California Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Springs, California.
- Location
- 2299 North Indian Canyon Drive, Palm Springs, California 92262
- CMS Provider Number
- 056428
- Inspections on file
- 51
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at California Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of pulmonary embolism and intact cognition did not receive ordered morning doses of Eliquis and Hydrochlorothiazide. The MAR showed the medications were not administered by the assigned LVN, and there was no documentation explaining the omission or any notification to the physician, despite care plan directives to administer these drugs as ordered and a facility policy requiring timely administration, documentation of held medications, and physician notification.
A resident with a g-tube did not receive a daily stoma dressing change as ordered by the physician. The nurse responsible failed to perform the treatment, did not endorse it to the next shift, and incorrectly documented it as completed in the TAR. Observation revealed the dressing had dried drainage and the site was red and tender. Facility policy required daily care and accurate documentation, which was not followed.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A nurse failed to provide wound care as ordered by the physician for a resident with a chronic leg wound, instead applying dressings from memory of previous treatments without a current order. The nurse did not seek clarification from the physician before changing the treatment, contrary to facility policy and expectations outlined by the DON.
A resident with legal blindness and moderate cognitive impairment was observed smoking without the required smoking apron, as staff failed to provide it during a supervised smoke break. Facility records and staff interviews confirmed that the resident's care plan and facility policy mandate the use of a smoking apron for safety, but this protocol was not followed during the incident.
Five residents experienced severe unplanned weight changes that were not properly addressed, as the facility failed to complete required change of condition assessments, initiate weekly weights, reassess by the RD, communicate with physicians, or update care plans. These residents, with complex medical conditions, were not consistently monitored for meal intake or supplement use, and staff interviews confirmed that expected processes for addressing significant weight changes were not followed.
A facility failed to ensure a Registered Dietitian provided timely monitoring and intervention for several residents experiencing severe unintentional weight changes, did not maintain an updated diet manual or follow approved therapeutic menus, and allowed unsanitary food practices in the kitchen, including a dirty ice machine, unsafe freezer temperatures, and improper dish storage.
Surveyors identified multiple failures in kitchen food safety and sanitation, including an ice machine with visible debris and slime, dish machine sanitizer at excessive concentration, lack of beard nets on staff, improperly cleaned and stored dishes, and the use of soiled oven mitts. These deficiencies were acknowledged by facility leadership and did not meet professional standards or facility policy.
The facility did not have a written QAPI plan addressing systemic issues with weight loss, kitchen and nutrition services, and broken call light systems. The QAPI committee failed to identify and correct problems related to kitchen services and call light repairs, and did not evaluate prior interventions for weight loss, resulting in multiple residents not receiving appropriate care and experiencing delayed call light responses.
Surveyors found that the facility did not maintain the reach-in freezer and ice machine in safe and sanitary condition. The freezer was repeatedly observed at temperatures above freezing, with food items not properly frozen, and the ice machine was found out of service with visible debris and slime inside. Staff acknowledged the issues, and facility records did not accurately reflect the equipment's condition.
The facility failed to maintain a fully functional call light system, as the nurse's station panel lacked an audible alert and a resident with severe cognitive impairment had no call light within reach, relying on yelling for assistance. Staff were either unaware of the system's requirements or had not reported the deficiencies, and facility policy requiring accessible and operable call lights was not followed.
A facility failed to properly secure an opened emergency narcotic kit, and nursing staff did not consistently document the administration of controlled substances on both the count sheet and MAR for two residents. Additionally, staff did not reconcile a pharmacy delivery of a controlled medication that did not match the physician's order, resulting in discrepancies in medication administration and inventory.
Kitchen staff lacked proper training in food safety and sanitation, as demonstrated by incorrect use of chlorine test strips for dish machine sanitizer and inability to calibrate food thermometers. These deficiencies in staff competency exposed all residents consuming food from the kitchen to risks associated with improper food handling and sanitation.
Multiple residents reported that meals were frequently served cold, and a test tray evaluation confirmed that both hot and cold foods were not at the required temperatures. Additionally, food items such as spinach, potato wedges, and garlic bread were found to lack flavor or be difficult to eat, with the Diet Service Manager/Registered Dietitian acknowledging the need for better seasoning and cooking practices.
Staff failed to maintain infection control by allowing entry into the clean laundry area from the hallway with the door open, not properly disinfecting shared BP cuffs and stethoscopes according to manufacturer instructions, and placing meal trays in unsanitary locations such as next to a urinal or on a visitor's chair. These actions did not follow facility policies or infection prevention standards.
A resident with severe cognitive impairment and no capacity to make medical decisions was not provided with a legal representative or conservator, despite facility policy requiring such action. The facility did not follow its process to identify or appoint a surrogate decision-maker, and no referral was made to external agencies, leaving the resident without appropriate representation for medical decisions.
A resident reported missing personal belongings, including a hairbrush, make-up, slippers, pajamas, and $50 cash, after a room transfer. The personal effects inventory was incomplete, and staff failed to update records or notify the Social Service Director as required. The missing items were not promptly investigated, and only the wallet was recovered, with the cash still missing.
A resident with altered mental status, brain disorder, and psychosis was not provided with a required PASARR Level II referral after a positive Level I screening. The state agency closed the case due to the resident's inability to participate, instructing the facility to submit a new Level I screening, but no new screening or referral was documented. The Social Service Director confirmed the follow-up was not completed.
A resident with a history of Peripheral Vascular Disease and documented toenail fungus was observed to have thickened, flaking toenails and painful nail borders. Despite a podiatrist's treatment plan and facility policy requiring care plan updates for new conditions, no care plan was initiated to address the resident's onychomycosis. This was confirmed by an LVN during interview.
Two residents received care that did not meet professional standards when one was allowed to self-administer an Albuterol inhaler without a required assessment or physician's order, and another received Vitamin D3 without the medication strength being clarified in the physician's order. Facility policies regarding medication administration and order completeness were not followed.
A resident was admitted with multiple dry scabs on both forearms, but staff did not refer the condition to a physician or develop a care plan as required. The skin issues were documented on admission, but the treatment nurse and DON confirmed that the facility's process for assessment and physician notification was not followed, resulting in a delay in appropriate treatment.
A resident with COPD and on oxygen therapy was repeatedly found with cigarettes and a lighter in his possession, both in his room and on the smoking patio, despite facility policy requiring staff to securely store smoking materials and only provide them under supervision. Staff confirmed the resident was not allowed to keep these items, but observations showed ongoing non-compliance, creating a safety hazard.
A resident with moderate to severe cognitive impairment and a history of incontinence was identified as a candidate for a scheduled toileting program through multiple MDS assessments and screeners. However, staff did not perform or document the required bowel and bladder assessment or implement scheduled toileting, as outlined in the facility's policy.
A resident with heart failure, asthma, and COPD was given oxygen at 4 LPM via nasal cannula, contrary to the physician's order for 2 LPM. This was confirmed by an LVN and the DON, and the facility's policy required oxygen to be administered as ordered by the physician.
A consultant pharmacist did not identify or report a missing strength on a physician's order for Vitamin D3 during a monthly medication regimen review. As a result, a resident with chronic kidney disease received daily doses of Vitamin D3 without the order being clarified, and nursing staff administered the supplement without confirming the correct dosage. The omission was acknowledged by both nursing staff and the DON, and facility policy required such irregularities to be reported.
Two residents with renal conditions did not receive meals consistent with their prescribed renal diets when kitchen staff substituted white rice for brown rice, contrary to the approved menu. The dietary manager confirmed that staff are expected to follow printed menus to ensure appropriate nutrition for residents with therapeutic diet needs.
A resident with diabetes and renal failure was found with chocolate candies and other non-compliant snacks in his room, brought in by family and known to staff. Despite dietary orders for a diabetic renal diet and a care plan requiring monitoring and education, staff did not document or address the presence of these foods, failing to follow facility policy on outside food.
Physician progress notes failed to document significant weight loss for two residents with multiple comorbidities and cognitive impairment. Despite evidence of notable weight loss and interdisciplinary team awareness, the medical records lacked physician documentation addressing the issue or interventions to prevent further decline, contrary to facility policy.
The facility did not provide the required minimum of 80 square feet per resident in several shared rooms, as four residents were housed in rooms measuring only 310 square feet each. The Administrator confirmed the deficiency, and residents interviewed stated they were comfortable, with no observed negative impact on health or safety.
A resident with moderate cognitive impairment was found to have a shotgun, two airsoft guns, and a chainsaw in their room, violating the facility's policy against weapons. The items were discovered during an unannounced visit following safety complaints. The resident had a history of going out on pass, and it was suspected that the items were brought back during one of these outings. Staff interviews revealed a failure to enforce the policy effectively, as belongings were not checked and recorded upon the resident's return.
The facility failed to adequately supervise and monitor two residents at risk for elopement. One resident, with a history of elopement attempts, successfully left the facility and was later found disoriented by law enforcement. The resident's care plan was not updated, and no additional interventions were implemented. Another resident was observed without a required WanderGuard bracelet, and staff were unaware of its placement and functionality, indicating a lack of proper monitoring.
The facility failed to update care plans for two residents after multiple elopement attempts. Despite being identified as at risk for elopement, the residents' care plans were not revised following incidents, and IDT meetings were either not conducted or documented. The facility's policy requires care plan reviews at the onset of new problems, which was not followed, leading to continued risks for the residents.
A CNA in an LTC facility addressed two residents disrespectfully, violating their rights to dignity and respect. One resident with cognitive impairment was called derogatory names, while another was subjected to profanity and blame for falls. These incidents were reported to the facility administrator.
A resident experienced emotional distress when an unknown visitor was allowed into her room by a CNA without verifying the visitor's identity. The visitor falsely claimed to be the resident's sister to gain access. Facility staff acknowledged the breach of privacy and the failure to follow visitation procedures.
The facility failed to report an alleged abuse involving two residents to CDPH within the required two-hour timeframe. A CNA used inappropriate language towards the residents, who both have moderate cognitive impairments and significant medical histories. The Administrator was aware of the incident in the morning, but the report was not made until later that evening.
A resident with a lumbar fracture and a history of falls eloped from the facility due to inadequate supervision and security measures. The resident expressed a desire to leave, but the facility failed to maintain a photograph on file and did not secure the entrance, allowing the resident to leave unnoticed.
A resident with COPD, asthma, and depression experienced a breach of dignity when a staff member used offensive language in response to the resident's call for emergency assistance. The incident was discovered during an investigation of a complaint, revealing a violation of the facility's policies on resident rights and employee conduct.
A resident with Alzheimer's Disease and severely impaired cognition eloped from the facility due to inadequate supervision. The resident was known to wander and was left unsupervised when the LVN left the nurse's station. The facility's policy on identifying and assessing elopement risks was not effectively implemented, leading to the resident's unsupervised departure and subsequent return by police.
The facility failed to maintain room temperatures within the required range, causing discomfort for residents and potential health risks. Two residents, one with heart valve disease and another with dementia, reported feeling too hot despite having cooling devices. The Maintenance Assistant confirmed a malfunctioning air conditioning unit, and temperature checks showed several rooms above the acceptable range. Staff highlighted risks like dehydration and exacerbation of medical conditions due to high temperatures.
A facility failed to provide a resident's representative with requested financial documents within the required 48-hour timeframe. The Business Office Assistant was unaware of the policy, and the documents were sent late, after the representative's initial request.
The facility failed to notify the physician when a resident refused emergency room evaluation after a fall and when the resident slid off their wheelchair, delaying notification until the following day. Both incidents jeopardized the resident's health and safety.
The facility failed to conduct an IDT meeting to determine the root cause of a resident's fall and did not accurately assess the resident's fall risk after another fall. The resident had a history of hemiplegia, hemiparesis, difficulty walking, and a history of falling. Despite these conditions, the necessary IDT meeting was not held, and the fall risk assessment was not updated accurately, which could have helped in preventing further falls.
A facility failed to ensure that a resident had a physician's order for two bottles of oral nutritional supplements and that they were not stored by the bedside. The resident, with multiple diagnoses, confirmed taking the supplements without a physician's order. Staff interviews and policy review confirmed the deficiency.
The facility failed to notify a resident of their bed hold rights prior to discharge to acute care, despite the resident's diagnoses including sepsis and end-stage renal disease. Interviews revealed that the facility's policy was not followed, as the bed hold agreement signed at admission did not include a completed notification section upon transfer.
Failure to Administer Ordered Morning Medications and Notify Physician
Penalty
Summary
A resident with a diagnosis of pulmonary embolism and no cognitive impairment, as evidenced by a BIMS score of 15, did not receive ordered morning medications on February 20, 2026. Physician orders for that morning included Eliquis 5 mg and Hydrochlorothiazide 25 mg. Review of the Medication Administration Record (MAR) for that date showed that the morning medications were not administered by the assigned LVN. The resident reported during interview that she did not receive her 9:00 a.m. medications on that date and stated she did not experience any adverse side effects from missing them. Record review revealed no progress note or other documentation explaining why the medications were not given and no indication that the physician was notified of the missed doses. The resident’s care plans directed staff to administer Hydrochlorothiazide and anticoagulant medications, including Eliquis, as ordered. The DON confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time and that, when medications are not administered, the nurse must notify the physician and document the reason. The LVN acknowledged being the medication nurse that morning, confirmed the medications were not administered, could not recall the reason, and verified that the physician was not notified and no progress note was entered, despite facility policy requiring both actions when medications are held.
Failure to Provide and Document Daily G-Tube Stoma Dressing Change
Penalty
Summary
A deficiency occurred when a treatment nurse failed to provide a daily gastrostomy tube (g-tube) stoma dressing change for a resident as ordered by the physician. The resident, who had a history of stroke and dysphagia and was cognitively intact, reported that the dressing change was not performed on the previous day. During observation, the nurse removed a dressing with a moderate amount of dried brown drainage and noted redness at the stoma site, which was also tender to touch. The nurse was unable to determine if the drainage was from the g-tube nutrition or the site itself and acknowledged the redness could be due to irritation from the drainage. Record review revealed that the treatment administration record (TAR) had been initialed by the nurse, indicating the dressing change was completed, even though the treatment was not provided. The nurse admitted to not performing the dressing change due to being occupied with rounds with the wound doctor and also failed to endorse the missed treatment to the next shift or notify the charge nurse, contrary to facility policy. The care plan for the resident required local care to the g-tube site as ordered and monitoring for infection, and facility policy mandated that treatments be provided as ordered and documented accurately.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
A deficiency occurred when a nurse failed to provide wound care treatment in accordance with the physician's order for a resident with peripheral vascular disease and a chronic leg wound. The resident's treatment order specified cleansing the wound with normal saline, patting it dry, applying oil emulsion gauze, wrapping with Kerlix, and securing with retention tape every other day. However, during an observation, the nurse was seen removing a different set of dressings, including Coban, Kerlix, a 4x4 gauze pad, calcium alginate, and Xeroform, which were not part of the current physician's order. The nurse admitted to applying these dressings based on memory of past treatments rather than the current order and confirmed there was no physician order for the calcium alginate and Xeroform dressings used. Further interviews revealed that wound treatments are sometimes changed based on wound condition, but the nurse did not seek clarification or new orders from the physician before altering the treatment. The Director of Nursing stated that the nurse should have either applied the current ordered treatment or contacted the physician for clarification upon discovering a change in the wound's condition. Facility policy requires treatments to be administered as ordered by a physician, and any changes to orders must be clarified and documented before implementation.
Failure to Provide Required Smoking Apron for Visually Impaired Resident
Penalty
Summary
During an unannounced visit, it was observed that a staff member failed to provide a required smoking apron to a resident who was smoking on the facility patio. The Activity Assistant, responsible for supervising the smoking area, admitted to forgetting to give the apron to the resident, who was nearly finished with his cigarette before the omission was noticed and corrected. The resident, who is legally blind and has moderate cognitive impairment as indicated by a BIMS score of 12, confirmed that he is supposed to wear a smoking apron while smoking and did not have one on during the observed incident. Record review showed that the resident's care plan and smoking safety assessment both required the use of a smoking apron due to his blindness. Facility policy also mandates that residents assessed as needing a smoking apron must wear one during smoking, and that staff are responsible for ensuring compliance. Interviews with the Activities Director and Director of Nursing confirmed that the expectation is for staff to provide and ensure the use of smoking aprons for residents who require them, and both verified that the policy was not followed in this instance.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to implement a comprehensive and systematic approach to monitor and maintain acceptable nutritional status for five residents, resulting in severe unplanned weight changes that were not properly addressed. For each of the five residents, significant weight loss or gain was documented over a period of months, but required actions such as completing a change of condition assessment, initiating weekly weights, reassessment by the Registered Dietitian (RD), communication with the physician, and updating the care plan were not performed. In several cases, the Interdisciplinary Team (IDT) did not address the weight changes, and the care plans did not reflect the interventions needed to address the residents' nutritional needs. The residents affected had complex medical histories, including diagnoses such as uncontrolled diabetes mellitus, hyperlipidemia, chronic kidney disease, hypothyroidism, dysphagia, and hemiplegia. Despite documented weight losses ranging from 5.78% to 12.3% over three months, and one case of a 10.26% weight gain, the facility did not follow its own policies for timely notification of physicians, reassessment by the RD, or implementation of appropriate interventions. In some cases, meal intake records and supplement consumption data were missing or incomplete, and the facility failed to provide requested documentation to surveyors. Observations and interviews revealed that residents were not consistently monitored for meal intake, and their preferences and needs were not always accommodated. Staff interviews confirmed that the expected processes for addressing significant weight changes were not followed. The RD and DON acknowledged that nutrition interventions and care plans should have been updated, and that communication with the physician and IDT was lacking. Facility policies required prompt evaluation and intervention for significant weight changes, but these procedures were not consistently implemented, resulting in compromised nutritional status for the affected residents.
Removal Plan
- Notify the Physicians for Residents 23, 43, 51, 58, and 673 of significant and severe weight change.
- Re-weigh all five residents and place on weekly weights.
- Review labs, weights, physician visits, PO intake, and therapy orders for the five identified weight loss residents 23, 43, 51, 58, and 673.
- The RD will re-assess and re-evaluate Residents 23, 43, 51, 58, and 673 nutrition status.
- Immediate training for Certified Nursing Assistants and Licensed Vocational Nurses on monitoring and recording meal intake percentages and supplement orders.
- The RD will monitor the weekly weights and residents with significant weight loss and residents who are under 100 pounds were reevaluated by the Senior Regional Registered Dietitian and followed up by the Facility RD, as well as the Weight Variance and Nutrition Condition Interdisciplinary team.
- IDT will monitor for sustainable compliance to determine weight variances/significant weight losses and accuracy of assessments to meet weight loss resident's nutritional needs and goals of care such as improved PO intake or weight goals are met. Identified concerns will be addressed and reported to the DON and Administrator for follow-up as warranted.
- Senior Regional Registered Dietitian provided one to one re-education to the Registered Dietitian on Evaluation of Weight & Nutritional Status Policy and Procedures and an RD competency with current facility's RD.
- Regional Quality Management Compliance and Senior RD completed education on Evaluation of Weight and Nutritional Status policy with IDT members.
- The Medical Director was notified by the Administrator and Director of Nursing of the concerns related to Weight Loss and Nutritional Assessments and presented and discussed the action plan for implementation.
- Pharmacy medication regimen review completed for the five identified weight loss residents 23, 43, 51, 58, and 673 for review of weight change related medications.
Failure to Ensure Adequate Nutrition Services and Food Safety
Penalty
Summary
The facility failed to ensure that a Registered Dietitian (RD) carried out essential nutrition and food service functions, resulting in multiple deficiencies. Five residents experienced severe, unintentional weight changes, including significant weight loss and one case of weight gain, over a three-month period. These residents had complex medical conditions such as uncontrolled diabetes, hyperlipidemia, hypothyroidism, chronic kidney failure, and dysphagia. The RD did not implement weekly weight monitoring, failed to reassess residents to determine appropriate interventions, and did not communicate significant weight changes to physicians. Documentation of nutrition goals and interventions was lacking, and the interdisciplinary team was not adequately involved in addressing these issues, as confirmed by interviews with the RD, corporate RD, DON, and medical director. The facility's diet manual was found to be outdated and not reviewed or signed off for the current year by the RD and medical director. Additionally, the facility did not consistently follow approved menus for therapeutic diets, such as renal diets. During meal service observations, staff substituted menu items without regard to dietary requirements, and the RD acknowledged the importance of adhering to approved menus to ensure residents received appropriate nutrition. The facility's policy required annual review and approval of the diet manual and adherence to planned menus, but these standards were not met. Multiple unsanitary and unsafe food practices were observed in the kitchen. The ice machine contained visible debris and slime, and was cleaned only monthly. The reach-in freezer repeatedly registered temperatures far above safe levels, with food items such as ice cream found soft and partially thawed. Kitchen equipment, including pans and strainers, was found with food debris and stored while still wet, and cutting boards were heavily marked. The RD and other staff acknowledged these conditions were unacceptable and not in compliance with infection control and food safety policies. These failures were documented in monthly kitchen inspection reports and were not adequately addressed.
Failure to Maintain Food Safety and Sanitation in Kitchen Operations
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in the kitchen as required by professional standards and facility policy. Surveyors observed that the ice machine was not properly maintained or cleaned according to manufacturer guidelines, with visible dark brown and black debris, as well as a slimy substance inside the bin and on internal parts. The Maintenance Supervisor was using dish soap and an unspecified solution for cleaning, which did not align with the manufacturer's recommended cleaning agents and procedures. The ice machine was marked out of service, and both the Director of Nursing and the Dietary Service Manager-Registered Dietitian acknowledged the unacceptable condition and the risk it posed to residents, especially those with weakened immune systems. Additionally, the dish machine sanitizer solution was found to be outside the correct chemical range, testing at 300-400 ppm, which is higher than the recommended level. Kitchen staff confirmed the sanitizer concentration was too high and acknowledged the need for adjustment. Observations also revealed that kitchen staff did not consistently wear beard nets while working, with one staff member admitting to forgetting this mandatory requirement. Furthermore, dishes and large metal pans with food debris and dripping water were stacked together in storage, and other utensils and cutting boards were found with dried residue and markings, indicating they were not properly cleaned or dried before being put away. Surveyors also noted that kitchen staff were using cloth oven mitts that were wet, soiled, and had food build-up and residue. The Dietary Service Manager-Registered Dietitian confirmed that these mitts should not be used due to the accumulation of dirt and potential bacteria. These findings were corroborated by facility policies and the 2022 Federal Food Code, which require proper cleaning, sanitizing, and personal hygiene practices in food service areas. The facility census at the time was 72.
Failure to Implement Comprehensive QAPI Plan for Systemic Issues
Penalty
Summary
The facility failed to maintain a written Quality Assurance Performance Improvement (QAPI) plan that addressed systemic process issues related to weight loss, kitchen and nutrition services, and the repair of broken call light systems. During the survey, it was found that the QAPI committee, which included the Administrator, DON, Medical Director, Radiology, Pharmacy, Laboratory, and department heads, did not have a program in place to identify, correct, and improve issues concerning the broken call light system and kitchen and nutrition services. Although the QAPI program identified issues with weight loss, it did not evaluate the effectiveness of interventions implemented prior to December 2024. As a result of these deficiencies, multiple residents did not receive appropriate care and treatment for weight loss and experienced delayed responses to call lights. The lack of a comprehensive and data-driven QAPI plan also placed other residents at risk of not achieving their highest physical, mental, and psychosocial well-being. The facility's documentation indicated that each department was supposed to review and report on performance and outcomes, but these processes were not effectively implemented for the identified issues.
Failure to Maintain Safe and Sanitary Food Service Equipment
Penalty
Summary
The facility failed to maintain essential food and nutrition services equipment, specifically the reach-in freezer and the ice machine, in safe operating condition. During multiple observations, the reach-in freezer was found to have internal temperatures significantly above the required freezing point, with readings ranging from 41.9 to 55 degrees Fahrenheit. Food items such as ice cream were noted to be soft, and there was water condensation inside the freezer. Staff interviews confirmed awareness of the temperature issues, and temperature logs did not reflect the actual elevated temperatures observed by surveyors. Additionally, the ice machine was found to be out of service and in an unsanitary condition. Observations revealed dark brown and black debris, as well as a slimy substance inside the bin and on the ice cubes. The machine was being cleaned by the maintenance supervisor using dish soap and another cleaning solution, but the presence of debris and slime was confirmed by both the Director of Nursing and the Dietary Services Manager-Registered Dietitian. Both acknowledged that the condition of the ice machine was unacceptable and could pose a risk to residents, especially those with weakened immune systems. A review of facility policies indicated that both the freezer and ice machine were to be maintained and cleaned regularly according to manufacturer guidelines. However, the observed conditions and staff interviews demonstrated that these procedures were not consistently followed, resulting in equipment that was not safe for food storage or preparation.
Non-Functional Call Light System and Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light system was fully functional and accessible to residents, as observed during a survey. The call light panel at the nurse's station did not emit an audible sound when activated from a resident's room, despite the light indicator being on. Multiple staff members, including the Registered Nurse Supervisor, Maintenance Supervisor, and Director of Nursing, confirmed that the audible alert had not been working since early January, and the issue had not been documented in the equipment log or discussed in the QAPI meeting. The Maintenance Supervisor had received an estimate for repair, but the deficiency persisted, and some staff were unaware that an audible alert was required for the system to function properly. Additionally, a resident was found in bed, alert but confused, and yelling for assistance, with no call light within reach or visible in the room. The resident, who had a history of severe cognitive impairment, psychosis, altered mental status, and incontinence, was unable to use the call light system and relied on yelling to communicate needs. A CNA confirmed that the resident's call light was not present and stated that facility policy requires call lights to be within reach of all residents, regardless of their ability to use them. Facility policies reviewed indicated that a functioning call system must be available to all residents in their rooms and toileting/bathing areas, and that call cords should be placed within reach and reported for immediate repair if defective. These requirements were not met, as evidenced by the non-functional call light panel and the absence of a call light for the resident, resulting in the potential for residents not to receive timely assistance from staff.
Deficient Handling and Documentation of Controlled Substances
Penalty
Summary
The facility failed to ensure proper provision of pharmaceutical services, specifically regarding the handling and documentation of controlled substances (CS). An emergency narcotic kit (E-kit) containing CS medications was found opened and unsealed in the medication room, without the required yellow lock. The Registered Nurse Supervisor (RNS) confirmed that after the kit was accessed, it should have been resealed and the pharmacy notified for replacement, as per facility policy. However, the kit remained unsealed, and the necessary procedures for securing and documenting the use of the E-kit were not followed. Additionally, there were multiple instances of incomplete or inconsistent documentation for the administration of CS medications to two residents. For one resident, several doses of hydrocodone-acetaminophen were signed out on the individual narcotic record (count sheet) but not documented on the Medication Administration Record (MAR), and vice versa. In some cases, doses were documented as administered on the MAR but not signed out on the count sheet. The Director of Nursing (DON) acknowledged that these discrepancies resulted in unaccounted doses and that the facility's policy required immediate and concurrent documentation on both the count sheet and MAR when CS medications are administered. Furthermore, the facility did not ensure that CS medications received from the pharmacy matched the current physician's orders. For one resident, the pharmacy delivered hydrocodone-acetaminophen with a frequency of every 8 hours, while the physician's order specified every 6 hours. Nursing staff failed to reconcile this discrepancy upon receipt, as required by facility policy. The DON and pharmacy representatives confirmed that the medication delivered should have matched the physician's order and that the discrepancy should have been identified and clarified at the time of delivery.
Deficient Staff Training in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that kitchen staff in the food and nutrition services department were adequately trained in accordance with standards of practice for food safety, sanitation, and facility policy. Specifically, one cook and a dietary aide demonstrated a lack of knowledge regarding the correct use of chlorine test strips to test sanitizer concentration in the dish machine. The cook misread the test strip results, and the dietary aide was unaware of the correct sanitizer concentration range, as well as the proper method for testing. The Dietary Service Manager-Registered Dietitian confirmed that both staff members did not know how to correctly test the sanitizer, which should be within the 50-100 ppm range as per facility policy and the 2022 Federal Food Code. Additionally, another dietary aide was observed to be unsure of how to calibrate a food thermometer, stating that this task was typically performed by the cook. The Dietary Service Manager-Registered Dietitian acknowledged this lack of knowledge. Facility job descriptions and policies require staff to maintain a safe and sanitary work environment and to calibrate thermometers periodically to ensure proper food temperatures. These deficiencies in staff competency exposed all 72 residents who consume food from the kitchen to practices associated with foodborne illness and potential cross-contamination.
Failure to Serve Food at Safe Temperatures and with Adequate Palatability
Penalty
Summary
The facility failed to ensure that food was served at acceptable temperatures and with adequate palatability, as required by facility policy. During a Resident Council meeting, multiple residents anonymously reported that food was served cold. An individual resident also stated that breakfast meals were cold almost every day. A test tray evaluation of both regular and pureed diets revealed that food items, such as roast beef and orange juice, were not at the recommended serving temperatures when measured with both the facility's and the surveyor's thermometers. The temperatures recorded for hot foods were below the facility's policy standard of greater than 140 degrees Fahrenheit, and cold beverages were above the required maximum of 41 degrees Fahrenheit. Additionally, the palatability of the food was found to be lacking. The spinach was described as having no flavor, the potato wedges were hard, and the garlic bread was dried out and tough to chew. The Diet Service Manager/Registered Dietitian acknowledged these issues, stating that improvements were needed in seasoning and cooking temperatures. These deficiencies were observed during meal service and confirmed through interviews, direct observation, and review of facility policies.
Infection Control Failures in Laundry, Equipment Disinfection, and Meal Service
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several key areas. In the laundry room, staff were observed entering the clean area from the resident hallway while the laundry door was open, and there was no signage indicating the clean area. The Housekeeping Supervisor and Infection Preventionist both acknowledged that leaving the door open and allowing staff to pass through the clean area increased the risk of contamination, which was contrary to facility policy requiring a clean and safe environment for linen handling. Nursing staff did not properly clean and disinfect shared blood pressure cuffs and stethoscopes between residents. Observations showed that staff used Sani-Cloth disposable wipes but did not adhere to the manufacturer's required two-minute contact time, and in some cases, alcohol pads were used instead of appropriate disinfectant wipes. The Infection Preventionist and Director of Nursing confirmed that staff were expected to follow the manufacturer's instructions for disinfection, which was not done, and that alcohol pads were not effective for this purpose. Facility policy required cleaning and disinfection of reusable resident care equipment according to CDC recommendations and manufacturer instructions, which was not followed. Additionally, meal trays were placed in unsanitary locations in residents' rooms. One resident's meal tray was observed on a bedside table next to a urinal, and another resident's tray was placed on a visitor's chair due to the absence of a bedside table. Staff acknowledged that these practices were not sanitary, and the Dietary Service Manager/Registered Dietitian stated that meals were expected to be served in a sanitary manner. Facility policy and the Federal Food Code require food to be protected from contamination and handled according to sanitary practices.
Failure to Appoint Legal Representative for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked capacity to make medical decisions was appointed a legal resident representative (RR) or conservator. The resident, who had diagnoses including altered mental status, a brain disorder, and psychosis, was documented as being able to make needs known but unable to make medical decisions, with a BIMS score indicating severe cognitive impairment. Despite this, records showed that the resident had no family or friends on file willing or able to serve as a legal representative, and the facility did not initiate the process to appoint a legal RR or conservatorship as required by their own policy. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that the facility's process for residents lacking decision-making capacity was not followed. The SSD acknowledged that a Bioethics Committee should have been convened to address the lack of legal representation, but this was not done. The facility's policy required efforts to identify a surrogate decision-maker and, if unsuccessful, to refer the case to the Office of Long Term Care Patient Representatives, but these steps were not documented or completed for the resident.
Failure to Protect Resident's Personal Property During Room Transfer
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's personal property, resulting in the loss of several items. A resident, who was alert and oriented with a history of hypertension and anxiety disorder, reported missing personal belongings including a hairbrush, expensive make-up, house slippers, pajamas, and $50 in cash after being transferred from one room to another. The resident stated she informed staff about the missing items but could not recall the exact date or the staff members involved. The personal effects inventory completed at admission listed some, but not all, of the missing items, and the wallet was documented as given to the charge nurse. Interviews with staff revealed that personal inventory lists should be updated upon room transfers and that missing property should be reported to the Social Service Director (SSD) for follow-up. However, the SSD was not aware of the missing items until interviewed by surveyors, and the resident's name was not on the facility's list of residents with missing property. Upon investigation, the SSD located the resident's wallet but found the $50 missing. The facility's policy required reasonable steps to protect residents' property, including securing valuables in the business office, but these procedures were not effectively followed, resulting in the loss of the resident's belongings.
Failure to Complete Required PASARR Level II Referral and Follow-Up
Penalty
Summary
The facility failed to ensure that a follow-up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR) was performed for one resident. The resident was admitted with diagnoses including altered mental status, a disorder of the brain, and psychosis. Documentation showed that the resident's Level I PASRR screening was positive, indicating the need for a Level II referral. However, there was no evidence that a Level II referral was completed. Further review revealed that the state agency had closed the case after determining the resident was unable to participate in the Level II evaluation, and instructed the facility to submit a new Level I screening to reopen the case. There was no documentation that a new Level I screening was performed or submitted. The Social Service Director confirmed that the necessary follow-up and referral for Level II screening were not completed, and acknowledged that this step was missed for the resident.
Failure to Initiate Care Plan for Toenail Fungus
Penalty
Summary
The facility failed to initiate a care plan for a resident with toenail fungus, despite clear evidence of the condition and related complications. During an observation, the resident was found to have dry, flaking skin and hypertrophic toenails on both feet. The resident's medical record indicated a diagnosis of Peripheral Vascular Disease and a recent podiatry evaluation documented onychomycosis, onychohypertrophy, and painful nail borders on all toenails. The podiatrist's treatment plan included trimming and electrical debridement of the affected toenails. Despite these findings and the facility's policy requiring care plan updates for new problems or changes in condition, no care plan was initiated to address the resident's toenail fungus. This omission was confirmed during an interview with a treatment nurse, who acknowledged that a care plan should have been started for the condition. The lack of a care plan had the potential to result in ineffective treatment of the resident's foot care needs.
Failure to Meet Professional Standards in Medication Administration and Order Clarification
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for two residents. For one resident with a history of Chronic Obstructive Pulmonary Disease (COPD), an Albuterol Sulfate inhaler was observed on the resident's nightstand. The resident reported self-administering the inhaler, and nursing staff were aware of this practice. However, there was no assessment for self-administration, no physician's order permitting self-administration, and no documentation in the medical record or care plan regarding the resident's ability to self-administer medication or bedside storage, as required by facility policy. For another resident with chronic kidney disease, a physician's order for Vitamin D3 supplementation did not specify the strength of the medication. Despite this, nursing staff administered one tablet daily over multiple days without clarifying the order with the physician. During medication administration observation, a nurse identified the missing strength and withheld the dose, but review of the medical record confirmed that the order had not been clarified and the medication had been given without a complete order. Facility policies require that all medications brought in by residents or family members be properly labeled, stored, and assessed for self-administration, and that all physician orders for medications include the name, dosage, frequency, duration, and route. In both cases, these policies were not followed, resulting in medication administration practices that did not meet professional standards.
Failure to Refer Resident's Skin Condition for Physician Orders and Care Planning
Penalty
Summary
The facility failed to ensure that a resident with multiple dry scabs on both forearms was referred to a physician for treatment orders upon admission. Observation and interviews revealed that the resident was admitted with these scabs, which were noted during the initial skin check. However, there was no documented evidence that the scabs were reported to a physician or that a care plan was developed and initiated to address the skin condition at the time of admission. The resident and a family member confirmed the presence of the scabs prior to admission, and the family member reported using Neosporin during visits. Further review and interviews with the treatment nurse and DON confirmed that the facility's process for skin assessment and physician notification was not followed. The treatment nurse was not involved until several days after admission, and the required care plan was not developed until that time. The facility's policy required licensed nurses to complete a skin evaluation and obtain physician orders for treatments, but this process was not adhered to in this case.
Failure to Enforce Safe Smoking Practices for Resident on Oxygen
Penalty
Summary
The facility failed to ensure safe smoking practices for a resident who was observed with cigarettes and a lighter in his possession, despite being on oxygen therapy via nasal cannula. Multiple observations confirmed that the resident kept cigarettes in his nightstand and wheelchair pocket, and was seen handing a lighter to another resident on the smoking patio. The resident's roommate was also on oxygen, increasing the potential for safety hazards. Staff interviews revealed that the resident was not permitted to have smoking materials in his possession, and facility policy required that such items be stored securely by staff and only provided during supervised smoking times. Record review indicated that the resident had a history of chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, and stimulant dependence. The care plan noted the resident's non-compliance with the smoking policy and the need for ongoing reeducation and monitoring for safety issues. Despite these measures, the resident continued to have access to cigarettes and a lighter, contrary to facility policy and individualized care planning, resulting in a failure to prevent potential accident hazards.
Failure to Implement Scheduled Toileting Program for Incontinent Resident
Penalty
Summary
The facility failed to ensure that a bowel and bladder assessment and evaluation were performed for a resident identified as a candidate for a scheduled toileting program. Despite the resident's care plan indicating a risk for bladder incontinence and the goal for continence during waking hours, there was no documented evidence that a bowel and bladder evaluation or scheduled toileting was implemented. The resident, who had moderate to severe cognitive impairment and was admitted with diagnoses including altered mental status and diabetes mellitus, was observed to use incontinence pads and required nursing assistance for changes. Multiple Minimum Data Set (MDS) assessments and Bowel and Bladder Program Screeners identified the resident as a suitable candidate for scheduled toileting on several occasions. However, interviews and record reviews confirmed that the required assessments and interventions were not documented or carried out as per facility policy. The facility's own procedures required licensed nurses to conduct assessments and document progress, but this process was not followed for the resident in question.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of heart failure, asthma, and COPD was observed receiving oxygen therapy at 4 liters per minute (LPM) via nasal cannula, despite a physician's order specifying oxygen at 2 LPM. This discrepancy was confirmed during observations and interviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the physician's order was not followed. Review of the resident's medical record and the facility's oxygen therapy policy further substantiated that oxygen should have been administered as per the physician's directive.
Consultant Pharmacist Failed to Identify and Report Missing Medication Strength
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported an irregularity during the monthly Medication Regimen Review (MRR) for a resident with chronic kidney disease. Specifically, the physician's order for Vitamin D3 did not specify the strength of the supplement, yet nursing staff administered one tablet daily over multiple days without clarification of the correct dosage. During medication administration observation, a licensed vocational nurse (LVN) noted the missing strength and stated the order required clarification, which had not been done at the time. Record reviews confirmed that the physician's order lacked a specified strength and that the medication administration record (MAR) documented daily administration of Vitamin D3. Both nursing staff and the Director of Nursing (DON) acknowledged the omission and the need for order clarification. The CP's MRR for the relevant month did not include any recommendations or identification of the missing strength as an irregularity, and the CP later acknowledged this oversight. Facility policy required the CP to identify and report such irregularities, but this was not done in this instance.
Failure to Follow Therapeutic Renal Diet Menus
Penalty
Summary
The facility failed to ensure that the therapeutic menu was followed for two residents on renal diets. Both residents had significant medical conditions, including chronic kidney disease, dependence on renal dialysis, and other comorbidities such as COPD, diabetes, hypertension, and hyperlipidemia. The prescribed diets for these residents required specific restrictions and modifications, including regulated protein, sodium, potassium, and fluid intake. However, during meal service, it was observed that the kitchen staff substituted white rice for brown rice on the renal diet tray, despite the menu specifying brown rice. The cook stated that white rice was the same as brown rice and served it due to the unavailability of brown rice. Interviews with the Dietary Services Manager-Registered Dietitian confirmed that it was the facility's expectation for kitchen staff to follow the printed menus to ensure residents receive appropriate nutrition according to their therapeutic needs. Documentation and menu reviews indicated that the renal diet was designed to regulate certain nutrients to protect kidney function. The failure to follow the approved menu resulted in the two residents receiving foods that did not meet their prescribed nutritional requirements.
Failure to Enforce Policy on Outside Food for Diabetic Resident
Penalty
Summary
The facility failed to implement its policy and procedure regarding food brought in from outside sources for a resident with diabetes and renal failure. During an observation, a resident was found with bite-size chocolate candies in his nightstand drawer, which he stated were brought by a family member and that staff were aware of their presence. The resident's medical record indicated he was on a diabetic renal diet and could not make medical decisions. The care plan included dietary restrictions and monitoring, but there was no documentation of staff addressing the non-compliant food items with the resident or family. Further review and interviews with staff, including an LVN and the DON, confirmed that the resident had additional non-compliant snacks at his bedside and that the facility's policy was not followed. The staff acknowledged that there was no documentation in the progress notes, physician orders, or resident/family education regarding the inappropriate snacks. The facility's policy required staff to ensure that outside food was compatible with the resident's care plan, to educate the resident and family if not, and to document and notify the physician, none of which occurred in this instance.
Failure to Document Significant Weight Loss in Physician Progress Notes
Penalty
Summary
The facility failed to ensure that physician progress notes in the medical records were accurately completed for two residents who experienced significant weight loss. For one resident with severe cognitive impairment and multiple diagnoses, including chronic kidney disease and malnutrition, a review of the medical record showed a weight loss of seven pounds (5.8%) over one month. However, the physician's progress notes during this period only addressed complaints of generalized pain and did not mention the resident's weight loss or any interventions to prevent further decline. Another resident, who had moderate cognitive impairment and diagnoses including COPD, chronic kidney disease, and lung cancer, experienced a six-pound (7%) weight loss over three months. The resident reported not having discussed her weight loss with her physician or the registered dietitian, and her medical record lacked any physician progress notes addressing the weight loss or monitoring efforts. Interdisciplinary team notes indicated that the physician was aware and that monitoring was ongoing, but this was not reflected in the physician's own documentation. Interviews with facility staff, including the DON, RD, and physicians, confirmed that the physician progress notes did not document the residents' weight loss. Both the DON and RD acknowledged the importance of including this information in the medical record for effective monitoring by the interdisciplinary team. The facility's policy required standardized and accurate completion of medical records, but this was not followed in these cases.
Failure to Meet Minimum Square Footage Requirements in Shared Resident Rooms
Penalty
Summary
The facility failed to ensure that bedrooms occupied by multiple residents met the required minimum of 80 square feet per resident. Specifically, rooms 3, 17, 20, and 33 each housed four residents but measured only 310 square feet per room, which is less than the required space per resident. This deficiency was confirmed through observation, interview, and record review, with the facility Administrator acknowledging that these rooms did not meet the space requirement. Residents interviewed in these rooms reported being comfortable with the space provided, and no negative impact on health and safety was observed during the survey.
Resident Found with Weapons in Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident was found to have a shotgun, two airsoft guns, and a chainsaw in his room. This incident was discovered during an unannounced visit following anonymous complaints about resident safety. The Director of Nursing (DON) confirmed that these items were found while the resident was at the hospital, and the local police were notified to take custody of the weapons. The resident had a history of going out on pass, and it was suspected that he brought these items back into the facility during one of these outings. The facility's policy prohibits weapons on the premises, and staff are required to check and record residents' belongings upon their return from passes. Interviews with facility staff, including the DON, a social worker, a licensed vocational nurse, and a nursing assistant, revealed that the staff were aware of the policy against weapons but failed to enforce it effectively. The resident involved had a history of anxiety, altered mental status, and depression, with a BIMS score indicating moderate cognitive impairment. Despite the facility's policy and procedures, there was a lapse in monitoring and recording the resident's belongings, leading to the presence of dangerous items in the resident's room, which posed a potential risk to the safety of other residents and staff.
Failure to Monitor and Supervise Residents at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for two residents identified as at risk for elopement. Resident 1, who had a history of multiple elopement attempts, was not placed under one-on-one supervision or frequent visual checks despite being identified as high risk. On one occasion, Resident 1 successfully eloped from the facility during the night shift, and staff were unable to bring him back. The resident was later found by law enforcement in a disoriented state, highlighting the facility's failure to implement effective interventions to prevent elopement. Resident 1's care plan and elopement risk assessments were not updated or revised following multiple elopement attempts, and there was no documented interdisciplinary team meeting to address the ongoing risk. Despite having a WanderGuard and being on probation with an ankle monitor, the facility did not take additional measures to ensure Resident 1's safety, such as implementing a 1:1 supervision or conducting more frequent checks. The facility's policy required immediate interventions and care plan updates after an elopement attempt, which were not followed in this case. Resident 2, also identified as at risk for elopement, was observed not wearing a WanderGuard bracelet as ordered by the physician. The staff, including licensed nurses, were unaware of the WanderGuard's placement and functionality, indicating a lack of proper monitoring and adherence to the facility's policy. The failure to ensure Resident 2 was wearing the WanderGuard as prescribed further demonstrated the facility's inadequate supervision and monitoring of residents at risk for elopement.
Removal Plan
- Resident 1 was taken to the hospital for evaluation.
- The DON/Designee reviewed and audited residents with multiple attempts to leave the facility. Resident 2 was identified and placed under one-on-one supervision for safety.
- The Maintenance Supervisor inspected all exit doors and the WanderGuard system to ensure the alarms were working. All alarms and systems were functioning properly.
- New orders to monitor WanderGuard placement and function were added to the medication administration records for the five residents who were at risk. All wander guards were in place as ordered. IDT and care plans were updated based on elopement risk assessments.
- The Administrator and DON provided in-service training to facility staff on the facility's wandering and elopement policies, focusing on interventions for residents attempting to leave the facility and monitoring the WanderGuard system. The Administrator initiated an in-service with facility staff regarding Adequate Supervision and providing the appropriate level of oversight for all residents based on their needs.
- The Administrator conducted an in-service to licensed nurses on using the transmitter tester for WanderGuard, including proper usage, storage, extra supplies, and battery changes.
- The elopement binder was updated, and residents are being monitored and supervised according to their care plans.
- The licensed nurses will conduct room rounds every 2 hours during their assigned shifts to ensure all residents are accounted for and safe.
- DON/Designee checked that all residents identified as risk for elopement had orange arm bands.
Failure to Update Care Plans After Elopement Attempts
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and updated after they attempted to elope from the facility. Resident 1, who was admitted with dementia and identified as at risk for elopement, had multiple elopement incidents documented in his care plan. Despite these incidents, there were no documented updates or revisions to his care plan after several elopements, including the most recent one on November 18, 2024. The interdisciplinary team (IDT) meetings were either not conducted or not documented following these incidents, and the care plan remained ineffective as Resident 1 continued to elope. Resident 2, also diagnosed with dementia and identified as at risk for elopement, had similar issues with the lack of care plan updates. Despite having a Wander Guard order and being placed on a 1:1 observation at times, there were no documented IDT meetings or care plan revisions after Resident 2's elopements on August 23 and September 6, 2024. The facility's Social Service Director (SSD) and Director of Nursing (DON) acknowledged the lack of documentation and IDT meetings, attributing some of the issues to staffing changes and orientation periods. The facility's policy requires care plans to be reviewed and revised by the IDT at the onset of new problems or changes in condition, which was not adhered to in these cases. The DON stated that IDT meetings should occur the day after an elopement incident, but this was not consistently practiced or documented. The failure to update and revise care plans after elopement incidents resulted in continued risks for the residents involved.
Disrespectful Conduct by CNA Towards Residents
Penalty
Summary
The facility failed to uphold resident rights for dignity and respect for two residents when a Certified Nurse Aide (CNA) addressed them in a disrespectful manner. Resident 1, who has moderate cognitive impairment and a history of brain disorder and anxiety, was reportedly called a 'pimp' by CNA 4 in the main lobby. Although Resident 1 may not have understood the comment due to his cognitive status, the language used had the potential to cause emotional distress. Additionally, the receptionist observed CNA 4 addressing Resident 1 with derogatory language, calling him a 'f*****g pig,' and reported this to the facility administrator. Resident 2, diagnosed with cerebral infarction and dysarthria, was also subjected to disrespectful language by CNA 4. The Activity Assistant reported hearing CNA 4 express frustration towards Resident 2, using profanity and blaming the resident for frequent falls. This incident was also reported to the administrator. The facility's policy on resident rights, which mandates treating all residents with kindness, respect, and dignity, was not adhered to in these instances.
Breach of Resident Privacy Due to Unverified Visitor Access
Penalty
Summary
The facility failed to ensure the personal privacy of a resident when an unknown visitor was allowed into the resident's room. The incident involved a resident who was cognitively intact and had the capacity to understand and make decisions. The resident reported that a Certified Nurse Aide (CNA) escorted an unknown female into her room, who then hugged her and began talking to her. The visitor falsely claimed to be the resident's sister to gain access. This encounter caused the resident to feel uncomfortable and emotionally distressed. The CNA admitted to not verifying the visitor's identity and assumed the visitor and the resident knew each other. The facility's policy requires visitors to check in at the front desk, sign in, and state their business, which was not followed in this case. Interviews with facility staff, including a Registered Nurse and the Director of Staff Development, confirmed that the proper procedure was not adhered to, and the incident was acknowledged as a violation of the resident's privacy. The facility's Administrator also recognized the potential for abuse and emotional distress caused by allowing unknown visitors access to residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged abuse involving two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved inappropriate language used by a Certified Nurse Aide (CNA) towards the residents. The CNA referred to one resident as a 'pimp' and used offensive language in the presence of another resident. The facility's Administrator became aware of the allegations on the morning of September 25, 2024, but the report to CDPH was not made until later that evening, at 7:02 p.m. Resident 1, who has a moderate cognitive impairment and cannot make medical decisions, was subjected to inappropriate language by the CNA. Resident 2, also with moderate cognitive impairment and similar decision-making limitations, was present during the incident. Both residents have significant medical histories, including brain disorders and mental health issues. The delay in reporting the incident to CDPH could have resulted in a delayed investigation and corrective actions, potentially placing the residents at further risk.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent the elopement of a resident, identified as Resident 3, who was admitted with a lumbar fracture and a history of falls, alcohol abuse, altered level of consciousness, and anxiety. Upon admission, Resident 3 expressed a desire to go home, indicating a risk for elopement. Despite this, the facility did not have a photograph of the resident on file, as required by their policy for residents at risk of elopement. The care plan for Resident 3 included interventions for wandering and elopement, but these were not effectively implemented. On the morning following Resident 3's admission, a housekeeper observed an unknown male leaving the facility, and later, a CNA discovered that Resident 3 was missing from his room. The front entrance was found to be unlocked, and there was no staff at the reception desk. Interviews with staff revealed that the facility's procedures for monitoring and securing the premises were not adequately followed, contributing to the resident's unsupervised departure. The lack of a photograph and the failure to secure the facility's entrance were significant factors in the resident's elopement.
Resident Dignity Compromised by Staff's Use of Offensive Language
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident when a staff member used offensive language in response to the resident's actions. The incident occurred during an unannounced visit to investigate a complaint. The resident, who had been admitted with chronic obstructive pulmonary disease (COPD), asthma, and depression, was experiencing shortness of breath and called emergency services for assistance. Despite being offered a rescue inhaler and breathing treatment by a Licensed Vocational Nurse (LVN), the resident refused and was transported to the hospital. During the investigation, a review of the 9-1-1 dispatch calls revealed that a staff member used foul language towards the resident, telling him to stop turning his call light on if he wanted to be left alone. This behavior was in direct violation of the facility's policies on resident rights and employee conduct, which emphasize treating residents with kindness, respect, and dignity, and prohibit the use of offensive language. The facility's Administrator and Director of Nursing were unable to identify the staff member responsible for the inappropriate conduct.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately assess, monitor, and supervise a resident, leading to an elopement incident. The resident, who was admitted with Alzheimer's Disease and had a severely impaired cognition score of 6 on the Brief Interview of Mental Status (BIMS), was observed wandering and confused prior to the incident. On the evening of the elopement, the resident was left unsupervised when the Licensed Vocational Nurse (LVN) left the nurse's station to make rounds, despite the resident's known wandering behavior. The facility's policy on wandering and elopement requires the identification and assessment of residents at risk for elopement, but this was not effectively implemented in this case. The resident eloped from the facility and was later found and returned by the police, unharmed. The LVN acknowledged the need for continuous supervision, and the facility's administrator confirmed that sitters could be provided when a risk for elopement is identified, but this protocol was not followed, resulting in the resident's unsupervised departure.
Facility Fails to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit, resulting in discomfort for residents and potential health risks. During an unannounced visit, it was observed that two resident rooms and a common area exceeded the maximum temperature limit, with one room reaching 82.9 degrees Fahrenheit and the activity room at 81.5 degrees Fahrenheit. This deficiency was identified through observations, interviews, and record reviews. Resident 1, who has a history of mitral valve prolapse, hypertension, and anxiety disorder, was found in her room with a portable air conditioner and fan running, yet still expressed discomfort due to the heat. Her medical records indicated she was cognitively intact, but her history and physical assessment suggested she lacked decision-making capacity. Resident 2, diagnosed with cholelithiasis, muscle weakness, and dementia, also reported feeling too hot and uncomfortable, despite having similar cooling devices in her room. Her records showed moderate cognitive impairment, but she was capable of participating in her care. The facility's Maintenance Assistant confirmed that one of the four main air conditioning units was not functioning, and portable units were provided to residents who complained. Temperature checks conducted by the Maintenance Assistant and the Director of Nursing revealed several rooms with temperatures above the acceptable range. Interviews with staff, including a Licensed Vocational Nurse and the Director of Nursing, highlighted the risks associated with high temperatures, such as dehydration and exacerbation of medical conditions. The facility's policy mandates maintaining a comfortable environment, but the failure to do so led to the identified deficiency.
Failure to Provide Financial Documents Within Required Timeframe
Penalty
Summary
The facility failed to provide a resident's representative with requested financial documents within the required 48-hour timeframe. The resident, who was severely cognitively impaired, had been discharged from the facility earlier in the year. The representative initially requested the financial documents on June 7, 2024, but the Business Office Assistant (BOA) had not responded to the request by June 13, 2024, as the documents were still being collected. The BOA admitted to not being aware of the facility's policy regarding the timeframe for responding to such requests. Further interviews revealed that the Business Office Manager (BOM) was also uncertain about the policy, initially believing the timeframe to be two weeks. However, upon reviewing the facility's policy, it was confirmed that financial document requests should be fulfilled within 48 hours, excluding weekends and holidays. The documents were eventually sent to the resident's representative on June 17 and June 20, 2024, well beyond the stipulated timeframe.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician regarding a change in treatment plan for a resident who refused emergency room evaluation after experiencing a fall. The resident, who had a history of hemiplegia, hemiparesis, difficulty walking, and falling, was assessed for injuries and an order for a CT scan was made. However, when the resident refused to go to the ER, the physician was not notified of this refusal, contrary to the facility's practice of notifying the physician on the same day. This lapse was confirmed by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) during interviews and record reviews. Additionally, the facility failed to notify the physician on the same day when the resident slid off their wheelchair in the activity room. The resident was assessed and found to have no injuries, but the physician was not notified until the following day. This delay in notification was also confirmed by the LVN and the DON, who stated that the facility's policy requires physician notification on the same shift if there is no sign of injury. Both incidents were found to jeopardize the health and safety of the resident.
Failure to Conduct IDT Meeting and Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to ensure a safe environment according to their fall management policy and procedure for a resident. The facility did not conduct an Inter-disciplinary Team (IDT) meeting to determine the root cause of the resident's fall on February 24, 2024. Additionally, the facility did not accurately assess the resident's fall risk after the resident sustained another fall on March 20, 2024. The resident had a history of hemiplegia, hemiparesis, difficulty walking, and a history of falling. Despite these conditions, the necessary IDT meeting was not held, and the fall risk assessment was not updated accurately, which could have helped in preventing further falls. The resident's records indicated that after the fall on February 24, 2024, the resident was assessed for injuries, and the fall was discussed during a staff huddle. However, no IDT meeting was held to develop interventions after determining the root cause. Furthermore, after the resident's fall on March 20, 2024, the fall risk evaluation did not account for the resident's use of psychotropic medications, which was confirmed by the LVN and the DON. The facility's policy required the IDT to review and update the resident's fall risk status and care plan post-fall, which was not followed in this case.
Failure to Ensure Physician's Order and Proper Storage of Nutritional Supplements
Penalty
Summary
The facility failed to ensure that two bottles of oral nutritional supplements for one resident had a physician's order and were not stored by the bedside. During an observation and interview, it was found that the resident had two bottles of Juice Plus nutritional supplements on his bedside table, one opened and one unopened. The resident confirmed that he had been taking the supplements. A review of the resident's records showed no documented evidence of a physician's order for the supplements or permission to store them by the bedside. The resident had diagnoses of hypertension, chest pain, kidney disease, and dysphagia. Interviews with two registered nurses confirmed that the resident did not have a physician's order for the supplements and that medication should not be stored by the bedside. The facility's policy, reviewed with the administrator and a licensed vocational nurse, indicated that residents should be assessed for the ability to self-medicate and that medications should be locked and secured. The policy also stated that bedside medication storage is only permitted with a written order from the prescriber. The administrator acknowledged that residents' medication should not be stored at the bedside.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide bed hold notification for a resident prior to discharge to acute care. The resident, who had diagnoses including sepsis, end-stage renal disease, and dependence on dialysis, was admitted to the facility and later discharged to an emergency room due to discoloration on an amputation site. Despite the facility's policy to notify residents of their bed hold rights upon transfer, there was no documentation indicating that the resident was informed of the bed hold option at the time of discharge. Interviews with the facility's Administrator, Business Office representative, and Registered Nurse Supervisor revealed that the facility typically extends a 7-day bed hold for Medi-Cal residents and a 3-day courtesy bed hold for others. However, the bed hold agreement for the resident in question, signed at admission, did not include a notification section completed upon transfer. The facility's policy requires written notification of the bed hold option any time a resident is transferred to an acute care hospital or requests therapeutic leave, which was not adhered to in this case.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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