform and document an assessment, implement existing orders or obtain new orders, and provide at least three days of observation and documentation for residents with a change in condition, which was not carried out in this case.
Late Administration of Scheduled Medications Outside One-Hour Window
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services by not administering scheduled 9 a.m. medications within the facility’s required one-hour before or after window for two residents. For the first resident, who had severe cognitive impairment and required substantial to maximal assistance with eating, oral hygiene, and personal hygiene, the admission and assessment records showed multiple diagnoses including type 2 diabetes with circulatory complications, hypertension, and dysphagia. The resident’s February medication orders included aspirin, ferrous gluconate, furosemide, metoprolol, a multivitamin, Tamiflu, spironolactone, and sacubitril-valsartan. Review of this resident’s Medication Audit Report for early February showed that on a specific date all eight of the resident’s 9 a.m. medications were administered at 11:27 a.m., which was 1 hour and 27 minutes after the scheduled time and outside the facility’s stated one-hour window. For the second resident, who had moderate cognitive impairment and required setup or clean-up assistance with eating, oral hygiene, and personal hygiene, the admission and assessment records documented diagnoses including lack of coordination, dysphagia in the oropharyngeal phase, and urinary retention. This resident had an order for Tamiflu 30 mg to be given twice daily for influenza. The Medication Audit Report for the second resident showed that on the same date the 9 a.m. Tamiflu dose was administered at 11:37 a.m., 1 hour and 37 minutes after the scheduled time, also outside the one-hour window. In interviews, one LVN stated that medications should be given one hour before or after the scheduled time and reported being behind on the medication pass due to having multiple tasks. Another LVN stated that the late administration for the second resident was due to a pharmacy delivery delay and acknowledged responsibility to follow up with the pharmacy if medications were not delivered on time. The DON confirmed that scheduled medications were to be administered within one hour before or after the scheduled time to ensure effectiveness and minimize side effects, and facility policy dated January 2017 specified that medications are to be administered within 60 minutes of the scheduled time unless otherwise specified by the prescriber.
Failure to Notify Physician and POA of Repeated Refusals of Antifungal Foot Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and power of attorney (POA) of repeated refusals of prescribed antifungal treatment for tinea pedis. The resident had diagnoses including diabetes mellitus and rheumatoid arthritis, was documented as alert and oriented in a history and physical, and had moderate cognitive impairment and an infection on both feet per the MDS. A physician’s order dated 11/6/2025 directed that Ciclopirox cream be applied to both feet once daily for tinea pedis. Progress notes documented that the resident refused treatment to both feet on 1/8/2026, 1/10/2026, 1/11/2026, and 1/12/2026, and the Treatment Administration Record showed refusals of the fungal treatment on 1/10/2026, 1/11/2026, and 1/12/2026. Despite these repeated refusals, the physician and the resident’s POA were not notified. During an interview, the treatment nurse stated he should have notified the physician and POA after the resident’s third refusal of the fungal treatment. In a concurrent interview and record review, the DON stated the treatment nurse should have completed a change of condition (COC) when the resident refused the foot fungal treatment for the third time so that the physician could be informed and a new plan of care considered, and that the POA should have been notified so they could talk to the resident about refusing care. The facility’s Change of Condition policy indicated that when a resident’s condition or care needs change, the nurse should use clinical judgment to contact the physician and notify the resident or resident representative of the change in condition and any changes in medical or nursing care. The failure to follow this process resulted in the resident not receiving the ordered treatment for four days and, as stated in the report, had the potential to cause infection, inflammation, and hospitalization.
Failure to Administer Prescribed Antifungal Medication for Toenail Fungus
Penalty
Summary
The facility failed to follow a physician's order for a resident who was under the care of a podiatrist for onychomycosis (nail fungus) of the great toes. The resident, who had a history of type 2 diabetes and moderate cognitive impairment, was prescribed Ciclopirox 8% nail lacquer to be applied daily to the affected toenails. Despite ongoing orders from the podiatrist to continue this treatment for six months to one year, the medication was not administered to the resident for a period of two months. Observations revealed that the resident's right and left great toes appeared thick and discolored, and the resident reported pain and emotional distress related to the condition of her toenails. Multiple office visit notes from the podiatrist documented the need for continued application of Ciclopirox 8% and highlighted the lack of improvement in the resident's condition. However, the treatment nurse confirmed that the resident had not been receiving the medication for some time, and the Assistant Director of Nursing acknowledged that the orders for Ciclopirox 8% were not present in the resident's chart and had not been implemented since mid-July. The delay in obtaining and reviewing the podiatrist's office visit notes contributed to the failure to transcribe and carry out the physician's orders in a timely manner. The facility's staff, including the ADON and DON, recognized that the absence of the medication order and the lack of follow-through on the podiatrist's recommendations resulted in the resident not receiving the prescribed treatment for her toenail fungus.
Failure to Obtain and Implement Physician Orders for Antifungal Treatment
Penalty
Summary
The facility failed to obtain and act upon Office Visit Summaries from outpatient physician visits for a resident, resulting in a lapse in prescribed treatment for onychomycosis (toenail fungus) of both great toes. The resident, who had a history of type 2 diabetes and moderate cognitive impairment, was under ongoing care for toenail fungus, with orders from an outside podiatrist to continue Ciclopirox 8% External Solution for an extended period. Despite these orders, the facility did not secure timely documentation from the podiatrist visits on two occasions, leading to a gap in the resident's treatment regimen. Observations and record reviews revealed that the resident's toenails remained thick and discolored, and the resident experienced emotional distress and depression related to the condition. Progress notes indicated that family members raised concerns about the toenails, and the wound care specialist confirmed the diagnosis of onychomycosis. Although the podiatrist provided clear instructions to continue the antifungal treatment, the facility did not maintain current orders for the medication, and the treatment was not administered for approximately two months. Interviews with facility staff, including the treatment nurse, Assistant Director of Nursing, and Director of Nursing, confirmed that there was confusion and lack of awareness regarding the process for obtaining and following up on Office Visit Notes. The Office Visit Summaries were not present in the resident's chart in a timely manner, and staff were unaware that the orders for Ciclopirox 8% had lapsed, resulting in the resident not receiving the prescribed treatment. The delay in obtaining and implementing physician orders led to a failure to provide appropriate care as directed by the resident's physician.
Failure to Provide Timely Psychiatric Evaluation and Monitoring for Depression
Penalty
Summary
The facility failed to ensure that a resident exhibiting signs and symptoms of depression received necessary behavioral health care and services as ordered. The resident, who had a history of mental and behavioral disorders, was admitted with diagnoses including a history of trauma and a colostomy. Multiple assessments and care plans identified the resident as being at risk for depression, with documented symptoms such as loss of interest in activities, excessive sleepiness, and feelings of sadness. Orders for psychiatric evaluation were placed on three separate occasions, but there was no documentation that the resident was seen by a psychiatrist until several months after the initial order. Despite clear care plan interventions requiring psychiatric consultation and monitoring of depressive symptoms, the facility did not arrange for timely psychiatric evaluations or consistently monitor and document the resident's behavioral health status. Interviews with the resident revealed ongoing depressive symptoms, including a desire to sleep all day, loss of interest in activities, and emotional distress. The resident reported communicating these feelings to staff and requesting psychiatric support, but did not receive the ordered consults in a timely manner. Staff interviews indicated a lack of awareness and follow-through regarding outstanding psychiatric consult orders. The Social Services Director was unaware of previous consult orders and did not document pending psychiatric visits. The Assistant Director of Nursing and Director of Nursing confirmed that the psychiatric consults were not completed as ordered and that there was no behavior monitoring as outlined in the care plan. The facility's own policy required provision of necessary behavioral health services and timely referrals, but these were not carried out, resulting in the resident experiencing worsening depressive symptoms.
Call Light Not Accessible to Resident with High Fall Risk
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. During an observation, the resident was seen searching for her call light, which was found wedged between the mattress and fitted sheet, out of her reach. The Assistant Director of Nursing confirmed that the call light was not accessible and acknowledged that it should have been within the resident's reach for safety reasons. The Director of Nursing also stated that call lights should be accessible to residents to allow them to request assistance in a timely manner. The resident involved had a history of neurocognitive disorder with Lewy bodies, adult failure to thrive, a history of falls, and severely impaired cognition. Her care plan specifically identified her as being at high risk for falls and required that her call light be placed within reach and that she be encouraged to use it for assistance. The facility's policy also required staff to ensure the call device was accessible before leaving the room. The failure to follow these protocols resulted in the resident being unable to call for help when needed.
Plan Of Correction
F550 Corrective Action Assigned CNA was inserviced 1:1 by DSD on 05/27/25 on Resident Rights, including the importance of keeping the call light within reach at all times. Assigned LVN was inserviced 1:1 by DSD on 05/27/25 on Resident Rights, including the importance of keeping the call light within reach at all times. Identification of Others at Risk All residents of this facility have the potential to be affected by this deficiency. The DSD has made observation rounds on 05/27/25 on call lights being within reach. All call lights were within reach. Process to Prevent Recurrence The DON and DSD have inserviced nursing and facility staff between 05/27/25 and 05/30/25 on Resident Rights, including the importance of keeping the call light within reach at all times. The Guardian Angels will observe the placement of the call lights during their routine rounds. Results will be reported to the Administrator for any needed follow-up. Monitoring Process The Administrator will provide results of the observation rounds to the QA&A committee during the monthly meeting. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 06/12/25
LVN Worked Multiple Shifts with Inactive License Due to Lapse in Verification
Penalty
Summary
The facility failed to ensure that one of its Licensed Vocational Nurses (LVN) maintained an active license in accordance with state law. Review of records showed that the LVN worked a total of 61 shifts over a period of several months while her license was inactive due to failure to renew. The issue was discovered when the Director of Nursing (DON) was notified by the state licensing board that the LVN's license was inactive. The LVN had mistakenly selected the inactive option instead of renewal during the online renewal process and did not verify the status of her license, assuming it was renewed because her payment was processed. The facility's policy required Human Resources (HR) to verify employee licenses upon hiring and monthly thereafter, and to notify the facility of any approaching expiration dates or inactive licenses. However, the HR department did not identify that the LVN's license had become inactive, and the LVN continued to be scheduled and worked multiple shifts without a valid license. The deficiency was identified through interviews and review of timecards, licensing records, and facility policies.
Plan Of Correction
Corrective Action LVN 2: LVN license was updated to active on 05/08/2025. Identification of Others at Risk All residents of this facility have the potential to be affected by this deficiency. A review of 25 RN and LVN licenses status has been done by the DON on 05/06/2025. All licenses were active. Process to Prevent Recurrence The DON has inserviced the licensed nurses between 05/7/2025 and 5/10/2025 on the importance of keeping their nursing license active. The DON/designee will check the status of the licensed nurses' licenses monthly X3 months and annually thereafter. Results of monthly review will be reported to QA&A committee. Monitoring Process The DON will report the results of the nursing license reviews to the QA&A committee monthly. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting x3 months. Complete Date: 06/11/2025
Failure to Document and Timely Intervene in Wound Care and Skin Integrity
Penalty
Summary
The facility failed to provide and document appropriate wound care and prevention measures for two residents with significant skin integrity issues. For one resident admitted with a stage 4 pressure ulcer of the sacral region and severe cognitive impairment, physician orders directed daily wound care using normal saline, medical-grade honey, and foam dressing. However, there was no documentation in the Treatment Administration Record (TAR) indicating that these treatments were provided on specific dates as ordered. Another resident, also with severe cognitive impairment and dependent on staff for hygiene, was admitted with moisture-associated skin damage (MASD) to the sacral region and buttocks. Upon admission, the initial nursing assessment identified MASD but did not document wound measurements or type, failing to establish a baseline for monitoring. Additionally, although MASD was identified on admission, a physician order for barrier cream was not obtained until three days later, delaying appropriate intervention. Interviews with nursing staff and the Director of Nursing confirmed that wound measurements should have been documented upon admission and that barrier cream should have been ordered and applied immediately when MASD was identified. The facility's own policy requires timely assessment, documentation, and intervention for skin injuries, as well as documentation of treatments as they are administered. These requirements were not met for the two residents in question.
Plan Of Correction
Corrective Action Resident 1: was discharged on 12/3/2024. Resident 2: returned from the hospital on 4/29/25. Treatments are in place for all skin conditions. Identification of Others at Risk All residents of this facility that have skin conditions have the potential to be affected by this deficiency. The Medical Records Director has reviewed the TARs for the month of May. 16 active residents with skin conditions were identified. Treatment orders were documented, no further follow-up needed. The DON has reviewed the TARs for the month of May and compared skin conditions identified upon admission against the TAR for 8 active residents. Skin conditions identified upon admission had treatment orders in place. No further follow-up was needed. The DON has inserviced the licensed nurses and the Skin IDT Committee members between 5/16/25 and 5/20/25 on the facility policy Skin And Wound Monitoring and Management, including identifying and documenting skin conditions upon admission and starting those treatments timely, and the need to document skin treatments when provided on the TAR. The Medical Records Director will review the TARs daily (M-F) for 30 days for completion. Results will be forwarded to the DON for needed follow-up. The DON/Designee will review daily (M-F) newly admitted residents to ensure that identified skin conditions have treatment orders in place. Monitoring Process The DON will provide results of the daily skin reviews to the QA&A committee during the monthly meeting for 3 months. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 5/20/2025 The DON has inserviced the licensed nurses and the Skin IDT Committee members between 5/16/25 and 5/20/25 on the facility policy Skin And Wound Monitoring and Management, including identifying and documenting skin conditions upon admission and starting those treatments timely, and the need to document skin treatments when provided on the TAR. The Medical Records Director will review the TARs daily (M-F) for 30 days for completion. Results will be forwarded to the DON for needed follow-up. The DON/Designee will review daily (M-F) newly admitted residents to ensure that identified skin conditions have treatment orders in place. Monitoring Process The DON will provide results of the daily skin reviews to the QA&A committee during the monthly meeting for 3 months. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 5/20/2025
Failure to Implement Effective Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as a high risk for falls, was adequately protected from falls and injuries. The resident's care plan, dated 7/5/2024, did not include specific interventions to prevent falls, and it was not reviewed or revised after the resident experienced a fall on 8/20/2024. Despite being on anticoagulant therapy, which increased the risk of bleeding, the care plan lacked detailed precautions to prevent falls and related injuries. The resident, who had a history of atrial fibrillation, repeated falls, and dementia, was admitted to the facility with a medium fall risk score. However, the care plan identified the resident as a high fall risk due to recurrent falls and attempts to get up unassisted. The facility's policy required individualized care plans with measurable objectives and timeframes for residents at risk of falls, but this was not implemented effectively for the resident. The resident's fall on 10/24/2024 resulted in significant injuries, including a subdural hematoma and a spinal fracture, necessitating hospitalization and surgical interventions. Interviews with facility staff revealed that the resident required frequent monitoring and supervision due to poor safety awareness. However, the care plan did not include measures such as assigning a 1:1 sitter or implementing frequent visual checks, which could have mitigated the risk of falls. The Director of Nursing acknowledged that these interventions should have been part of the care plan, indicating a lapse in the facility's adherence to its fall management policy.
Inadequate Supervision Leads to Multiple Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who was at high risk for falls, resulting in three unwitnessed falls within a month. The resident, who had a history of cerebral infarction, dementia, and atrial fibrillation, required supervision or assistance for activities of daily living and was on anticoagulant medication, increasing the risk of complications from falls. Despite being identified as a high fall risk, the resident was not consistently monitored, particularly while using the restroom, leading to multiple incidents of falling. The resident's care plan included interventions such as frequent visual checks and assistance with transfers, but these were not adequately implemented. On several occasions, the resident attempted to go to the bathroom unassisted, resulting in falls. Interviews with staff revealed inconsistencies in understanding the resident's need for 1:1 supervision, with some staff providing privacy without maintaining visual contact, contrary to the care plan requirements. The facility's policy on fall management emphasized the need for an environment free of accident hazards and appropriate interventions to prevent falls. However, the lack of consistent supervision and adherence to the care plan contributed to the resident's repeated falls. The Director of Nursing acknowledged that frequent monitoring and visual checks were necessary to reduce the risk of falls, but these measures were not effectively implemented for the resident.
Failure to Document and Monitor Sitter Intervention for Fall-Risk Resident
Penalty
Summary
The facility failed to document and monitor the effectiveness of interventions for a resident at high risk for falls, who was assigned a 1:1 sitter. The resident, who had diagnoses including cerebral infarction, dementia, and atrial fibrillation, was admitted with fluctuating decision-making capacity and mild cognitive impairment. Despite requiring supervision for activities of daily living, the facility did not have a care plan or physician's order for the sitter, and there was no documentation of the sitter's effectiveness in preventing falls. Interviews with the Director of Nursing (DON) and other staff revealed that the resident had multiple falls and required constant redirection. The DON acknowledged the absence of a care plan for the sitter and stated that the charge nurse should document any episodes of the resident attempting to get up unassisted. However, there was no documentation of such monitoring, and the facility's policy indicated that the care plan should reflect when a resident is assigned to the Sitter Program. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) involved in the resident's care reported that the resident frequently attempted to get up unassisted and was noncompliant with using the call light. Despite the presence of a sitter, there was no formal documentation of the resident's behaviors or the effectiveness of the sitter intervention. The Director of Staff Development (DSD) also confirmed the lack of monitoring and documentation, emphasizing the need for a care plan to prevent falls effectively.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program by not ensuring that all staff, including registry staff, were tested for COVID-19 according to local health department guidance. Interviews with Certified Nurse Assistants (CNAs) revealed that registry staff did not perform COVID-19 tests prior to starting their shifts. The local health department's guidance required two rounds of facility-wide testing for all staff and residents, and emphasized the importance of wearing well-fitting masks and proper use of personal protective equipment (PPE). The Infection Prevention Nurse (IP) was unaware if registry staff were tested before their shifts, despite the facility's policy requiring testing on specific days and prior to shifts. Additionally, the facility did not provide COVID-19 protocol in-services to all staff shifts, as only day shift staff received training. The Director of Nursing (DON) acknowledged that all staff should receive infection control practice in-services to stay updated with current information and to address any questions. The facility's policy, dated May 2023, indicated that the Infection Prevention and Control Program should follow national standards to prevent and control infections. These failures increased the risk of cross-contamination and the spread of COVID-19 within the facility and the community.
Failure to Resolve Call Light Response Grievances
Penalty
Summary
The facility failed to resolve grievances related to call light response times for a resident, leading to repeated complaints. The resident, who was admitted with a diagnosis including removal of right ankle internal fixation, had intact cognition and required moderate assistance with activities of daily living. Despite filing grievances in December 2024 and January 2025 about lengthy call light response times, particularly during the night shift, the issue persisted. The Director of Staff Development provided in-service training to staff on the importance of timely call light responses, but the problem was not resolved. Interviews revealed that the Social Services Director acknowledged the issue was related to shifts staffed by registry CNAs, making it difficult to ensure prompt responses. The Administrator admitted that the recurring grievance should have been included in the Quality Assurance and Performance Improvement plan, with call light response times monitored to prevent recurrence. The facility's grievance policy required immediate action to resolve concerns and prevent further violations, but this was not effectively implemented, resulting in the continued deficiency.
Failure to Monitor and Treat Nephrostomy Tube and Suprapubic Catheter
Penalty
Summary
The facility failed to ensure proper monitoring and treatment of a resident's nephrostomy tube and suprapubic catheter. The resident, who was admitted with diagnoses of hydronephrosis and obstructive uropathy, had physician orders for the nephrostomy tube to be cleansed with normal saline, patted dry, and secured with a dry dressing daily, and for the suprapubic catheter to be cleansed with normal saline, rinsed, and dried every shift. However, the Treatment Administration Record (TAR) indicated that these treatments were not completed from January 8 to January 10, 2025. Interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that there should have been orders for monitoring and treatment of the resident's nephrostomy tube and suprapubic catheter. The LVN and DON acknowledged that the treatments were not performed as required, and the sites should have been monitored for signs of infection, dislodgement, and cleaned and dressed daily. The facility's policy and procedure indicated that the charge nurse or director of nursing services should place orders for all prescribed treatments, which was not adhered to in this case.
Failure to Prevent Stage III Pressure Injury
Penalty
Summary
The facility failed to prevent the development of a Stage III pressure injury in a resident who was assessed at moderate risk for skin injury upon admission. The resident, who had intact skin at the time of admission, developed a pressure ulcer on the sacro-coccyx area. The facility did not implement the care plan intervention to turn and reposition the resident every two hours, which was crucial to relieve pressure and prevent skin breakdown. The resident's medical history included conditions such as a fracture of the greater trochanter of the right femur, osteoporosis, type 2 diabetes mellitus, and impaired mobility, which increased the risk of pressure injuries. Despite these risk factors, the facility did not adhere to its policy and procedure for skin and wound monitoring and management, which required repositioning to prevent pressure injuries. Interviews with the resident and nursing staff confirmed that the resident was not repositioned as required, leading to the development of the pressure ulcer. The deficiency was further highlighted by the lack of documentation indicating that the resident was turned and repositioned every two hours. The care plan was not updated with new interventions when the pressure injury was identified, and the facility's failure to follow its own procedures contributed to the resident's condition. The Director of Nursing acknowledged the importance of repositioning to prevent pressure injuries and confirmed that the care plan should have been updated to reflect necessary interventions.
Inappropriate Modification of RNA Programs by Unqualified Staff
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Aide (RNA) programs for two residents were modified by qualified and competent staff. For Resident 27, the RNA program was altered by two Restorative Nursing Assistants (RNA 1 and RNA 2) who independently decided to assist the resident with motorized exercise device exercises without a proper order. Despite the resident's request, they did not notify a licensed nurse or the Rehabilitation Department, which was necessary for reassessment and modification of the RNA program. The RNAs acknowledged that they were not qualified to modify the RNA program and should have followed the existing orders, which only included applying splints and performing passive range of motion exercises. For Resident 31, RNA 3 independently modified the RNA program by applying a splint to the resident's right hand without a physician's order. The resident had orders for sit-to-stand exercises, but no order for the application of a splint. RNA 3 admitted that there should have been an order for the splint application, and the Director of Staff Development confirmed that any modifications to the RNA program should be communicated to the Director of Rehabilitation for reassessment by a qualified therapist. The facility's policies and procedures clearly state that only licensed therapists are qualified to establish and modify RNA programs. The RNAs are expected to implement the RNA treatment program as ordered and are not permitted to make independent modifications. The failure to adhere to these protocols resulted in the potential for harm and injury to the residents, as the RNAs lacked the necessary qualifications and training to modify the RNA programs safely.
Failure to Update Informed Consent and Ensure Medical Diagnosis for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent for a psychotropic medication was updated for one resident, and that another resident had a medical diagnosis indicated for the use of a psychotropic medication. For the first resident, the informed consent for Seroquel, a psychotropic drug, was not updated to reflect the current order. The resident was admitted with diagnoses including bipolar disorder and anxiety disorder, and the informed consent was last signed on 2/20/2024 for a different dosage and reason than what was currently being administered. The Licensed Vocational Nurse (LVN) acknowledged that the informed consent did not match the current order, which could lead to the resident receiving medication for the wrong reasons. The interim Director of Nursing (DON) confirmed that informed consent for psychotropic medications should be updated every six months or when the order changes. The facility's policy, as well as guidance from the California Department of Public Health, requires written informed consent for psychotropic drugs and renewal every six months. The failure to update the informed consent could result in the resident receiving unnecessary medication, potentially violating their right to refuse treatment. For the second resident, the facility failed to ensure that a medical diagnosis was documented for the use of Haloperidol, a psychotropic medication. The resident was admitted with an anxiety disorder and had severe cognitive impairment. The medication was ordered for schizophrenia, but the Registered Nurse Supervisor confirmed that there was no diagnosis of schizophrenia in the resident's medical records. The Director of Nursing emphasized the importance of having a medical diagnosis to justify the use of psychotropic medications, as per the facility's policy, which prohibits administering such drugs without a documented condition.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications appropriately for three residents during a medication pass, resulting in a medication error rate of 22.58%. Resident 24 and Resident 69 were both observed swallowing chewable aspirin tablets instead of chewing them as prescribed. This error was confirmed by LVN 2, who acknowledged that swallowing the aspirin could affect its absorption and effectiveness. The Director of Nursing (DON) interim also confirmed that medications should be administered as ordered to ensure their effectiveness. Resident 140 experienced multiple medication errors during the same medication pass. The resident, who had a gastrostomy tube, was administered five different medications crushed and mixed together, contrary to the facility's policy. LVN 2 admitted that each medication should have been administered separately to monitor for any adverse reactions. The DON reiterated that medications should be given one at a time via the G-tube to ensure proper administration and monitoring. The facility's policies on medication administration were not followed, leading to these errors. The policy for administering chewable aspirin was not adhered to, and the procedure for administering medications via a feeding tube was also violated. These lapses in following established protocols contributed to the high medication error rate observed during the survey.
Failure to Administer Medications Individually via G-tube
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering medications individually via a G-tube. A Licensed Vocational Nurse (LVN) was observed crushing and mixing five different medications together before administering them to a resident through a G-tube. This practice was contrary to the facility's policy, which requires medications to be administered separately with a flush of water between each to ensure safety and effectiveness. The resident involved had a history of a stroke and was using a gastrostomy tube for medication administration. The medications in question included Losartan, Olanzapine, Paroxetine, Quetiapine, and Carvedilol, which were prescribed for conditions such as hypertension, psychotic features, depression, and mood disorders. The Director of Nursing confirmed that medications should be administered one at a time to monitor for any adverse reactions and ensure resident safety.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe handling and storage of medications for two residents. In the first instance, a registered nurse observed a medicine cup with an unidentified white pasty substance and a tongue depressor on the bedside table of a resident with severe cognitive impairment. The resident required supervision and assistance with daily activities, including eating and personal hygiene. The presence of the medication at the bedside was acknowledged by the RN as unsafe, and the Director of Nursing confirmed that leaving medications at residents' bedsides was against safety protocols. In the second instance, a licensed vocational nurse found an opened Budesonide Inhalation foil envelope without an open date in a medication cart. The medication, used for treating COPD, should be used within 14 days of opening according to the manufacturer's instructions. The absence of an open date could lead to the administration of an ineffective dose. The interim Director of Nursing acknowledged the importance of adhering to the manufacturer's guidelines to ensure the medication's effectiveness. The facility's policy on medication storage, updated in 2017, requires medications to be stored securely and according to the manufacturer's recommendations.
Deficiencies in Food Labeling and Hair Net Usage
Penalty
Summary
The facility failed to ensure proper labeling of open dates for seven seasoning containers in the kitchen. During an observation and interview, it was noted that these containers were not marked with open dates, which is necessary to ensure that food items are used before their expiration dates. The Dietary Supervisor confirmed that the facility's policy requires opened food items to be labeled with an open date. This oversight in labeling could potentially lead to the use of expired food items, posing a risk of food-borne illnesses. Additionally, the facility did not ensure that staff wore hair nets properly while handling dishes in the dishwashing area. During an observation, it was found that a Dietary Aid had exposed hair around the right ear and shoulder, which was not fully covered by a hair net. The facility's policy on dress code requires that hair nets be worn properly to prevent hair from falling into food. The Dietary Supervisor acknowledged that the Dietary Aid should have covered her hair completely to prevent contamination.
Unqualified Personnel Conduct Joint Mobility Assessments
Penalty
Summary
The facility failed to ensure that Joint Mobility Assessments (JMA) for three residents were completed by qualified personnel, specifically a Physical Therapist (PT) or Occupational Therapist (OT). Instead, an Occupational Therapy Assistant (OTA), who was also the Director of Rehabilitation (DOR), performed these assessments independently. This practice was not in compliance with the Occupational Therapy Practice Act and the California Code of Regulations, which require that such assessments be conducted by licensed therapists and not by OTAs independently. For Resident 15, who was admitted with diagnoses including quadriplegia, muscle weakness, and muscle spasms, the OTA performed the JMA independently, noting a decline in range of motion (ROM) in both knees and ankles. The OTA admitted to possibly collaborating with an OT but had no documented evidence of such collaboration. Similarly, for Resident 29, who had a left-hand contracture and muscle weakness, the OTA conducted the JMA without supervision, despite the resident's severe cognitive impairment and functional ROM limitations. The OTA confirmed that she was not qualified to perform these assessments independently. Resident 34, who had left-sided hemiplegia and hemiparesis following a cerebral infarction, also had their JMA conducted by the OTA without proper supervision. The OTA noted changes in the resident's ROM but again lacked documentation of OT involvement. Interviews with the OT and the Director of Nursing (DON) confirmed that the OTA's actions were outside the scope of practice, potentially leading to inaccurate assessments and inappropriate care recommendations. The facility's policies and procedures, as well as state regulations, clearly outlined that JMAs should be performed by licensed therapists, highlighting the deficiency in the facility's adherence to these guidelines.
Inaccurate Documentation of Restorative Nursing Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aide (RNA) services were accurately documented for two residents, leading to a deficiency in the provision of necessary care. For Resident 27, the RNAs did not accurately document passive range of motion (PROM) exercises as required by the physician's order. Despite the order for PROM exercises to be performed on both arms, the RNAs only applied splints to the resident's hands and did not perform the exercises. This discrepancy was confirmed during interviews and record reviews, where the RNAs admitted to not being aware of the PROM order and inaccurately documenting the services provided. Resident 31 also experienced a lack of accurate documentation regarding the application of a splint to the right hand. Although the resident was observed wearing the splint on multiple occasions, RNA 3 confirmed that there was no documentation to reflect the application of the splint. This lack of documentation could potentially impact the resident's care and the facility's ability to track the effectiveness of the interventions provided. The Director of Nursing (DON) acknowledged the importance of accurate documentation to reflect the services provided and the effectiveness of interventions. The facility's policy on ROM and contracture prevention emphasized the need for appropriate documentation to address program goals and resident tolerance. However, the grouped RNA orders for PROM and splinting led to confusion and inaccurate documentation, as the RNAs did not have a clear method to document when one task was completed and not the other.
Infection Control Deficiencies in PPE Usage and Documentation
Penalty
Summary
The facility failed to provide annual documentation verifying the review of their Infection Prevention and Control Program (IPCP) policies and procedures. During interviews and record reviews, it was found that the sign-in sheet for the IPCP policies updated in January 2024 was undated and lacked a title indicating which policies were reviewed. The Director of Staff Development (DSD), who was also the interim Infection Preventionist Nurse (IPN), and the Director of Nursing (DON) acknowledged the absence of proper documentation and the need to update the sign-in sheet to reflect the reviewed policies. The facility also failed to ensure that staff wore appropriate personal protective equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). Observations revealed that the DSD/IPN, a Licensed Vocational Nurse (LVN), and a Certified Nurse Assistant (CNA) did not wear isolation gowns while providing direct contact care to two residents on EBP. Resident 1, who had an indwelling medical device, and Resident 40, who had a stage 3 pressure injury, were both on EBP due to their conditions. Despite the requirement for PPE during high-contact care activities, staff were observed not adhering to these protocols. Interviews with the DSD/IPN and LVN confirmed the oversight in wearing isolation gowns during care activities. The DSD/IPN admitted to not wearing an isolation gown while providing direct care to Resident 1 and acknowledged the importance of following infection control protocols to prevent the spread of infection. Similarly, the LVN admitted to forgetting to don an isolation gown while administering wound care to Resident 40. The DON emphasized the importance of adhering to proper infection control protocols to prevent infection spread within the facility.
Failure to Conduct Quarterly IDT Care Conference
Penalty
Summary
The facility failed to conduct the quarterly Interdisciplinary Team (IDT) care conference for Resident 25, involving the resident's family member, Family Member 1 (FM 1). Resident 25 was admitted with diagnoses including type 2 diabetes, dementia, and Alzheimer's disease, and was dependent on staff for all activities of daily living due to severely impaired cognition. The last documented IDT care conference for Resident 25 was on November 14, 2023, which was confirmed to be overdue by Registered Nurse (RN) 1. FM 1 reported that the facility staff used to inform the family about the resident's care and held IDT meetings every three months, but this practice had stopped, and FM 1 could not recall the last meeting. The Director of Nursing (DON) stated that IDT care conferences were supposed to be completed on admission and quarterly to ensure family involvement in the resident's care plan. The facility's policy and procedure on comprehensive resident-centered care plans, revised in February 2023, indicated that the resident's family should participate in the development of the care plan, and every effort should be made to accommodate their availability. However, the facility failed to adhere to this policy, resulting in a violation of Resident 25 and FM 1's rights to be informed and participate in the resident's plan of care.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to assess a resident's capability to self-administer medications, which is a requirement for ensuring safe medication practices. The resident, who was diagnosed with asthma and allergic rhinitis, was observed self-administering Azelastine nasal spray, Spiriva inhalation solution, and Symbicort inhalation aerosol without documented assessment by the facility's team. The resident's medical records indicated the capacity to understand and make decisions, but there was no documentation of an assessment to determine if self-administration was appropriate. Interviews with facility staff, including the medical records director and the interim Director of Nursing, revealed that there was no documentation supporting the resident's ability to self-administer medications safely. The facility's policy requires that residents who wish to self-administer medications must be assessed by the interdisciplinary team, and the results must be recorded in the resident's medical record. The policy also states that medications authorized for self-administration should be labeled accordingly, which was not done in this case.
Failure to Obtain Consent and Order for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of physical restraints, specifically bolsters at the foot of the bed, and did not obtain informed consent or a physician's order for their use. The resident, who was admitted with diagnoses including type 2 diabetes, dementia, and Alzheimer's disease, was observed to have bolsters and side rails on their bed. While the side rails had the necessary orders, assessments, and consent, the bolsters did not. This oversight was identified during an observation and interview with a registered nurse, who acknowledged that the bolsters could be considered a restraint as they restrict the resident's movement. The Director of Nursing confirmed that any device preventing a resident's free movement requires consent, assessment, and a physician's order. The facility's policy on physical restraints, revised in February 2023, defines restraints as any device that restricts a resident's freedom of movement and requires informed consent and a physician's order. The failure to follow these procedures for the bolsters resulted in a violation of the resident's rights to be free from restraints.
Failure to Report Unknown Injury
Penalty
Summary
The facility failed to report an unknown injury of a resident to the California Department of Public Health (CDPH). The incident involved a resident with severe cognitive impairment and multiple medical conditions, including type 2 diabetes, dementia, Alzheimer's disease, and contractures. On February 9, 2023, a certified nurse assistant observed the resident's left lower leg bent inward, possibly indicating a fracture. Despite this observation, the facility's administrator did not report the incident, believing it was not reportable. This decision was contrary to the facility's policy, which requires reporting injuries of unknown source to the appropriate authorities. The resident was taken to a general acute care hospital's emergency department on February 8, 2023, where the deformity was noted, and a social work consult was conducted due to the unexplained injury. The facility's interim Director of Nursing later confirmed that unknown injuries should be reported within the legally required timeframe. The facility's policy on abuse prevention and prohibition outlines that injuries of unknown source must be reported when the source is unobserved, unexplained by the resident, and suspicious due to the injury's extent, location, or frequency.
Failure to Investigate and Report Unknown Injury
Penalty
Summary
The facility failed to investigate and report an unknown injury for a resident, identified as Resident 25, who was observed with a potentially fractured left lower leg. The incident occurred on 2/9/2023 when a CNA reported the abnormality to a supervisor, who confirmed the leg appeared bent inward. Despite this observation, the facility did not conduct a documented investigation or report the incident to the California Department of Public Health (CDPH) within the required five working days. The resident, who was nonverbal with advanced dementia, was taken to a general acute care hospital emergency department, where the injury was noted as unexplained, prompting a social work consult. The facility's policy on abuse prevention and prohibition requires that all injuries of unknown source be reported to relevant agencies and thoroughly investigated. However, during interviews, the administrator admitted to not reporting the incident, believing it was not reportable, and there was no evidence of an investigation by the previous Director of Nursing. The interim Director of Nursing acknowledged the requirement to report unknown injuries within the legal timeframe. The failure to investigate and report the injury hindered CDPH's ability to investigate the incident timely and posed a risk of other unknown injuries going unreported.
Failure to Complete PASARR Screening for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed for a resident upon their readmission on July 1, 2023. This resident, identified as Resident 55, was admitted with diagnoses of schizoaffective disorder and bipolar disorder, conditions that necessitate a Level II PASARR. The Minimum Data Set (MDS) for Resident 55, dated September 20, 2024, indicated that the resident's cognition was moderately impaired. Despite these indicators, the required PASARR screening was not conducted upon the resident's readmission. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the oversight. The ADON acknowledged that based on the resident's mental health diagnoses, a Level II PASARR was necessary, and an updated Level I PASARR should have been completed upon readmission. The DON emphasized the importance of accurate and timely completion of PASARR as mandated by law. A review of the facility's policy, revised in February 2023, reiterated the requirement for PASARR completion for every resident upon admission to ensure appropriate referrals for specialized services.
Lack of Care Plan for Splint Application
Penalty
Summary
The facility failed to initiate a care plan for a resident requiring the assistance of a Restorative Nursing Assistant (RNA) for splinting. The resident, who was admitted with diagnoses including hemiplegia and contracture of the right hand, was observed wearing a splint on multiple occasions. However, there was no documented order or care plan for the RNA to apply the splint, as confirmed by both the RNA and the Occupational Therapist (OT). The RNA stated that they performed sit-to-stand exercises and applied the splint daily, but acknowledged the absence of an order for the splint application. The OT and the interim Director of Nursing (DON) both emphasized the necessity of having an order and care plan for splint application to ensure proper frequency, duration, and technique, thereby preventing risks such as skin breakdown. The facility's policy on Comprehensive Person-Centered Care Planning requires a care plan with measurable objectives and timeframes for each resident's needs, which was not adhered to in this case. This oversight had the potential to negatively impact the resident's care and safety.
Failure to Monitor Suprapubic Catheter Site
Penalty
Summary
The facility failed to adequately monitor and document the condition of a suprapubic catheter stoma site for a resident, as ordered by the physician. The resident, who was admitted with a history of urinary tract infection and obstructive reflux uropathy, had a suprapubic catheter inserted after being initially admitted with a Foley catheter. The physician's order required monitoring for signs and symptoms of infection, skin breakdown, unusual odor, and secretions, but these were not documented in the Treatment Administration Record (TAR) for November. During an observation, a Licensed Vocational Nurse noted redness, discharge, and blood clots around the catheter site but was unsure if these were healthy signs. The nurse stated she would report these findings to the physician. The Director of Nursing confirmed that the TAR did not indicate that staff were monitoring the insertion sites for signs of infection or injury, which is crucial after surgical procedures. This lack of documentation and monitoring could delay the detection of early signs or symptoms of infection.
Failure to Provide Ordered ROM Exercises
Penalty
Summary
The facility failed to provide the necessary treatment and services to a resident to prevent a decline in joint range of motion (ROM). The resident, who was admitted with diagnoses of rheumatoid arthritis and osteoarthritis, had a physician's order for Restorative Nursing Aide (RNA) to perform passive ROM (PROM) exercises on both arms three times a week. However, the RNAs did not perform these exercises as they were unaware of the order, leading to a potential decline in the resident's physical functioning. During observations, it was noted that the resident's fingers were bent and hyperextended, indicating a lack of proper ROM exercises. The RNAs only applied splints to the resident's hands and did not perform the ordered PROM exercises. The RNAs confirmed that they were unaware of the order for PROM exercises and mistakenly believed the order was only for the application of hand splints. Interviews with the Director of Staff Development and the Director of Nursing revealed that the RNA program was designed to maintain residents' functional abilities and prevent contractures. The RNAs were expected to follow the RNA orders exactly as written, but the failure to do so could negatively impact the resident's mobility and ROM. The facility's policies emphasized the importance of providing services to maintain or improve residents' ROM and mobility, which was not adhered to in this case.
Failure to Implement Dietician's Tube Feeding Recommendations
Penalty
Summary
The facility failed to implement the Registered Dietician's recommendation to increase the tube feeding rate for a resident in a timely manner. The resident, who was admitted with diagnoses including type 2 diabetes, dementia, and gastrostomy status, was dependent on staff for all activities of daily living. The Minimum Data Set indicated the resident's cognition was severely impaired. Despite the Registered Dietician's recommendation on 10/24/2024 to increase the tube feeding rate to 60 cc per hour to meet the resident's nutritional needs, the tube feeding was observed to be running at 50 cc per hour on 11/5/2024. The Dietary Supervisor confirmed that the Registered Dietician's recommendations should have been followed to prevent weight loss and ensure the resident's nutritional needs were met. The Director of Nursing stated that the dietician's recommendations should be followed if the physician agrees. The facility's policy on Nutrition Status Management, revised in 12/2023, requires the assessment of each resident's nutritional status and the maintenance of acceptable parameters such as body weight. However, the failure to adjust the tube feeding rate as recommended by the dietician was not in compliance with this policy.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses including depression and PTSD, had a federally mandated assessment indicating moderate cognitive impairment and varying levels of assistance required for daily activities. However, upon review of the resident's medical records, it was found that there were no trauma-informed care plans or assessments in place. The Assistant Director of Nursing confirmed the absence of documented evidence of trauma assessment, identification of triggers, or personalized interventions for the resident's PTSD. Interviews with facility staff, including the Director of Nursing, revealed that the facility's policy required the development of individualized trauma-informed care plans for residents with PTSD to prevent re-traumatization. Despite this policy, the necessary assessments and care plans were not implemented for the resident in question. The facility's policy emphasized the importance of providing culturally competent trauma-informed care, including the identification of triggers and specific interventions to mitigate their effects, but these measures were not in place for the resident.
Deficiency in Resident Room Size Standards
Penalty
Summary
The facility failed to ensure that resident rooms met the required space standards, specifically providing at least 80 square feet per resident in multiple resident rooms. During a review of the facility's client accommodation analysis form, it was found that several rooms, accommodating three residents each, measured only 223 square feet, and rooms accommodating two residents each measured 144 square feet. This deficiency was identified through observation, interviews, and record reviews, indicating a potential impact on residents' quality of life, safety, health, and provision of care. The Administrator acknowledged the issue during an interview, stating that a room waiver had been requested for 36 rooms, asserting that it would not adversely affect residents' health or safety. Observations conducted over several days did not reveal any immediate issues with residents' needs, health, or safety due to the room sizes. The Department recommended the continuation of the room waiver.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary psychotropic medications, leading to over-sedation and multiple falls. The resident was prescribed and administered Ativan, Seroquel, and Risperdal without documented indications for their use. The resident received Ativan 1 mg every four hours for agitation and shortness of breath for 14 days, along with other psychotropic medications, causing over-sedation. Additionally, the resident was prescribed two antipsychotic medications simultaneously, which were not indicated for use in residents with vascular dementia and Alzheimer's disease. The facility did not adequately monitor the resident's condition or notify the attending physician when there was a change in the resident's condition. The resident experienced four falls during the period of medication administration, resulting in injuries such as a concussion and a hematoma. The facility also failed to provide informed consent for the increase in Ativan dosage, and the licensed nurses did not document or report the resident's change of condition or adverse effects from the medications. The facility's policies and procedures regarding psychotropic medication administration and monitoring were not followed. The licensed nurses did not verify informed consents, monitor for adverse side effects, or document the resident's behavior and response to the medications. The lack of coordination between the facility's nursing staff and the hospice team further contributed to the resident's over-sedation and falls.
Failure to Inform and Obtain Consent for Medication Change
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident was informed and provided consent when there was a change in the dosage and frequency of the resident's medication, Ativan, which is used to treat anxiety. The resident, who had severe cognitive impairment and required significant assistance with daily activities, was initially prescribed Ativan 0.5 mg every four hours as needed. This dosage was later increased to 1 mg every four hours without the RP being properly informed or consent being obtained, as required by the facility's policy. The RP was only informed of the resident's increased agitation and gave consent for a PRN increase, but was not aware of the regular dosage change. During a visit, the RP noticed the resident was excessively sedated and expressed concerns about overmedication. Interviews with facility staff revealed confusion about who was responsible for obtaining consent for medication changes, and the facility's policy clearly stated that consent should be obtained prior to administering new or changed psychotropic medications. This oversight had the potential to lead to unnecessary medication administration and adverse effects.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for one of the residents, resulting in a deficiency. The resident, who had a history of chronic obstructive pulmonary disease, chronic kidney disease, and anemia, was found with a reddish-purple discoloration on the left arm and right rib flank. Despite the resident's ability to make independent decisions, they were unaware of how the discoloration occurred. The incident was not reported to CDPH, preventing a timely investigation. Interviews with staff revealed that the resident had an altercation involving a pair of scissors, during which their wheelchair almost tipped over. The resident later alleged being attacked by staff, and further skin evaluations showed additional discoloration. The Director of Nursing Services attributed the bruising to the resident's medical history, including anticoagulant and steroid therapy, and did not report the incident. The facility's policies required reporting such occurrences, but this was not adhered to, leading to the deficiency.
Failure to Investigate Alleged Abuse and Unexplained Injuries
Penalty
Summary
The facility failed to conduct an investigation for a resident who reported being attacked by nursing staff and exhibited reddish-purple discoloration on the left arm and right rib flank area. The resident, who was admitted with chronic obstructive pulmonary disease, chronic kidney disease, and anemia, was able to make independent decisions according to the Minimum Data Set. Despite the resident's report of an attack and visible discoloration, the facility did not investigate the cause of the injuries. Interviews with staff revealed that the resident had an incident involving a pair of scissors, during which a Licensed Vocational Nurse (LVN) intervened to prevent the resident from falling. The resident later alleged an attack by nursing staff, and a subsequent skin evaluation noted new discoloration. The Director of Nursing Services acknowledged the new discoloration but attributed it to the resident's medical history, including anticoagulant and steroid therapy. However, the facility's policy required a prompt investigation of such allegations, which was not conducted, as indicated by the absence of an investigation in the clinical record.
Failure to Account for Resident's Belongings Upon Discharge
Penalty
Summary
The facility failed to ensure that all items on the inventory list for a resident were accounted for upon discharge. The resident, who had a fluctuating capacity to understand and make decisions, was admitted with diagnoses including schizoaffective disorder, mood disorder, and depression. Upon discharge, the facility did not review or sign the resident's inventory list with the resident's Power of Attorney (POA), which is a legal authorization for a designated person to make decisions about another person's property, finances, or medical care. This oversight resulted in the inability to verify if the resident's belongings were accounted for before being handed over to the POA. The Social Service Director (SSD) did not review the inventory list with the POA when the resident's belongings were picked up, leading to the discovery that the resident's cell phone was missing. The POA was unaware of the facility's process and did not check the belongings at the time of collection. The facility's policy and procedure titled "Theft & Loss" required that personal effects and valuables be inventoried and surrendered upon discharge in exchange for a signed receipt, which was not followed in this case. This deficiency had the potential to affect the accountability of other residents' property as well.
Failure to Timely Report Missing Debit Card
Penalty
Summary
The facility failed to report the missing debit card of a resident to the California Department of Health (CDPH), the State Long Term Care Ombudsman, and the local police department within the required 24-hour timeframe. This deficiency was identified when it was discovered that the resident's debit card had been used for unauthorized transactions totaling approximately $11,254.00 over several months. The resident, who had a fluctuating capacity to understand and make decisions due to schizoaffective disorder and other mental health conditions, was not residing at the facility when the misuse of the debit card was reported by the Power of Attorney (POA) to the Social Services Director (SSD). The POA initially informed the SSD about the missing debit card on May 14, 2024, but the SSD did not report the issue to the necessary authorities or the facility's administration until May 28, 2024, 14 days later. The SSD believed that since the resident was no longer at the facility, there was no need to report the missing card. However, the SSD later acknowledged that an investigation should have been conducted to prevent potential misuse of other residents' debit cards. The delay in reporting resulted in a lack of timely investigation by the CDPH and other authorities. The facility's administrator was not made aware of the missing debit card until June 14, 2024, a month after the initial report by the POA. The administrator was unaware of the requirement to report the missing card because the resident was no longer at the facility. The facility's policy, revised in October 2022, mandates that all alleged violations involving misappropriation of resident property be reported immediately, but not later than 24 hours if the event does not involve abuse or result in serious bodily injury.
Fall Risk Management and Communication Deficiencies
Penalty
Summary
The facility failed to ensure the safety of residents assessed as high risk for falls, leading to serious consequences for several residents. Resident 1, with a history of falls and assessed as high risk, suffered a fall resulting in head trauma, intracranial hemorrhage, and subsequent surgical interventions. Preventative measures such as landing mats and bed alarms were not implemented as per the care plan. Additionally, staff, including LVN 1, lacked knowledge of Resident 1's fall risk and care plan interventions, highlighting a breakdown in communication and training within the facility. Similarly, Resident 3, assessed as a high fall risk due to a history of seizures, did not have their bed in the lowest position as care planned, potentially exposing them to fall-related injuries. Resident 4, also assessed as high risk for falls, did not have their bed in the lowest position as required, indicating a systemic issue in implementing fall prevention measures for residents at risk. The facility lacked a clear protocol for identifying high fall risk residents and ensuring appropriate interventions were in place, leading to inadequate supervision and preventative measures for vulnerable residents.
Failure to Address Fall Incidents in QAPI Meetings
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to identify and address falls as a current issue in their QAPI meetings. Despite having multiple fall incidents over a three-month period, including four falls in January, three falls in February, and eight falls in the first half of March, the committee did not consider falls a significant issue. The Administrator stated that the facility compared its fall incidents to surrounding facilities and determined that their numbers were lower, thus not warranting inclusion in the QAPI plan. The facility's policy and procedure for QAPI, revised in January 2022, emphasizes the importance of continually assessing performance to deliver person-centered care. However, the QAPI meeting minutes from February 28, 2024, did not reflect any discussion or action plans regarding the fall incidents. This oversight had the potential to affect all 21 residents assessed as high fall risks, as the facility did not systematically implement and evaluate measures to prevent falls and ensure resident safety.
Failure to Conduct Timely IDT Care Conference After Resident Readmission
Penalty
Summary
The facility failed to ensure an Interdisciplinary (IDT) Care Conference meeting was held following the readmission of a resident from a General Acute Care Hospital (GACH). The resident, who had multiple diagnoses including epilepsy, dementia, and hemiplegia, was readmitted to the facility after experiencing syncope during dialysis. Despite being assessed as a high fall risk, the facility did not conduct an IDT Care Conference within seven days of the resident's readmission, as required by their policy. This failure violated the resident and their responsible party's right to participate in the development and implementation of the resident's person-centered plan of care. The resident's medical records indicated that the last IDT Care Conference was conducted on 12/26/2023, and no further conferences were held after the resident's readmission on 1/19/2024. The resident's responsible party had requested specific fall prevention interventions, such as bed alarms and fall mats, after the resident sustained multiple falls. However, these interventions were not implemented, and the facility did not schedule a care conference to address these concerns. During an interview, the Social Services Director acknowledged that an IDT Care Conference should have been conducted within seven days of the resident's readmission. The facility's policy on Comprehensive Person-Centered Care Planning requires the IDT to develop a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's needs. The failure to hold the required care conference delayed the discussion of needed care and services for the resident, thereby compromising the resident's care plan and safety.
Failure to Administer Prescribed Skin Treatment
Penalty
Summary
The facility failed to ensure that a resident with physician's treatment orders for skin scratches received the prescribed treatment. Resident 5, who had diagnoses including malignant neoplasm of the ovary, weakness, and aphasia, was admitted to the facility with hospice care. The resident was totally dependent on staff for daily activities and was incontinent of urine and stool. On 2/27/2024, treatment orders were placed to cleanse and apply triple antibiotic ointment to scratches on the resident's left buttocks and abdomen. However, the treatment administration records for February and March 2024 indicated that no treatments were provided for the resident's skin scratches. Interviews with facility staff revealed a lack of awareness and follow-through regarding the new treatment orders. The Treatment Nurse (TN) 1 and TN 2 both stated they were not aware of the new orders. The hospice RN 3 confirmed that the hospice LVN 5 had notified the facility's LVN 4 about the scratches and the treatment orders. However, LVN 4 admitted that she did not assess the resident's skin or follow up to ensure the new orders were received and transcribed. The Assistant Director of Nursing (ADON) stated that it is the responsibility of the licensed nurses to transcribe and carry out all physician's orders, and failure to do so results in residents not receiving necessary care. The facility's policies and procedures were reviewed, indicating that the charge nurse or the Director of Nursing (DON) is responsible for placing orders for prescribed medications and treatments. The policy on Skin and Wound Monitoring and Management emphasized that nursing staff should administer treatment to affected areas as per the physician's order. Despite these policies, the facility failed to provide the necessary treatment for Resident 5's skin scratches, leading to a deficiency in care.
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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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