California Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 6700 Sepulveda Blvd., Van Nuys, California 91411
- CMS Provider Number
- 056149
- Inspections on file
- 67
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at California Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident lacking decision-making capacity had extensive PHI, including PASSR screening, H&P, MD/NP progress notes, MARs, MD orders, nursing and therapy notes, care plans, NOMNC, insurance eligibility, and consent/hospital records, copied to an unencrypted, non–password-protected USB drive after the authorized representative requested a complete medical record. The MRD mailed the USB via certified mail when email transmission failed due to file size, and the envelope was later returned torn open and without the USB, resulting in unauthorized exposure of the resident’s PHI despite a facility policy requiring protection of PHI privacy.
The facility lacked a policy and procedure governing the use of USB drives for transmitting PHI, leading to an incident in which a resident’s complete medical record was saved to an unencrypted, non–password-protected USB drive and mailed to the resident’s authorized representative. After email transmission failed due to large file size, the MRD used a USB drive containing the resident’s medical records, medical record number, insurance details, residency dates, and share of cost, and sent it by certified mail. The envelope was later returned torn open with the USB drive missing. The ADM acknowledged that existing PHI policies were outdated and did not address USB drives or current technology.
A resident with malignant neoplasm, muscle weakness, and impaired mobility expressed a preference, through IDT discharge planning, to return to the community, with the goal of transfer to an assisted living or board and care closer to a family member. The family member requested a specific receiving facility and provided its name to social services. The Social Services Director sent clinical information to that facility, which declined admission, but did not inform the family of the denial and did not offer alternative facility options or referrals to community agencies or support services. This inaction conflicted with the facility’s discharge policy requiring resident/representative involvement in discharge planning and referrals to local agencies when a resident is interested in returning to the community.
A resident with malignant neoplasm, muscle weakness, and impaired mobility had intact cognition and documented preferences for activities such as exercise, TV, music, and spiritual visits. The activity assessment noted that recreation staff provided an activity calendar and discussed potential group activities. A family member reported the resident stayed in bed all day without activities. The AD stated that activity staff greet residents daily, offer group activities, and provide documented room visits for those who do not attend groups. However, review of the electronic records showed no documentation of room visits or activities for this resident over an extended period, and the AD admitted she had conducted room visits on the resident’s unit but failed to document them, contrary to facility policies requiring complete and accurate charting of services provided.
A resident with cognitive impairment and full dependence on staff for personal care was unable to alert staff for assistance due to a non-functional call light above their door. The issue was confirmed by both a CNA and the DON, and facility policy requiring regular checks of the call system was not followed.
Several residents with severe cognitive impairment and total dependence on staff were found to have damaged bed rail padding and a broken wall molding in their rooms. The damaged padding was ripped and gouged, exposing porous foam and bed rails, while the wall molding behind a resident's bed was missing a piece. Staff confirmed that these issues had not been reported or repaired as required by facility policy, resulting in an environment that was not safe, clean, or comfortable.
Two residents with significant medical needs were found with both upper and lower bed side rails raised, despite only having consent and physician orders for upper rails. Required assessments and consents for lower rail use were not completed, and staff confirmed this practice was against facility policy and could be considered a restraint.
Two residents did not receive accurate assessments: one was incorrectly coded for schizophrenia in the MDS despite being in a persistent vegetative state and lacking supporting documentation, while another had hearing impairment that was not properly documented or followed up, resulting in delayed access to hearing aids and services. These assessment failures led to inaccurate care planning.
Two residents did not have updated, comprehensive care plans to address significant clinical needs: one with a stage II pressure ulcer did not have a care plan for wound care and treatment, and another with a recent diet order change did not have a care plan reflecting the new mechanical soft diet. Staff were unaware of these changes due to the lack of updated care plans, contrary to facility policy requiring timely and person-centered care planning.
A resident with significant medical issues and documented hearing impairment was not provided with timely access to audiology services or hearing aids, despite an active order and recommendations from an ENT. Missed and cancelled appointments, lack of in-house audiology services, and incomplete assessments contributed to the resident waiting approximately six months without needed hearing support.
Multiple residents at high risk for falls and injury did not receive required safety interventions, including the absence of physician-ordered floor mats at the bedside for two residents, a resident with ripped bed rail padding exposing a hard surface, and another resident with incomplete fall risk assessments. Staff and DON confirmed these deficiencies, and facility policies requiring such interventions were not followed.
The facility did not reconcile controlled medications in two emergency medication kits at every shift, as required by policy. Both a medication room and a medication cart were found to have eKITs containing controlled substances without accountability logs for shift-by-shift reconciliation. Nursing staff confirmed the lack of reconciliation and documentation, which was inconsistent with facility procedures for controlled medication handling.
Two residents experienced medication errors when a nurse administered a blood pressure medication outside the prescribed time window and another nurse failed to give a stool softener as ordered and provided the wrong type of multivitamin. These actions resulted in a medication error rate above 5%, contrary to facility policy and physician orders.
Surveyors found that staff failed to remove and discard expired or improperly stored medications, including insulin and Procrit, for three residents. An opened insulin pen was kept past its expiration date, another insulin vial was stored without an open date and at the wrong temperature, and a single-dose Procrit vial was not discarded after use. Nursing staff and the DON confirmed these medications were not handled per policy, and facility procedures require proper labeling, storage, and timely disposal of such medications.
Staff failed to consistently prepare and serve food at required temperatures, with hot foods served below 135°F and cold foods above 40°F. Dietary staff did not always check or record food temperatures, and some items were left at room temperature before service, placing many residents on regular, therapeutic, and puree diets at risk.
Staff prepared pureed pasta for residents on a pureed diet without measuring thickening agents, resulting in a sticky, lumpy texture that did not meet required standards. Dietary staff and the RD confirmed the food was not smooth as required by policy and IDDSI guidelines, potentially affecting 18 residents who require pureed diets due to chewing and swallowing difficulties.
Multiple deficiencies were identified in dietary services, including unlabeled and undated opened frozen foods, unsanitary kitchen equipment and storage areas, damaged and rusted shelving and utensils, improper staff hygiene practices such as wearing jewelry and nail polish during food preparation, improper storage of dented cans, wet stacking of clean dishware, lack of separation between clean and dirty areas, and failure to monitor freezer temperatures. These issues were confirmed through direct observation and staff interviews.
Soiled gloves, empty bottles, and other trash were found scattered around the dumpster area, with both the Dietary Supervisor and Maintenance Director acknowledging the issue and its potential to attract pests and spread illness. Facility policy and food code require daily waste disposal and cleanliness of the area, which was not maintained.
A resident with significant mobility limitations did not receive restorative nursing aide (RNA) services in accordance with physician orders, as documentation showed that passive range of motion (PROM) was not provided to both legs as required. Instead, the RNA provided active assistive range of motion (AAROM) to both arms and the right leg, and PROM only to the left leg. This discrepancy was confirmed through record review, observation, and staff interviews, and the facility lacked a policy to ensure medical record accuracy.
Surveyors found that staff did not consistently follow Enhanced Barrier Precautions during high-contact activities with residents at high risk for infection, such as those with tracheostomies, in the therapy gym. Staff also improperly cleaned cloth gait belts with disinfectant wipes not intended for porous surfaces, allowed oxygen tubing to touch the floor, and stored urinals on trash cans. Additionally, foam bed rail padding was found to be damaged and not cleanable, and medical supplies were stored in a dirty room with personal items on top and boxes on the floor, all contrary to facility policy.
Surveyors found that the therapy gym did not have adequate space or properly maintained equipment to meet residents' needs. One therapy mat was broken and used for storage, some therapy equipment was damaged or not in use, the only available ultrasound gel was expired, and an oxygen concentrator lacked service documentation. The Director of Rehabilitation confirmed these deficiencies during interviews and observations.
A resident admitted with neurological and mobility impairments did not have a comprehensive MDS assessment completed within the required timeframe. The MDS lacked the RN Assessment Coordinator's signature, and the MDSC confirmed the assessment was incomplete due to unsubmitted sections from various departments. The resident, who was alert and seeking rehabilitation to return home, had a history of brain surgeries and mobility challenges.
A resident with multiple medical conditions expired, and the required discharge MDS assessment was not completed or submitted to CMS within the mandated timeframe. Both the MDS Coordinator and DON confirmed the lapse, and facility policy review supported the requirement for timely submission.
A resident with multiple diagnoses, including neurogenic bladder requiring an indwelling catheter, was readmitted and did not have catheter care addressed in the baseline care plan within 48 hours as required. Physician orders specified daily catheter care, but the baseline care plan omitted this need, as confirmed by interviews with the ADON and DON and review of facility policy.
A resident with severe cognitive impairment and total dependence on staff had their restraint freedom splint discontinued by physician order, but the care plan was not updated to reflect this change. Both the SD and DON confirmed that the care plan should have been revised after the change in condition, in accordance with facility policy.
A resident with cognitive impairment and a primary language of Chinese was not provided with a communication board or device in her preferred language, despite being dependent on staff for ADLs and having a care plan that called for such support. Staff and the resident confirmed the absence of the device, leading to communication challenges and reliance on gestures to express needs.
A resident who had an indwelling catheter removed and subsequently became more alert and mobile was not reassessed for a bladder retraining program, despite being observed as continent and expressing interest in such a program. Facility staff did not repeat the required screening or update the care plan to reflect the resident's improved condition, contrary to facility policy.
A resident with a gastrostomy tube did not receive required daily site care and dressing as ordered, despite documentation indicating the care was completed. Multiple staff observations confirmed the absence of a dressing on the site, and the nurse responsible could not account for its removal. The DON confirmed that care must be documented immediately after completion and that the absence of a dressing means the care was not performed.
A resident with chronic respiratory failure was administered oxygen at a rate higher than the physician's order, with unlabeled oxygen tubing and an empty humidifier. Staff confirmed the oxygen tubing was not labeled with the date and time of last change, and the humidifier was not maintained as required by facility policy. These actions did not comply with physician orders or established procedures.
A resident with a history of cancer and post-surgical pain received as-needed oxycodone without documented attempts of non-pharmacological pain interventions, despite physician orders and facility policy requiring such steps. Nursing staff and the DON confirmed that these interventions were not always tried or documented before administering pain medication.
A resident with end stage renal disease and a right upper chest quinton catheter for hemodialysis did not receive required monitoring of the dialysis access site as outlined in the care plan, with no documentation found in the MAR. Additionally, staff failed to implement a physician’s order for fluid restriction, as a water pitcher and other fluids were observed at the bedside despite orders and facility policy to the contrary. These failures were confirmed by staff interviews and record reviews.
A resident with severe cognitive impairment and multiple diagnoses did not receive a required quarterly social service assessment as mandated by facility policy. The Social Service Director acknowledged the assessment was missed due to workload, and both the SSD and DON confirmed the requirement for quarterly and annual social service assessments.
A resident with significant mobility impairments and a goal of regaining ambulation with a single point cane did not receive a timely PT evaluation as ordered by the physician. The facility delayed the evaluation while waiting for insurance authorization, despite facility policy not requiring such a delay, and the order was not submitted for review promptly. The resident continued to receive restorative nursing interventions but did not receive the specialized PT assessment needed to determine further therapy needs.
A resident with significant medical needs continued to receive hospice services after the responsible party requested discontinuation, due to the facility's failure to designate a coordinator for hospice care, lack of documentation, and poor communication between the Social Service Director, hospice agency, and other staff.
A deficiency was found when a fly was observed in the kitchen, including the preparation and trayline areas, with the insect landing on a dessert rack. The Dietary Supervisor confirmed the last pest control visit was the previous month and acknowledged the risk of disease transmission. Review of facility policy and the Food Code showed the requirement for ongoing pest control and regular inspections, which was not met in this instance.
The facility failed to document weekly skin assessments for two residents at risk for pressure ulcers, as required by policy. Both residents had significant risk factors, including reduced mobility and cognitive impairments. The lack of documentation in the Licensed Nurses Notes meant the facility could not verify that the residents' skin was assessed weekly, potentially delaying necessary treatments.
A resident with a history of falls and dementia experienced a fall and elevated WBC, but the facility failed to update the care plan following these changes. Despite being at high risk for falls, the care plans were not revised after the incident, as required by the facility's policies. Interviews with staff confirmed the oversight, highlighting a deficiency in care plan management.
A resident with a history of falls and dementia experienced a fall in the facility, but staff failed to complete a fall risk assessment as required by the facility's policy. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, fell from the bed and was later hospitalized. Despite the resident's high fall risk score, the necessary assessment was not conducted upon their return, as confirmed by the ADON and DON.
A resident with multiple health conditions and moderately impaired cognition was not communicated with regarding his preferred shower time on a scheduled shower day. The CNA assigned to him did not discuss his ADL care preferences due to a busy schedule, contrary to facility policy, which emphasizes promoting residents' well-being and dignity.
A resident was not readmitted to the facility after hospitalization despite being cleared for discharge and a bed being available. The facility's administrator prioritized other residents over the returning resident, contrary to the facility's policy that prioritized readmission upon bed availability. Interviews confirmed the facility's census showed an available bed, but the request was declined.
A resident with hemiplegia and brain damage had worsening blisters on their hand that were not documented by a CNA, despite facility policies requiring such documentation. The CNA marked the resident's skin as 'OK' on the Daily Body Check Report, contrary to observations made by an RN. This failure to document and report skin integrity issues could have affected the resident's care.
A resident with cerebral infarction and hand contractures was not provided with a prescribed left-hand splint, as required by their care plan and physician's orders. Despite the facility's policy and the resident's care plan indicating the need for both hand splints to prevent further contractures, observations showed that the resident's hands were contracted, highlighting a failure in implementing necessary interventions.
Two residents with severe cognitive impairments and physical limitations were found with dirty fingernails, despite care plans indicating the need for assistance with grooming. The facility failed to adhere to its policy on supporting activities of daily living, leading to deficiencies in maintaining proper grooming standards.
A facility failed to ensure proper infection control practices when two therapy staff did not wear isolation gowns while treating a resident under enhanced standard precautions due to medical devices and a wound. The resident had a complex medical history and was dependent on staff for daily activities. Signage indicating the need for precautions was present but not followed, risking infection spread.
A resident with impaired cognition and vision, dependent on staff for daily activities, had their call light placed out of reach, contrary to the facility's policy. This was confirmed during an observation by the Infection Preventionist Nurse, highlighting a failure to accommodate the resident's needs.
A resident with impaired cognition and vision, dependent on staff for daily living activities, was found with dirty fingernails, indicating a failure in maintaining personal hygiene. The facility's staff acknowledged the issue, and the DON confirmed the responsibility of nursing staff to ensure cleanliness. The facility's policy requires support for residents unable to perform daily activities independently.
A facility failed to ensure Physician Progress Notes were completed for a resident with cerebrovascular disease, a skull fracture, and seizures. Despite scheduled ENT and hearing aid appointments, no corresponding notes were found in the resident's records. This was confirmed by an LVN and the DON, who acknowledged the facility's failure to receive these notes on the day of the visits, contrary to OBRA regulations.
The facility failed to attempt non-pharmacological interventions before administering narcotic pain medication to a resident with a femur fracture and did not provide prescribed pain medication to another resident due to unavailability. The facility's policies on pain management and medication ordering were not followed, leading to inadequate pain management.
The facility failed to ensure non-pharmacological interventions were attempted before administering lorazepam to two residents. One resident with anxiety disorder and another with dementia received the medication multiple times without documentation of alternative interventions. The DON emphasized the importance of trying non-pharmacological methods first to minimize medication use and potential side effects.
A facility failed to ensure a window screen in a resident's room was properly affixed, resulting in a gap that could allow insect entry. The issue was identified during a facility tour, with the ADON confirming the gap and acknowledging the potential hazard. Despite regular inspections to maintain a safe environment, this deficiency indicated a lapse in the facility's maintenance and inspection processes.
Unencrypted USB With Resident PHI Lost in Mail
Penalty
Summary
The facility failed to protect the confidential personal and medical information of one resident by copying the resident's complete facility records onto an unencrypted USB drive and mailing it to the resident's family member. The resident had been admitted with diagnoses including malignant neoplasm of the ribs, chronic obstructive respiratory failure, and autistic disorder, and a History and Physical documented that the resident did not have the capacity to understand and make decisions. The resident's authorized representative requested copies of the complete medical record, including medical charts, nursing notes, MARs, physician orders, care plans, incident reports, therapy notes, vital signs, admission/transfer/discharge records, and internal communications related to care. The Medical Records Director attempted to send the requested records via email, but the files were too large, so she saved all requested documents to a USB flash drive that was not password protected or encrypted and mailed it via certified mail to the address provided by the family member. The envelope containing the USB drive was later returned to the facility marked "Return to Sender; Attempted - Not Known Unable to Forward" and was torn open, with the USB drive missing. The Administrator confirmed that the USB drive with the resident's medical records was lost in the mail and that it was not encrypted or password protected, resulting in an unauthorized exposure of the resident's PHI. The information on the USB drive included the resident's Level 1 PASSR screening, insurance eligibility, History and Physical, MD/NP progress notes, all electronic health records (including admission record, MD orders, MAR, nursing progress notes, social services notes, dietary notes, change of condition documentation, IDT meeting notes, and care plans), rehabilitation notes, NOMNC, and copies of the physical paper chart such as consent forms and hospital records. The facility's Privacy Notice policy required the facility by law to maintain the privacy of PHI.
Loss of Unencrypted PHI on USB Drive Due to Lack of Policy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a policy and procedure governing the use of USB drives for transmitting Protected Health Information (PHI). The governing body was responsible for establishing and implementing policies for managing and operating the facility and for appointing an administrator to manage the facility. The Medical Records Director (MRD) received an email request from a resident’s authorized representative for copies of the resident’s complete medical record. The MRD initially attempted to send the requested records via email, but the files were too large to transmit. The MRD then saved all requested medical record documents onto a USB flash drive and mailed it via certified mail to the address provided by the authorized representative. The USB drive contained the resident’s medical records, medical record number, payor/insurance provider and eligibility information, residency dates at the facility, and share of cost. The facility later received the envelope back marked “Return to Sender; Attempted – Not Known Unable to Forward,” and the envelope was torn open with the USB drive missing. The MRD stated the USB drive was not password protected and confirmed there was no policy or procedure addressing the use of USB drives to send PHI. The Administrator reported that, after learning of the lost unencrypted USB drive, he reviewed the facility’s PHI-related policies and found they were outdated and did not address the use of USB drives or current technology, and acknowledged that if USB drives were being used to send PHI, there should have been a policy requiring password protection.
Failure to Inform Family of Transfer Denial and Provide Discharge Planning Resources
Penalty
Summary
The facility failed to provide required referrals to local agencies and support services for discharge planning and failed to notify a resident’s representative of a denial of admission from a preferred receiving facility. One resident was admitted with malignant neoplasm of the ribs, sternum, and clavicle, along with muscle weakness and difficulty walking. An MDS assessment showed the resident had intact cognition, required setup or clean-up assistance with eating, and was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. An IDT discharge planning note documented that the resident preferred to return to the community, with a plan to locate an assisted living facility or board and care. During discharge planning, the resident’s family member informed social services staff that she wanted the resident discharged to a facility closer to her home, which was more than three hours away, and she provided the name of a specific facility. The Social Services Director acknowledged receiving this request and documented in the IDT discharge planning record that the plan was to discharge the resident to a facility near the family member. The Social Services Director faxed the resident’s clinical information to the requested facility and received a response the next day indicating that the facility was unable to admit the resident. Despite receiving the denial, the Social Services Director did not inform the family member that the preferred facility had declined admission and did not provide names of other facilities or community resources to assist with identifying alternative placement closer to the family member. The Social Services Director stated that she did not provide additional resources or support for discharge planning and acknowledged that it was her responsibility to do so. The Administrator stated that IDT meetings are used to coordinate necessary services for safe discharge and that the Social Services Director should have assisted the family in finding an appropriate facility closer to them and informed the family of the denial, consistent with the facility’s discharge policy requiring involvement of the resident/representative and referrals to local agencies when there is interest in returning to the community.
Failure to Document Activity Services in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate clinical records for one resident by not documenting activities and room visits as required by policy and accepted professional standards. The resident was admitted with malignant neoplasm of the ribs, sternum, and clavicle, muscle weakness, and difficulty walking, and had intact cognition per the MDS. The MDS also showed the resident required setup or clean-up assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. An activity assessment identified the resident’s preferred activities as exercise/sports, watching TV, music stimulation, book tapes, talking/conversing, and spiritual visits, and indicated that recreation staff provided an activity calendar, informed the resident where recreation materials were available, and discussed which groups he might like to attend. A family member reported that the resident remained in bed in his room all day with no activities. The AD stated that each of the four nursing stations had an activity assistant, that activity staff greet residents daily, review the activity calendar, and conduct room visits for residents who do not attend group activities, and that room visits are to be documented in the facility’s computer system. However, upon review of the resident’s documentation survey report for independent activity and room visits, the AD confirmed there was no documented evidence of room visits by activity staff for this resident from admission through the review period. The AD acknowledged that she conducted room visits on the resident’s unit but did not document the activities provided and stated there was no excuse for not documenting, despite facility policies requiring that health services and progress toward care plan goals, as well as changes in the resident’s condition, be documented in the medical record to facilitate communication among the interdisciplinary team.
Non-Functional Call Light Prevents Resident from Requesting Assistance
Penalty
Summary
A deficiency was identified when the call light above a resident's door was found to be non-functional, preventing the resident from alerting staff when assistance was needed. During an observation and interview, it was noted that pressing the call button did not activate the light above the door, as confirmed by a CNA. The Director of Nursing also acknowledged that the call light was not working and should have been repaired to ensure proper notification of staff. The affected resident had been admitted with diagnoses including Parkinson's Disease, spinal stenosis, and elevated white blood cell count. According to the Minimum Data Set, the resident was cognitively impaired and fully dependent on staff for toileting, showering, bathing, personal hygiene, and footwear. Facility policy required regular checks of the call system to ensure functionality, but this was not adhered to in this instance, resulting in the deficiency.
Failure to Maintain Safe and Homelike Environment Due to Damaged Equipment and Fixtures
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents by not repairing or replacing damaged equipment and room fixtures as required. Specifically, one resident with multiple diagnoses including multiple sclerosis, diabetes, and dementia, who was totally dependent on staff for all activities of daily living and had severe cognitive impairment, was found to have a broken wall molding with a piece missing behind their bed. This issue was confirmed by both the DON and the Administrator during observations and interviews, who acknowledged that the damage had not been reported to the Maintenance Department as required by facility policy. Additionally, three other residents with severe cognitive impairments and total dependence on staff for daily activities were found to have bed rails covered with black foam padding that was ripped, gouged, and in poor repair. The exposed porous foam and bed rails were observed during a walk-through with the Subacute Director, who stated that while the padding is changed regularly, there is no set schedule for replacement. The DON confirmed that the damaged padding could potentially harbor bacteria and that all equipment should be in good repair for safety purposes. The facility's own policy and procedure on maintaining a homelike environment, last reviewed in July 2024, requires that residents be provided with a safe, clean, and comfortable environment. Despite this, the facility did not ensure timely repair or replacement of damaged wall molding and bed rail padding, as evidenced by direct observations and staff interviews.
Failure to Assess and Obtain Consent for Bed Rail Use Resulting in Physical Restraint
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints by not performing required assessments and not obtaining proper physician orders prior to the use of bed rails. Specifically, two residents were found with both upper and lower side rails raised on their beds, despite only having consent and physician orders for the use of upper side rails. Facility policy requires a comprehensive assessment, informed consent, and physician order before implementing bed rails, as well as consideration of alternatives and evaluation of potential risks such as entrapment. For one resident, who had diagnoses including metabolic encephalopathy, acute respiratory failure with hypoxia, and congestive heart failure, records showed dependency on staff for all activities of daily living and limited mobility. Although there was informed consent for upper side rails, observations revealed that both upper and one lower side rail were up. Facility leadership confirmed that the lower side rail should not have been raised without proper assessment and consent, as it could be considered a restraint and posed a risk of entrapment. A second resident, admitted with conditions such as adult failure to thrive, dysphagia, and major depressive disorder, also required substantial assistance with daily activities. This resident had a physician's order and informed consent for bilateral upper half side rails only. However, during observation, both upper and one lower side rail were found raised. Staff interviews confirmed that the lower side rail should not have been up and could be dangerous. Review of facility policies reiterated that bed rails are prohibited unless all criteria, including assessment and consent, are met.
Failure to Accurately Assess and Document Resident Needs
Penalty
Summary
The facility failed to ensure accurate and comprehensive assessments for two residents, resulting in deficiencies related to both hearing and mental health diagnoses. For one resident, the Admission Record indicated a diagnosis of schizophrenia, but the Minimum Data Set (MDS) assessments were inconsistently coded. The Admission MDS did not list schizophrenia as an active diagnosis, while subsequent Quarterly MDSs did, despite the resident being in a persistent vegetative state and lacking documentation to support an active diagnosis according to DSM-5 criteria. The MDS Coordinator acknowledged that the Quarterly MDSs were incorrectly coded, as the resident's condition did not meet the criteria for schizophrenia, and the diagnosis was carried over from the hospital without sufficient supporting documentation. Another resident was admitted with multiple diagnoses, including diabetes, heart failure, acute kidney failure, and depression. The MDS assessment indicated the resident had adequate hearing, but the Social Service Hearing Assessment noted impaired hearing and did not recommend hearing appliances or consultation. The resident reported significant difficulty hearing and a prolonged wait for hearing aids, with missed and canceled audiology appointments due to logistical issues. The Social Service Director confirmed that the assessment should have indicated a need for a hearing consultation and that a follow-up assessment was not completed as required. The MDS Coordinator also stated that the resident's hearing should have been coded as moderately impaired rather than adequate. Facility policies required staff to attest to the accuracy of MDS assessments and to assist hearing-impaired residents in obtaining necessary services. However, the assessments for both residents were not completed accurately, and required follow-up actions, such as timely hearing assessments and proper documentation of mental health diagnoses, were not performed. These failures resulted in inaccurate depictions of the residents' needs and affected their care plans.
Failure to Develop and Implement Comprehensive Care Plans for Pressure Ulcer and Diet Change
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to both pressure ulcer management and dietary changes. For one resident with type 2 diabetes, generalized muscle weakness, reduced mobility, and moderately impaired cognition, the facility did not create a care plan addressing a stage II pressure ulcer on the sacrococcyx, despite physician orders for daily wound care. The Minimum Data Set Coordinator confirmed that no care plan was in place for the pressure ulcer or its treatment, and the Director of Nursing acknowledged that this omission could result in the resident not receiving proper care. Another resident, admitted with diffuse traumatic brain injury, gastrostomy, and tracheostomy, experienced a significant change in diet order from a twice-daily pureed diet to three daily meals of regular mechanical soft texture. Staff interviews revealed that both a Certified Nursing Assistant and a Registered Nurse were unaware of the new diet order, and the care plan had not been updated to reflect the change. The Director of Nursing confirmed that care plans should be revised as residents' conditions change, but this was not done in this case. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan within specified timeframes, including measurable objectives and timeframes, and to revise care plans as residents' conditions change. In both cases, the lack of updated care plans meant that staff were not properly guided in providing necessary care and services for the residents' current needs.
Failure to Provide Timely Audiology Services for Hearing-Impaired Resident
Penalty
Summary
A resident with multiple medical conditions, including diabetes, heart failure, acute kidney failure, and depression, was admitted to the facility and had a documented need for hearing support. The resident's records included an active order for an audiology consult as needed for hearing problems. Despite this, the resident reported ongoing difficulty hearing and stated he had been waiting approximately six months for hearing aids. He also described a missed appointment with an ear doctor due to lateness and subsequent unfulfilled promises of an in-facility evaluation. The resident expressed that his hearing impairment made it very difficult to enjoy his favorite activity, watching TV. Facility documentation showed that a Social Service Assessment (Hearing) was completed, but it indicated that hearing appliances and consultation were not needed, contrary to the resident's ongoing complaints and the ENT's recommendation for an audiology exam for hearing aids. Attempts to schedule audiology appointments were unsuccessful due to the audiology office's inability to accommodate a gurney, and no in-house audiology services were available. The Social Service Director acknowledged that the assessment should have indicated a need for a hearing consultation and that a follow-up assessment was not completed as required. Facility policy required staff to assist hearing-impaired residents in accessing needed services, but this was not effectively carried out for this resident.
Failure to Implement Fall and Injury Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision and implementation of safety interventions for multiple residents at high risk for falls and injury. For one resident with metabolic encephalopathy, legal blindness, and a history of falling, the physician ordered floor mats to be placed at the bedside to reduce injury risk. However, observations on multiple occasions revealed that no floor mats were present, and staff confirmed the absence of this intervention despite the resident's high fall risk. The Director of Nursing acknowledged that not providing the prescribed floor mats could potentially result in injury if a fall occurred. Another resident with a history of falling, muscle weakness, and seizures was also ordered to have floor mats on both sides of the bed. Despite this, observations and staff interviews confirmed that no floor mats were present at the bedside. The care plan for this resident included the use of floor mats as a fall prevention measure, but this intervention was not implemented. The Director of Nursing confirmed the omission and recognized the increased risk of injury due to the lack of floor mats. Additionally, a resident with severe cognitive impairment and total dependence on staff had a physician's order and care plan for padded bed rails to prevent injury. During observation, the bed rail padding was found to be ripped, exposing the hard bed rail, and staff acknowledged that this would not protect the resident from injury. Another resident with a history of falls and seizures had incomplete and inaccurate fall risk assessments, with missing documentation of predisposing factors and recent falls. The Director of Nursing confirmed the importance of accurate assessments for effective care. Facility policies reviewed indicated that staff are required to implement and monitor interventions to prevent falls and injuries, but these were not consistently followed.
Failure to Reconcile Controlled Medications in Emergency Kits
Penalty
Summary
The facility failed to reconcile controlled medications (CMs) in emergency medication kits (eKITs) at every shift in two separate locations: Medication Room Station 1 and Medication Cart Station 2B. During observations and interviews, it was found that the eKIT labeled 109 in Medication Room Station 1 and the eKIT labeled 318 in Medication Cart Station 2B, both containing CMs, did not have accountability logs documenting reconciliation of CM inventory for the month of May 2025. Registered and vocational nursing staff confirmed that these eKITs were not reconciled at every shift, as required, and acknowledged the importance of this process for accountability and prevention of CM diversion or accidental exposure. A review of the facility's policy and procedure on controlled medication storage indicated that all CMs, including those in emergency supplies, must be physically inventoried by two licensed nurses and documented at each shift change. Despite this policy, the required reconciliation and documentation were not performed for the identified eKITs in the specified medication room and cart, resulting in a lack of compliance with federal and state regulations regarding the handling of controlled substances.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 34 opportunities, resulting in an 8.82% error rate. One error involved a nurse administering carvedilol to a resident with hypertension at a time inconsistent with the physician's order, which specified administration at 8 a.m. with food. The nurse acknowledged administering the medication outside the facility's 60-minute window for scheduled medications, as outlined in facility policy, and recognized this as a medication error. Another resident, who had diagnoses including malnutrition and failure to thrive, did not receive docusate as ordered and was given a multivitamin with minerals instead of the prescribed multivitamin without minerals. The nurse responsible stated that docusate was withheld due to a soft stool, despite the order specifying to hold only for loose stools, and admitted this was an error. The nurse also acknowledged administering the incorrect form of multivitamin, contrary to the physician's order. Interviews with the Director of Nursing confirmed that these incidents were considered medication errors according to facility policy and procedures. Documentation review supported that the medications were not administered as prescribed, and the facility's policies require strict adherence to physician orders and scheduled administration times.
Improper Storage and Failure to Discard Expired Medications
Penalty
Summary
Surveyors identified that the facility failed to properly remove and discard expired or improperly stored medications, including insulin and Procrit, in accordance with manufacturer requirements and facility policies. Specifically, an opened insulin Aspart Flexpen for one resident was found stored in the refrigerator with a label indicating it had expired after 28 days, but it was not removed from use. Another instance involved an opened Humulin R insulin vial for a different resident, which was stored in the refrigerator without a label indicating when it was first opened, contrary to manufacturer instructions that require room temperature storage and use within 31 days of opening. Additionally, a single-dose vial of Procrit for another resident was found in the refrigerator with unused medication remaining, despite manufacturer and facility policy requiring immediate disposal after initial use. Interviews with nursing staff and the Director of Nursing confirmed that these medications were not handled according to policy, with staff acknowledging that expired or unlabeled medications should have been removed and disposed of to prevent accidental administration. Facility policy reviews corroborated the requirement for medications to be labeled with open dates, stored according to manufacturer guidelines, and discarded after specified periods or after single use. The observed deficiencies were limited to the improper storage, labeling, and failure to discard expired or used medications, as directly evidenced by the surveyor's findings and staff interviews.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served at safe and appetizing temperatures, as required by their policies and procedures. Observations during meal service revealed that hot foods, such as zesty spinach, were served at 121°F, which is below the required minimum of 135°F, and cold foods, such as chocolate cake and milk, were served at temperatures ranging from 47°F to 60°F, exceeding the maximum allowable temperature of 40°F for cold items. Staff were observed not consistently taking or recording food temperatures, and some items, like spinach, were placed directly into serving pans without temperature checks. Additionally, cold items such as green salad, chocolate cake, and milk were left at room temperature for extended periods before service. Interviews with dietary staff and supervisors confirmed awareness of the facility's standards for food temperatures and the importance of maintaining hot foods above 135°F and cold foods below 41°F. Staff acknowledged that the observed food temperatures did not meet these standards and that proper temperature checks were not always performed. The facility's own policies emphasized the need for food to be prepared and served at appropriate temperatures to preserve flavor, appearance, and safety, but these procedures were not consistently followed, placing a significant number of residents at risk.
Failure to Prepare Pureed Foods to Required Consistency
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet the individual needs of residents on a pureed diet. During observation of meal preparation, staff were seen adding potato flakes to pureed pasta without measuring, relying instead on visual assessment and a spoon tilt test. When the pureed pasta was evaluated by the Dietary Supervisor and Registered Dietitian, it was found to contain small pasta particles and to be sticky, rather than smooth and pudding-like as required. The Dietary Supervisor confirmed that the sticky consistency would require more chewing and could pose a problem for residents with chewing and swallowing difficulties. The facility's policies, diet manual, and standardized recipes all specify that pureed foods should be smooth, moist, and free of lumps, and that recipes should be followed with correct ingredient measurements to achieve the proper texture and consistency. Eighteen residents on pureed diets were potentially affected by this failure, as the pureed pasta did not meet the required standards for texture and consistency. The facility's menu, policies, and IDDSI guidelines all require that pureed foods be smooth, not sticky, and pass specific consistency tests, but these standards were not met during the observed meal preparation. The deficiency was identified through direct observation, interviews with dietary staff, and review of facility documentation.
Widespread Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations of improper food handling and unsanitary conditions. Opened bags of frozen pancakes and pie crusts were found in the freezer without labels or dates, contrary to facility policy and food code requirements. Additionally, several areas and pieces of kitchen equipment, including the reach-in refrigerator, drawers, plate warmer, push carts, and condiment containers, were observed to have dust, dirt, food debris, and hair, indicating a lack of proper cleaning and sanitization. Staff interviews confirmed that cleaning schedules were not consistently followed, and these areas were not cleaned as required. Further deficiencies were noted in the maintenance of kitchen equipment and utensils. All green shelves in the walk-in refrigerators were found to have cracks, chips, and rust, while the chopping board and juice rack were stained, scratched, and rusted, making them difficult to clean and sanitize. Staff members were observed wearing jewelry, including wristwatches, bracelets, and a diamond ring, as well as nail polish while preparing food, which is prohibited by both facility policy and food safety codes. Dented cans were stored with non-dented cans, and food containers, plates, and trays were stacked while still wet, rather than being air-dried as required. There was also a lack of separation between clean and dirty areas, with a trash can placed near the bowl storage area and water splashes observed from the handwashing area to the clean storage area. Additionally, a resident's freezer was found to have no thermometer, and there was no evidence that freezer temperatures were being monitored or logged. These failures were observed during kitchen tours and interviews with dietary staff and supervisors, who acknowledged the lapses and the importance of adhering to proper food safety and sanitation protocols.
Improper Disposal of Garbage and Refuse Around Dumpster
Penalty
Summary
Surveyors observed soiled gloves, empty plastic bottles, and other trash scattered on the ground around the facility's dumpster bin during a walkthrough with the Dietary Supervisor. The Dietary Supervisor acknowledged that the presence of trash in this area was not acceptable, as it could attract pests and potentially spread illness to residents. The supervisor also stated that he was unaware of who was responsible for maintaining the cleanliness of the trash area. In a subsequent interview, the Maintenance Director confirmed that he was responsible for maintaining the dumpster and its surrounding area, and agreed that the area needed to be kept clean to prevent the attraction of flies, rats, and other animals. The Maintenance Director also recognized that the presence of trash could contribute to the spread of disease among residents. Review of the facility's policies and the Food Code 2022 confirmed that waste should be disposed of daily, the outside garbage bin should remain closed, and the surrounding area must be kept clean to prevent unsanitary conditions.
Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that restorative nursing aide (RNA) records accurately reflected the provision of passive range of motion (PROM) to both legs for a resident with significant mobility limitations, as ordered by the physician. The resident, admitted with diagnoses including neoplasm of the meninges, nontraumatic intracerebral hemorrhage, lack of coordination, muscle weakness, foot drop in both feet, and reduced mobility, had a physician's order for active assistive range of motion (AAROM) to both arms and PROM to both legs. However, documentation from 4/22/2025 to 5/5/2025 indicated that the RNA provided AAROM to both arms and the right leg, and PROM only to the left leg, which did not align with the physician's order. Observations and interviews confirmed that the RNA was performing AAROM on the right leg and PROM on the left leg, rather than providing PROM to both legs as ordered. The resident was able to participate in AAROM for the right leg with some assistance, but the documentation and care provided did not match the original physician's order. The discrepancy was identified during a review of the resident's medical records and through direct observation of the RNA session. Further review with the Director of Medical Records (DMR) confirmed that the documentation did not accurately reflect the care ordered by the physician. The DMR acknowledged that the RNA services documented from 4/22/2025 to 5/5/2025 were inconsistent with the physician's order and that the facility did not have a policy or procedure in place to ensure medical record accuracy. This resulted in inaccurate provision and recording of care in the resident's medical records.
Failure to Implement and Maintain Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices in several key areas, as observed and documented by surveyors. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents with high infection risk, such as those with tracheostomy tubes or recent tracheostomy removal, during high-contact activities in the therapy gym. Specifically, staff members assisted residents with transfers and mobility without wearing required gowns and gloves, despite care plans and facility policy indicating the necessity of these precautions. Interviews with staff and review of CDC guidance confirmed that EBP should be followed during such activities, both inside and outside resident rooms. Additionally, the facility failed to properly clean and disinfect cloth gait belts used for resident transfers. Staff were observed using disinfecting wipes intended for hard, non-porous surfaces on cloth gait belts, contrary to manufacturer instructions and facility policy. This practice was acknowledged by the Infection Prevention Nurse as ineffective for porous materials like cloth, raising concerns about the potential for cross-contamination. The improper handling and storage of resident care items extended to other areas, such as oxygen tubing being allowed to touch the floor and urinals being hung on trash cans containing waste, both of which were confirmed by staff as inappropriate and against facility policy. Environmental deficiencies were also noted, including the presence of ripped and gouged foam bed rail padding that could not be properly cleaned, and the improper storage of medical supplies in a dirty storage room with personal items placed on top of supply boxes and boxes stored directly on the floor. Staff interviews and policy reviews confirmed that these practices did not align with facility protocols for maintaining a clean and safe environment, and could contribute to the transmission of infectious microorganisms among residents.
Therapy Gym Lacked Adequate and Maintained Equipment
Penalty
Summary
The facility failed to ensure that the therapy gym had adequate space and properly maintained equipment to meet residents' needs. During observations, one of two therapy mats was found to be non-functional and used for equipment storage, making it inaccessible for resident care. Therapy equipment, including a bean bag toss game, hand weights, arm bicycles, and a therapy rainbow arch, was scattered over the broken mat. One of the eight hand weights had its protective coating chipped off, exposing the metal, and was being used as a paperweight rather than for resident care. The Director of Rehabilitation confirmed that the mat was broken, the arm bicycles were also broken and meant to be discarded, and the hand weight was not in use for therapy. Additionally, the facility failed to maintain other essential therapy equipment. The only container of ultrasound gel available for use with the ultrasound machine was found to be expired by one and a half years, which the Director of Rehabilitation acknowledged could limit the effectiveness of therapy for pain and soft tissue concerns. An oxygen concentrator present in the therapy gym did not have documentation of its last service date, raising concerns about its ability to deliver oxygen effectively. The facility's policy and procedure required that therapy equipment be safe and adequate for resident needs, but these requirements were not met as observed.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for one resident within the required timeframe following admission. The resident was admitted with multiple diagnoses, including neoplasm of the meninges, nontraumatic intracerebral hemorrhage, lack of coordination, muscle weakness, foot drop of both feet, and reduced mobility. The resident's Admission MDS, dated 11 days after admission, lacked the required signature of the RN Assessment Coordinator, indicating it was not fully completed. The MDS Coordinator confirmed that the assessment was not finalized because all departments had not completed their assigned sections. During interviews and record reviews, it was established that the resident was alert, communicative, and expressed a desire to receive rehabilitation services to regain mobility and return home. The resident reported a history of multiple brain surgeries and previous use of a single point cane due to left leg weakness. The failure to complete the Admission MDS by the 14th day of admission, as required by the Resident Assessment Instrument (RAI) Manual, was acknowledged by the MDS Coordinator, who noted that this could result in areas of care not being addressed for the resident.
Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) system for one resident. The resident was admitted and later readmitted with diagnoses including type 2 diabetes, urinary tract infection, and essential hypertension. The resident subsequently expired, and records indicated the body was released and the resident was designated as DNR. A review of the resident's discharge summary and MDS assessment showed that the required discharge MDS was not completed or submitted to CMS as required. During interviews, the MDS Coordinator confirmed that the facility is required to complete and submit the discharge MDS within 14 days of a resident's discharge, but acknowledged that this was not done for the resident in question. The Director of Nursing also confirmed the requirement and noted that the discharge assessment had not been completed or submitted on time. Review of the facility's policy and the CMS RAI User's Manual further confirmed the requirement for timely electronic submission of MDS data within 14 days of the care plan completion or MDS completion date.
Failure to Include Indwelling Catheter in Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who was readmitted with an indwelling catheter. The resident had multiple diagnoses, including type 2 diabetes mellitus, obstructive uropathy, and reflux uropathy, and required staff assistance for daily activities. Physician orders indicated the need for indwelling catheter care every day shift for 30 days due to neurogenic bladder. However, upon review, the baseline care plan did not address the presence of the indwelling catheter or specify related care interventions. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the baseline care plan was incomplete and did not reflect the resident's catheter or the necessary care instructions. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including all immediate health and safety needs, but this was not followed in the resident's case. The omission was identified through record review and staff interviews, highlighting a failure to document and plan for the resident's catheter care needs upon admission.
Failure to Update Care Plan After Discontinuation of Restraint
Penalty
Summary
The facility failed to update and revise a resident's care plan after the discontinuation of a restraint freedom splint. The resident, who had diagnoses including acute and chronic respiratory failure, encephalopathy, and quadriplegia, was totally dependent on staff for all activities of daily living and had severely impaired cognitive skills. The care plan, last revised on 3/26/2025, continued to indicate the use of a restraint freedom splint and identified the resident as high risk for injury and complications due to pulling life-sustaining equipment. A physician order dated 4/17/2025 directed the discontinuation of the freedom splint to the resident's left upper extremity. However, the care plan was not updated to reflect this change. Both the Subacute Director and the DON confirmed during interviews that the care plan should have been revised following the change in the resident's condition, but this was not done. The facility's policy also requires care plans to be revised as residents' conditions change, but this was not followed in this instance.
Failure to Provide Communication Device in Resident's Preferred Language
Penalty
Summary
A deficiency was identified when a resident with a primary language of Chinese and diagnoses including dysphagia, hypertension, and a need for assistance with personal care was not provided with a communication device or board in her preferred language. The resident's Minimum Data Set indicated moderately impaired cognitive skills and dependence on staff for multiple activities of daily living (ADLs), with a documented need or desire for an interpreter to communicate with healthcare staff. The resident's care plan included interventions such as speaking clearly, explaining procedures, and utilizing translators or communication devices as indicated. During multiple observations and interviews, it was found that the resident did not have access to a communication board or device in Chinese, either at her bedside, on her wheelchair, or in the activity room where she spent significant time. Staff, including the Activity Assistant and Activity Director, confirmed the absence of such a device and acknowledged the difficulty in communicating with the resident. The resident herself reported often relying on gestures to communicate her needs and expressed a wish to speak English to better express herself. The facility's Director of Nursing confirmed that staff are required to provide communication boards or devices in the resident's spoken language, but acknowledged that this was not done for the resident in question. Facility policies reviewed indicated that communication needs should be identified and addressed through care planning, and that appropriate support should be provided for residents unable to carry out ADLs independently, including assistance with communication.
Failure to Provide Bladder Retraining Program After Change in Resident Condition
Penalty
Summary
Facility staff failed to provide a toileting program or bowel and bladder retraining for a resident who had been admitted with an indwelling catheter and later had the catheter discontinued. The resident's initial bowel and bladder screening indicated they were a poor candidate for retraining due to sleepiness and forgetfulness. However, after the catheter was removed, the resident became more alert and mobile, and was observed to be continent on several occasions and able to walk to the bathroom independently. Despite these changes, staff did not repeat the screening or initiate a bladder retraining program as required by facility policy. The resident expressed interest in participating in a bladder retraining program, stating they could feel the urge to use the bathroom when awake. Interviews with the ADON and DON confirmed that the required reassessment was not completed after the resident's condition improved, and no individualized retraining program was provided. Facility policy required reassessment and care plan updates within 14 days of admission and quarterly, but this was not followed in the resident's case.
Failure to Provide and Document Required Gastrostomy Tube Site Care
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube (GT) did not receive appropriate care and services to prevent complications associated with enteral feeding. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with diagnoses including tracheostomy, gastrostomy, and dementia. The resident's care plan required daily GT site care, including cleaning with normal saline, patting dry, and covering with a dry dressing, as well as assessment for signs of infection. Physician orders and facility policy also specified daily care and immediate documentation after completion of the task. On the day in question, multiple observations by staff revealed that there was no dressing present on the resident's GT insertion site, despite documentation in the Treatment Administration Record (TAR) indicating that care had been provided. The treatment nurse confirmed that he had documented the care as completed but was unsure what happened to the dressing, suggesting the resident may have removed it. The Director of Nursing confirmed that if the dressing is not present, the care was not done, and emphasized the requirement for immediate documentation after care. The facility's policy indicated that staff are trained to recognize and report complications related to feeding tubes.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A resident with a history of acute and chronic respiratory failure, hypoxia, type 2 diabetes mellitus, and falls was admitted and readmitted to the facility. The resident required substantial to maximal assistance with daily activities and was receiving oxygen therapy as part of their care plan. Physician orders specified that oxygen should be administered at two liters per minute via nasal cannula, with titration up to three liters per minute to maintain oxygen saturation above 90%. The orders also required weekly changes of oxygen tubing, with labeling of the date and time, and the use of a humidifier when oxygen was administered at three liters per minute or more. During an observation, the resident was found to be receiving oxygen at six liters per minute via nasal cannula, which exceeded the physician's order. The oxygen tubing in use did not have a label indicating the date and time it was last changed, and the humidifier attached to the oxygen machine was empty. Staff interviews confirmed that the resident was receiving oxygen at a higher rate than ordered, the tubing was not labeled as required, and the humidifier was not filled. Staff acknowledged that these actions did not comply with physician orders or facility policy. The facility's policy on oxygen administration required licensed staff to follow physician orders, change and label oxygen tubing weekly, and ensure the humidifier was full when oxygen was administered at three liters per minute or more. The deficiencies observed included failure to administer oxygen at the ordered rate, failure to label and change oxygen tubing as required, and failure to maintain the humidifier, all of which were confirmed by staff and documentation review.
Failure to Attempt and Document Non-Pharmacological Pain Interventions Prior to Administering Oxycodone
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented prior to administering as-needed oxycodone for pain management for one resident. The resident, who had diagnoses including sarcoma, right knee pain, and post-surgical aftercare, had physician orders specifying that non-pharmacological pain interventions such as repositioning, dimming lights, distraction, relaxation techniques, hot/cold applications, music, and massage should be tried and their effectiveness documented before administering pain medication. However, review of the Medication Administration Record (MAR) revealed that on multiple occasions, there was no documentation that these interventions were attempted prior to giving oxycodone. Interviews with nursing staff confirmed that non-pharmacological interventions were not always offered or documented before administering pain medication, despite clear physician orders and facility policy requiring this protocol. The Director of Nursing also acknowledged that non-pharmacological interventions should be tried first to assess their effectiveness before considering medication. The facility's policy emphasized the importance of these interventions and the potential adverse effects of pain medications, but the required steps were not consistently followed or documented for the resident in question.
Failure to Monitor Dialysis Access and Enforce Fluid Restriction for Resident on Hemodialysis
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who was dependent on hemodialysis. The resident had a right upper chest quinton catheter for dialysis access and was cognitively impaired, requiring staff assistance for most activities of daily living. The care plan required monitoring of the dialysis access site for signs of infection, bleeding, pain, clotting, swelling, drainage, and discoloration, with documentation of monitoring every shift. However, review of the Medication Administration Records (MAR) showed no documentation that the resident’s right upper chest quinton catheter was monitored as required by the care plan. Both the registered nurse and the director of nursing confirmed that licensed staff did not implement the care plan intervention and did not monitor the catheter site. Additionally, the facility failed to implement a physician’s order for fluid restriction for the same resident. The physician’s order and care plan specified that no water pitcher should be placed at the resident’s bedside to help manage fluid intake. Despite this, observations revealed a full pitcher of water, a glass of milk, and juice at the resident’s bedside, and the infection preventionist confirmed that staff failed to follow the fluid restriction order. The facility’s policy also required the removal of water pitchers for residents on fluid restrictions, but this was not followed in practice. The facility’s policies and procedures for care of residents receiving renal dialysis and for fluid-restricted diets both required assessment and monitoring of central line sites and adherence to physician-ordered fluid restrictions. The failure to monitor the dialysis access site and to enforce fluid restrictions were confirmed by staff interviews and record reviews, indicating that the facility did not follow its own policies or the resident’s care plan and physician orders.
Missed Quarterly Social Service Assessment for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to follow its policy and procedure for conducting timely social service assessments for a resident with dementia care needs. Specifically, the Social Service Director (SSD) did not complete a required quarterly social service assessment for a resident who had been admitted and readmitted with diagnoses including pneumonia, Parkinsonism, and schizophrenia. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and total dependence on staff for daily activities. The last social service assessment was conducted in January, but the quarterly assessment due in March was missed because the SSD was backed up with assignments for other residents. Interviews with the SSD and the Director of Nursing (DON) confirmed that quarterly and annual social service assessments are required by facility policy. The SSD acknowledged the omission and explained that the assessment includes evaluating psychosocial history, physical, cultural, and spiritual factors, as well as discharge planning. The facility's policy, last reviewed in July, outlines the requirement for timely and appropriate resident assessments, including quarterly assessments, which was not followed in this instance.
Failure to Provide Timely PT Evaluation as Ordered
Penalty
Summary
The facility failed to provide a required Physical Therapy (PT) evaluation for a resident with significant mobility and range of motion (ROM) concerns, despite a physician's order. The resident, who had a history of brain surgery, muscle weakness, foot drop, and reduced mobility, was admitted with the goal of regaining the ability to walk with a single point cane (SPC) and returning home. Initial PT evaluation and treatment were started but discontinued after a few days due to the facility's understanding that the resident's health insurance would no longer cover therapy services. However, a subsequent physician's order for a PT evaluation and treatment was issued in response to the resident's request, but the evaluation was not performed in a timely manner. The delay in providing the PT evaluation was attributed to the facility's process of waiting for health insurance authorization before proceeding, even though the facility's own policy and procedure (P&P) did not require waiting for such authorization. The case manager did not submit the physician's order for insurance review until several days after it was written, citing workload and absence from work as reasons for the delay. During this period, the resident continued to express a desire for more therapy and showed some improvement in right leg movement, as reported by restorative nursing staff. Despite these developments, the PT evaluation was not completed within the 48-hour timeframe specified by the facility's P&P. Interviews with facility staff, including the Director of Rehabilitation, case manager, and administrator, confirmed that the PT evaluation was not performed as ordered and that the facility's policy did not mandate waiting for insurance authorization. The resident remained dependent on restorative nursing interventions and did not receive the specialized rehabilitative assessment that could have determined eligibility for further therapy to meet her goal of increased mobility and discharge to home.
Failure to Coordinate and Discontinue Hospice Services per Family Request
Penalty
Summary
The facility failed to provide appropriate hospice services to a resident by not designating a specific member of the interdisciplinary team to coordinate care between the facility and the hospice agency, as required by policy. The Social Service Director (SSD) was acting as the coordinator but was not formally identified in the facility's policy, and this lack of clear designation contributed to communication failures. The SSD did not document conversations with the resident's responsible party (RP) or the hospice agency regarding the request to discontinue hospice services, nor did she inform the physician or facility administration of the request. The resident in question had a history of falling, muscle weakness, cerebrovascular disease, seizures, and was receiving palliative care. The resident was dependent on staff for all activities of daily living and was under hospice care for a diagnosis of cerebrovascular accident. The responsible party requested on multiple occasions that hospice services be discontinued and expressed a desire to transfer the resident to another facility. Despite these requests, hospice staff continued to visit and provide services after the request to end hospice care had been made. Interviews revealed that the hospice agency did not receive notification from the facility to discontinue services, and the SSD acknowledged not documenting or communicating the responsible party's wishes appropriately. The facility's policy on hospice care did not specify who was responsible for coordinating care, and the SSD admitted to not fulfilling her responsibilities in this regard. The lack of documentation and communication resulted in the resident continuing to receive hospice services against the wishes of the responsible party.
Failure to Maintain Sanitary Conditions in Food Services Due to Presence of Fly
Penalty
Summary
A deficiency was identified in the facility's food services department due to the presence of a fly in the kitchen area. During observations, a fly was seen flying around the preparation area and landing on the dessert rack, as well as flying around the trayline area where food is assembled for residents. These observations were made during food preparation times, indicating that the pest was present in areas where food was exposed. An interview with the Dietary Supervisor confirmed that the pest control vendor had last visited at the beginning of the previous month. The Dietary Supervisor acknowledged that a fly landing on the food rack is unacceptable due to the risk of disease transmission through food contact. A review of the facility's pest control policy and the Food Code 2022 revealed that the facility is required to maintain an ongoing pest control program and keep the premises free from insects and rodents through regular inspections and control measures. The failure to prevent the presence of a fly in food preparation and assembly areas constituted a breach of these requirements.
Failure to Document Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to ensure that residents at risk for developing pressure ulcers had their skin assessed and documented on a weekly basis, as per the facility's policy and procedure. This deficiency was identified for two residents, both of whom had significant risk factors for skin breakdown, including reduced mobility and cognitive impairments. Resident 1, who had diagnoses of diabetes mellitus and Alzheimer's Disease, was dependent on staff for personal care and had a documented risk of developing pressure ulcers. Despite having a care plan that included weekly body checks, the facility's records showed that the skin management protocols were not marked in the weekly Licensed Nurses Notes, leaving the resident's skin condition undocumented. Similarly, Resident 2, who had a broken hip and dementia, was also at risk for pressure ulcers due to factors such as incontinence and reduced mobility. The care plan for Resident 2 also included weekly body checks, but the facility's documentation failed to indicate whether the skin was clear or if there were any alterations. The Director of Nursing confirmed that the licensed nurses did not document the skin conditions for both residents, which meant the facility could not verify that the residents' skin was assessed weekly. The facility's policies on pressure sore management and licensed nurses notes required that all measures be taken to reduce skin breakdown and that weekly progress notes include pertinent information about the residents' skin conditions. However, the lack of documentation in the Licensed Nurses Notes for both residents indicated a failure to adhere to these policies, potentially delaying necessary treatments and increasing the risk of skin breakdown.
Failure to Update Care Plan After Resident's Fall
Penalty
Summary
The facility failed to review and update a care plan for a resident after a change of condition, which included a fall and an elevated white blood cell count. The resident, who had a history of falls and was at high risk for potential falls, experienced a fall on December 25, 2024, after showing signs of restlessness and abnormal behavior. Despite these changes, the resident's care plans, including the risk for fall care plan and the falling star program care plan, were not reviewed or revised following the incident. The resident was initially admitted to the facility in 2014 and readmitted with diagnoses including unspecified dementia, a need for assistance with personal care, and a history of falling. The resident's Minimum Data Set indicated moderately impaired cognitive skills and dependence on staff for various activities of daily living. The resident's fall risk assessments consistently showed a high risk for falls, with scores well above the threshold indicating high risk. Interviews with the Registered Nurse and the Director of Nursing revealed that the care plans were not updated after the resident's fall, contrary to the facility's policies and procedures. The facility's policies require care plans to be revised when there is a significant change in a resident's condition, such as a fall. The failure to update the care plans after the resident's fall and change of condition was identified as a deficient practice, with the potential to result in inadequate care and supervision for the resident.
Failure to Conduct Fall Risk Assessment After Resident Fall
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Assessing Falls and Their Causes' by not completing a fall risk assessment for a resident after a fall on 12/25/2024. This oversight was identified during a review of the resident's records and interviews with the facility's nursing staff. The resident, who had a history of falls and was diagnosed with unspecified dementia, was admitted to the facility with a high fall risk score. Despite this, after the resident experienced a fall, the required fall risk assessment was not conducted, which is a violation of the facility's procedures. The resident's Minimum Data Set indicated moderate cognitive impairment and dependency on staff for various activities of daily living. On the day of the fall, the resident exhibited restlessness and abnormal behavior, which led to a fall from the bed onto a floor mat. Although the resident was transferred to the hospital for further evaluation due to elevated white blood cell count, the facility did not complete a fall risk assessment upon the resident's return. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the lapse in procedure, acknowledging that the failure to conduct the assessment could lead to insufficient care and increased risk of recurrent falls.
Failure to Communicate ADL Preferences
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity by not communicating with him about his preferred time to receive activities of daily living (ADL) care, specifically regarding his shower schedule. The resident, who was admitted with diagnoses including sepsis, heart failure, pneumonia, and anemia, required assistance with personal care and had moderately impaired cognition. On a scheduled shower day, the resident informed his responsible party that he had not been offered a shower, which was confirmed by the responsible party to the registered nurse on duty. The Director of Staff Development stated that certified nursing attendants are instructed to discuss ADL care preferences with residents at the beginning of their shifts. However, the CNA assigned to the resident on the day in question did not discuss the shower schedule with him, citing a busy schedule as the reason for the oversight. The Director of Nursing confirmed that the CNA should have communicated with the resident about his preferred shower times, as per the facility's policy on dignity, which emphasizes caring for residents in a manner that promotes their well-being and self-esteem.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, which resulted in an unnecessary prolonged hospitalization. The resident, who was originally admitted with serious medical conditions including intracranial injury and acute respiratory failure, was transferred to a general acute care hospital due to abnormal CT scan results. Despite the resident being cleared for discharge and a bed being available at the facility, the resident was not readmitted. The facility's administrator stated that since the resident had been discharged for more than 60 days, returning to the subacute unit would be considered a new admission. The administrator believed it was fair to prioritize long-term subacute residents who had been discharged for no more than 30 days. However, the facility's policy indicated that residents discharged to the hospital should be given priority for readmission upon the first availability of a bed. Interviews with the facility's Admission Director and Director of Nursing confirmed that there was an available male bed during the relevant dates, and the facility's policy should have prioritized the resident's readmission. Despite this, the facility declined the bed request, citing no available subacute bed, which contradicted the facility's census records and policy guidelines.
Failure to Document and Address Skin Integrity Issues
Penalty
Summary
The facility failed to ensure proper documentation and care for a resident with blisters on the left posterior hand. The resident, who was readmitted with diagnoses including hemiplegia, head injury, and brain damage, was dependent on staff for activities of daily living. During a review of the Daily Body Check Report, it was found that a Certified Nurse Assistant (CNA2) marked the resident's skin as 'OK' despite the presence of blisters. This discrepancy was noted after a Registered Nurse observed multiple fluid-filled bumps on the resident's hand, which the CNA admitted had been worsening over the past month. The facility's policy requires CNAs to report any skin integrity issues on the Daily Body Check Report, which CNA2 failed to do. The Assistant Director of Nursing confirmed that CNAs are expected to document such findings. The facility's policies on Change of Condition and Quality of Care emphasize the need for prompt handling and documentation of changes in a resident's condition, which was not adhered to in this case. This oversight had the potential to impact the resident's care and treatment negatively.
Failure to Provide Prescribed Splint for Resident's Contracture Management
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident 3, to maintain or improve their range of motion. Resident 3, who was admitted with conditions including cerebral infarction, right and left hand contractures, tracheostomy, and gastrostomy, was not provided with a left-hand splint as prescribed. The physician's order dated 7/17/2024 required the application of bilateral elbow splints, a right hand splint, and a left knee splint for four to six hours daily, as tolerated, with daily skin checks. However, the left-hand splint, crucial for preventing further contractures, was not applied, as confirmed by the Director of Rehabilitation during an interview and record review. The resident's care plan, revised on 2/29/2024, indicated the need for both hand splints to minimize the risk of further loss of range of motion. Despite this, observations and interviews revealed that both of Resident 3's hands were contracted, indicating a failure to implement the prescribed interventions. The facility's policy on Joint Mobility Contracture Management emphasized the importance of consulting with physicians and therapists regarding splint use upon a resident's readmission, which was not adhered to in this case.
Failure to Maintain Resident Grooming Standards
Penalty
Summary
The facility failed to maintain proper grooming standards for two residents, resulting in dirty fingernails with black substances under the tips. Resident 2, who was admitted with diagnoses including dementia, tracheostomy, and gastrostomy tube, was observed to have yellowish to blackish substances under the fingernails, with one nail being long and curved. The resident's care plan, which was supposed to address self-care deficits due to cognitive impairments and joint limitations, included interventions for grooming and trimming fingernails. However, these interventions were not effectively implemented, leading to the observed deficiency. Similarly, Resident 3, who had cerebral infarction, hand contractures, tracheostomy, and gastrostomy tube, was found with long and dirty fingernails. The resident's care plan also highlighted self-care deficits related to joint limitations and muscular weakness, with a goal for the resident to be clean and well-groomed. Despite this, the facility did not ensure the resident's fingernails were properly maintained. The facility's policy on supporting activities of daily living, which includes grooming and personal hygiene, was not adhered to, resulting in the observed deficiencies.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices by not ensuring that two staff members, a Certified Occupational Therapy Assistant and a Physical Therapy Assistant, wore isolation gowns while providing therapy services to a resident in their room. This resident was under enhanced standard precautions due to the presence of indwelling medical devices and a wound, which increased the risk of infection. The staff members were observed not wearing the required protective apparel during a therapy session, with one staff member admitting it was her first day and she did not notice the signage, while the other acknowledged awareness of the precautions but failed to comply. The resident involved had a complex medical history, including cerebral infarction, seizures, a tracheostomy, and a gastrostomy, and was dependent on staff for various activities of daily living. The facility's infection prevention nurse indicated that a letter 'E' on the resident's name plaque and signage at the head of the bed were used to communicate the need for enhanced standard precautions. The facility's policy required wearing gloves and gowns for high-contact activities, but this was not adhered to, potentially risking the spread of infection.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs. The resident, who was admitted with conditions including cerebrovascular disease, a skull fracture, and seizures, had moderately impaired cognition and highly impaired vision. The resident was dependent on staff for various activities of daily living, such as oral hygiene, toileting, and mobility. The care plan for the resident included ensuring the call light was within reach to address these needs. During an observation, the call light was found placed on the seat of the resident's wheelchair, tangled with belongings, and out of reach. This was confirmed by the Infection Preventionist Nurse, who acknowledged that the call light should always be accessible to residents. The facility's policy, last reviewed in July 2024, mandates that call lights be accessible to residents from various locations, including the bed and toilet, to ensure timely responses to their needs.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for a resident, resulting in the resident having dirty fingernails. The resident, who was admitted with diagnoses including cerebrovascular disease, skull fracture, and seizure, was found to have moderately impaired cognition and highly impaired vision. The resident was dependent on staff for various activities of daily living, including personal hygiene and grooming. Despite the care plan indicating the need for assistance with grooming and trimming of fingernails, the resident's fingernails were observed to have a black substance and were in need of cleaning and trimming. During an observation and interview, the Director of Staff Development and the Infection Preventionist Nurse acknowledged the condition of the resident's fingernails and stated that they should be cleaned and trimmed immediately. The Director of Nursing confirmed that it is the responsibility of all nursing staff to ensure residents' fingernails are clean and trimmed at all times. The facility's policy on supporting activities of daily living, which was last reviewed shortly before the observation, mandates that residents unable to perform these activities independently should receive necessary services to maintain good grooming and hygiene.
Incomplete Physician Progress Notes for Resident Appointments
Penalty
Summary
The facility failed to ensure that Physician Progress Notes were completed as required for a resident, leading to a deficiency in care coordination. The resident, who was admitted with conditions including cerebrovascular disease, a skull fracture, and seizures, had moderately impaired cognition and highly impaired vision. The resident was dependent on staff for various daily activities. Despite having scheduled medical appointments, such as an ENT appointment and a hearing aid appointment, there were no corresponding Physician Progress Notes found in the resident's records for these visits. The absence of these notes was confirmed during a review with a Licensed Vocational Nurse, who stated that the facility received consultation notes from the ENT clinic only on a later date, rather than on the day of the visits. The Director of Nursing also acknowledged that the facility should have ensured the receipt of these notes on the same day the services were provided. The facility's policy, in accordance with OBRA regulations, requires that physician orders and progress notes be maintained properly, which was not adhered to in this case.
Deficiencies in Pain Management and Medication Administration
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering narcotic pain medication to a resident. Resident 11, who was admitted with a fracture of the left femur, had a care plan that included non-pharmacological interventions for pain management. However, documentation showed that hydrocodone-acetaminophen was administered multiple times without any record of non-pharmacological interventions being attempted first. The Director of Nursing acknowledged the importance of trying non-pharmacological methods to reduce the risk of adverse side effects from narcotic medications. Additionally, the facility did not provide pain medication as ordered for another resident, Resident 179, who was at risk for pain due to multiple fractures. The resident was prescribed oxycodone hydrochloride for severe pain, but the medication was not administered on several occasions due to unavailability. The MAR indicated that the medication was awaiting supply, and the staff did not utilize the emergency kit or follow up with the pharmacy to ensure timely administration of the medication. The facility's policies on pain management and medication ordering were not followed, leading to these deficiencies. The policy required non-pharmacological interventions as part of the pain management program and mandated that medications be reordered in advance to ensure availability. The failure to adhere to these policies resulted in inadequate pain management for the residents involved.
Failure to Attempt Non-Pharmacological Interventions Before Administering Lorazepam
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed lorazepam to two residents. Resident 11, who was readmitted with an anxiety disorder, received lorazepam multiple times over several days without documentation of any non-pharmacological interventions being attempted first. The Minimum Data Set (MDS) Nurse could not find any records indicating such interventions were tried before administering the medication. The Director of Nursing (DON) acknowledged the importance of trying non-pharmacological methods first to reduce the risk of adverse side effects from the medication. Similarly, Resident 166, admitted with dementia and severely impaired cognition, also received lorazepam on multiple occasions without any documented attempts of non-pharmacological interventions. The MDS Nurse confirmed the absence of such documentation, and the DON reiterated the significance of attempting non-pharmacological approaches to minimize medication use and potential side effects. The facility's policy on psychotropic medication use emphasizes the use of non-pharmacological approaches unless contraindicated, to minimize medication dependency and allow for the lowest possible doses.
Deficient Window Screen in Resident Room
Penalty
Summary
The facility failed to ensure that the window screen in one of the resident's rooms was properly affixed to the frame, resulting in a gap or opening from top to bottom measuring half an inch. This deficiency was identified during an initial facility tour and room observation, where it was noted that the room was occupied by three residents. The Assistant Director of Nursing (ADON) confirmed the observation, acknowledging the gap in the window screen and recognizing the potential hazard it posed by allowing insects to enter the room. The ADON mentioned that staff frequently conduct room inspections to maintain a safe environment, ensuring rooms are clutter-free and free from insect infestations. However, the gap in the window screen indicated a lapse in these inspections, as it was not identified and addressed prior to the surveyor's observation. The facility's policy and procedure, titled Maintenance Service, last reviewed on 10/17/2023, states that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Despite this policy, the deficiency in Room A's window screen was not rectified, highlighting a failure in the facility's maintenance and inspection processes.
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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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