California Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 909 S Lake Street, Los Angeles, California 90006
- CMS Provider Number
- 055461
- Inspections on file
- 68
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 53 (2 serious)
Citation history
Health deficiencies cited at California Post Acute during CMS and state inspections, most recent first.
Two residents with DM, impaired cognition, and recent unplanned weight loss did not receive fully implemented and clearly specified nutritional and weight-monitoring interventions as outlined in their care plans. For one resident with dysphagia and pneumonitis, the care plan called for meal intake to be monitored and recorded at each meal, but intake was only documented on scattered dates and times, and the care plan did not specify the frequency, time of day, or type of scale for weight checks. For another resident with protein-calorie malnutrition and reduced mobility, the care plan also lacked defined frequency, time, and scale for weight monitoring despite a documented seven-pound loss in one week. The DON confirmed that meal intake monitoring was inconsistent and that both care plans were missing specific details required for effective weight management.
A resident with DM, protein calorie malnutrition, reduced mobility, moderately impaired cognition, wounds, and an indwelling catheter required extensive assistance with ADLs. The MDS documented the indwelling catheter, and the resident was observed in bed with the catheter in place, but the care plan only reflected Enhanced Barrier Precautions (EBP) for a wound and did not include the catheter. During interview and record review, the DON confirmed the resident should be on EBP due to both wounds and the indwelling catheter and that no physician order for EBP had been obtained, despite facility policies requiring timely care plan revision and indicating EBP for residents with wounds and/or indwelling medical devices.
A resident with morbid obesity, muscle weakness, chronic pain syndrome, and impaired lower-extremity ROM, who was cognitively intact and wheelchair-bound, received a special manual wheelchair paid for by health insurance and delivered to the facility for her personal use. The wheelchair was not added to the resident’s personal property inventory as required by facility policy, and when the resident was transferred to a hospital and later admitted to another facility, the wheelchair was not returned. The ADM reported not knowing what happened to the wheelchair and confirmed it was not listed on the belongings inventory, while the DOR and the wheelchair company confirmed that the wheelchair was resident-owned and that the facility was responsible for its safekeeping, resulting in the resident being without her wheelchair for mobility.
A resident with multiple medical and behavioral diagnoses left the facility unsupervised and was missing for several hours before returning. Staff notified the police and searched for the resident, but did not report the elopement to the State Survey Agency or investigate how the resident was able to leave, contrary to facility policy.
Two exit doors, including the main entrance and a door near the kitchen, were found to have non-functioning locks. Multiple staff members, including an LVN, housekeeping, the receptionist, the maintenance supervisor, and the DON, were unable to secure these doors after visiting hours as required by facility policy. Policy review confirmed the expectation that these doors be locked at night for safety.
A resident with schizophrenia and other medical conditions was not permitted to return to the facility after a psychiatric hospitalization, despite being ready for discharge and the facility's policy allowing return after hospitalization. The facility refused re-admission due to the resident's prior aggressive behavior and AMA departure, without required physician documentation supporting the refusal.
A resident with multiple medical conditions did not have a physician-ordered blood draw completed as scheduled. The lab service log indicated a refusal, but the resident denied refusing, and there was no documentation in the nursing notes to support a refusal. The LVN signed the log but did not document the event, and the DON confirmed that such refusals should be documented and the physician notified.
A resident with schizophrenia and end stage renal disease experienced continuous side effects from Quetiapine, as documented in the MAR over multiple days. Despite facility policy and physician orders requiring monitoring and notification for adverse reactions, staff did not notify the physician or initiate a Change of Condition, as confirmed by interviews with the RN Supervisor and DON.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
The facility did not ensure proper care for pressure ulcers and failed to prevent new ulcers from developing. Staff did not consistently follow protocols for assessment, monitoring, and treatment, leading to inadequate interventions for a resident with existing ulcers and insufficient preventive measures for those at risk.
The QAPI and QAA committees did not identify or discuss issues related to CPR and dialysis, as confirmed by the absence of these topics in meeting minutes and statements from the IDON. This failure meant that concerns affecting residents needing dialysis or CPR were not addressed by the facility's quality improvement processes.
Two residents received psychotropic medications without adherence to required protocols: one continued on an antipsychotic without a documented gradual dose reduction despite no recent symptoms, and another received anti-anxiety medication without informed consent from the responsible party, even though the resident was unable to make medical decisions. Facility policy requiring informed consent and regular medication review was not followed.
The facility did not maintain complete employee files for several staff members, including an LVN, a treatment nurse, and the interim DON, as required documentation such as performance evaluations, skills competency checklists, and BLS certifications were missing. Interviews and record reviews confirmed these omissions, despite facility policies mandating such records to ensure staff competency and CPR readiness.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Surveyors found that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the acceptable threshold.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
During a meal service, pureed foods including meat, corn, and potato were prepared with a thin, loose consistency that did not meet IDDSI Level 4 standards. The Dietary Supervisor and a cook confirmed the foods did not hold their shape and were more liquid than required, due to excess liquid being added during preparation. Facility recipes and IDDSI guidelines specify that pureed foods must be smooth, hold their shape, and pass specific consistency tests, which was not achieved in this instance.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of the resident's care needs.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Surveyors observed that trash bins, including one large bin and two recyclable bins, were left uncovered and overfilled with boxes, with a cat present in the area. Both the dietary and maintenance supervisors acknowledged that bins should be covered and boxes broken down to prevent pest attraction, but these practices were not followed, resulting in unsanitary conditions.
A resident with incontinence, limited mobility, and multiple comorbidities developed Moisture-Associated Skin Damage (MASD) in the perineal area due to insufficient perineal care and inadequate monitoring for incontinence. Despite a care plan outlining necessary interventions, staff provided perineal care only twice per shift, leading to skin breakdown, pain, and visible skin injury.
A resident with heart failure and muscle weakness, who required assistance with food setup, was served a meal containing items specifically listed as dislikes on their meal ticket. The resident also reported not consistently receiving preferred meal options, and the dietary supervisor confirmed that such preferences are accessible to kitchen staff but were not followed.
A resident was discharged home in stable condition with her family and medications, but the facility did not complete or transmit the required MDS discharge assessment to CMS. Review of records and staff interviews confirmed that the discharge MDS was not created or sent, as required by facility policy and federal regulations.
A resident with heart failure and muscle weakness experienced a lack of privacy because of broken window blinds, which allowed visibility into her room from the main street. Staff and the DON acknowledged that the issue affected resident privacy and comfort, and the facility's policy on dignity was not upheld.
Staff did not promptly inform a resident, the resident's doctor, and a family member about events such as injury, decline, or room changes that affected the resident, as required by regulations.
A resident with multiple chronic conditions was not provided with a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) when Medicare Part A skilled services ended, despite facility policy requiring such notification. Staff interviews revealed a lack of understanding of the SNFABN process, and the resident was not informed of their potential financial liability or appeal rights.
A resident with multiple medical conditions and impaired hand mobility did not receive prescribed resting hand splints due to their unavailability, as observed by staff and confirmed through interviews. This omission led to worsening contractures and pain during passive range of motion exercises, despite clear therapy recommendations and facility policy requiring such interventions.
A resident with significant mobility impairments and on anticoagulant therapy was not frequently visually monitored as required by the care plan, despite being at high risk for falls. The resident was found with curtains drawn around the bed, making monitoring difficult, and staff confirmed that frequent checks were not performed. The resident experienced a fall but did not sustain injury. The facility's fall risk assessment was inaccurate, and the policy requiring adequate supervision was not followed.
A resident with a gastrostomy tube was found with an unlabeled and undated syringe and tube feeding formula at the bedside. An LVN confirmed the items should have been labeled and dated, and the interim DON acknowledged that this failure could result in expired formula being administered. Facility policy requires all enteral feeding containers to be properly labeled and dated to ensure safe administration.
The facility did not ensure proper infection control measures for two residents: one did not have a required physician order for enhanced barrier precautions (EBP) despite having wounds, and another had conflicting signage for contact precautions and EBP outside their isolation room, potentially causing staff confusion about PPE use. These lapses were identified through observation, interview, and record review.
Rooms designated for multiple residents were found to be less than 80 square feet per resident, and single resident rooms were less than 100 square feet, as required by regulations.
Two laundry carts containing clean linen and towels were observed stored in the facility's parking lot, covered with plastic, due to a lack of indoor space. The Maintenance Supervisor confirmed the carts held clean linen, and the interim DON stated this practice was unhygienic and an infection control issue. Facility policy requires clean linen to be stored and transported in a safe and aseptic manner, with carts covered and kept in designated indoor areas.
A resident with impaired cognition and a known elopement risk left the facility unsupervised while an LVN was assisting another individual. Although the facility notified police, family, and internal leadership, the DON and administrator did not report the elopement to the SSA as required by policy, resulting in a delay in investigation and assurance of the resident's safety.
A resident with cognitive impairment and a documented risk for elopement was left unsupervised when the assigned staff member assisted another individual, resulting in the resident leaving the facility and being found several miles away. Despite care plans and facility policy requiring one-to-one supervision, this was not provided at the time of the incident.
A resident with multiple diagnoses, including Parkinson's disease and heart failure, was identified as underweight and in need of additional calories. Despite being assessed as malnourished and receiving high protein supplements, no care plan was developed or implemented to address or monitor the resident's nutritional and hydration needs, contrary to facility policy.
A resident with multiple health conditions and an indwelling catheter did not have their fluid intake and urine output consistently monitored as ordered by the physician, and was not provided with a fortified diet as recommended by the RD. The RD did not follow up on the resident's nutritional needs after the initial assessment, and documentation of urine output was incomplete, leading to inadequate evaluation of the resident's hydration and nutritional status.
A resident who was dependent on staff for toileting and other daily activities did not receive timely assistance during the night shift due to inadequate CNA staffing. Only two CNAs were available for 48 residents after two scheduled CNAs called in sick and were not replaced, resulting in the resident waiting for hours for help and experiencing distress.
A facility failed to follow physician orders for a resident with dysphagia, gastrostomy, and dementia, resulting in unmonitored nutritional and fluid needs. The resident experienced significant weight loss, and the registered dietitian did not conduct necessary assessments or meetings. Additionally, the facility did not document intake and output monitoring as ordered, despite the resident receiving gastrostomy tube feeding. The facility's policies required comprehensive nutrition assessments and monitoring, which were not adhered to.
A facility failed to follow physician orders for a resident receiving enteral nutrition through a gastrostomy tube, including maintaining head elevation and checking tube placement. The resident, with conditions such as dysphagia and dementia, was at high risk for aspiration. The lack of adherence to these protocols was confirmed by the DON and a nurse practitioner, who noted the potential for aspiration pneumonia due to improper positioning.
A facility failed to document a care meeting for a resident with dysphagia, a gastrostomy, and dementia, resulting in an incomplete medical record. Despite the meeting involving the resident's responsible party and facility staff, it was not recorded due to being considered informal. The DON acknowledged the need for documentation as per facility policy.
A resident with schizoaffective disorder and cognitive impairment exhibited aggressive behavior, which was not properly assessed or addressed by the facility's interdisciplinary team. This led to the resident sexually abusing a cognitively impaired roommate. The facility failed to follow its policies on behavior assessment and abuse prevention, resulting in a deficiency in protecting residents from abuse.
A resident reported a fall and subsequent back pain, but the LTC facility failed to assess the resident immediately or notify the physician promptly. The resident contacted his own doctor, who ordered an MRI, but the facility delayed the MRI by 19 days due to authorization issues. The facility did not follow its policies on change in condition and assessing falls, leading to significant deficiencies in care.
A resident with visual impairment and a history of falls experienced another fall due to the facility's failure to follow physician's orders for visual hourly safety checks and to update the At Risk for Falls Care Plan. The resident fell from the bed, resulting in a laceration and subsequent admission to the ICU for an acute stroke. The facility's outdated care plans and incorrect documentation contributed to inadequate supervision and failure to implement necessary interventions.
A resident was administered quetiapine fumarate (Seroquel) without informed consent. Despite being cognitively intact, the resident was not informed about the medication's risks and benefits and did not sign a consent form. The DON confirmed the oversight, which violated the facility's policy requiring informed consent documentation before administering psychotherapeutic drugs.
A facility failed to provide proper indication and monitoring for a resident started on Seroquel. The physician's order lacked the indication and targeted behavior, and the informed consent was incomplete. The resident was not monitored for adverse reactions, contrary to facility policy. Interviews with staff confirmed these deficiencies.
A resident with a high fall risk and dependency on staff for toilet transfers fell and sustained a hip fracture due to inadequate supervision and assistance. The facility failed to follow the care plan requiring assistance every two hours, and care plans were not updated or revised as needed. Staff interviews revealed the resident was confused and did not consistently use call lights, and the facility did not document required rounds for toileting assistance.
A resident with severe cognitive impairment and incontinence was not properly monitored for bladder habits, leading to a fall and injury. The care plan required assistance every two hours, but staff conducted random checks instead. The resident attempted to go to the bathroom independently, resulting in a fall and a fracture. The facility failed to update the care plan to address the resident's high fall risk.
A facility failed to update a resident's care plans quarterly, as required, for risks related to falls, incontinence, and ADLs. The resident, with a history of muscle weakness, cognitive deficits, and chronic kidney disease, was dependent on staff for mobility and toileting. Despite the facility's policy mandating quarterly updates, the care plans were not revised in June 2024, as confirmed by staff interviews.
A resident with moderate cognitive impairments alleged being slapped by a CNA, an incident supported by another resident and a CNA who heard the slap. Despite reports to the RN and DON, the facility failed to investigate or report the incident to authorities. The facility's policy requires thorough investigation and reporting, but no documentation was provided to confirm this occurred.
A resident was injured during a transfer using a hoyer lift when a CNA failed to control the lift properly, causing it to lower quickly and hit the resident in the face. The facility did not investigate the incident or inspect the lift for malfunctions, contributing to the deficiency.
Failure to Implement and Specify Nutritional and Weight Monitoring in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to implement and specify care plan interventions related to nutritional monitoring and weight management for two residents with unplanned weight loss. For one resident with diagnoses including DM, dysphagia, and pneumonitis, and with moderately impaired cognition and dependence on staff for most ADLs, the care plan initiated on 12/31/25 identified unplanned/unexpected weight loss related to poor oral intake and food refusal, with a goal of no further weight loss for three months. The care plan interventions required monitoring and recording food intake at each meal and weighing the resident at the same time using a specified scale, but the frequency, time of day, and scale type were not actually documented. Review of the meal intake records showed that this resident’s intake was only recorded on scattered dates and times rather than after each scheduled meal, and the DON acknowledged that monitoring of this resident’s meal intake was inconsistent despite established mealtimes. For the second resident, admitted with DM, protein-calorie malnutrition, reduced mobility, moderately impaired cognition, and dependence or substantial assistance for most ADLs, the care plan initiated on 12/10/25 documented an unplanned/unexpected seven-pound weight loss in one week related to disease process, with a goal of no further weight loss for three months. The nursing interventions included weighing the resident at the same time of day and recording the weight, but again the care plan did not specify the frequency of weighing, the time of day, or the scale to be used. During concurrent interview and record review, the DON confirmed that the care plans for both residents lacked these specific details and stated that the care plan should be specific and thorough. Facility policies on comprehensive care plans and weight management required development and implementation of person-centered care plans and review and updating of care plans as indicated, but the documented care plans for these two residents did not include the required specificity for weight monitoring.
Failure to Revise Care Plan and Obtain EBP Order for Resident With Indwelling Catheter
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to timely and accurately revise the comprehensive care plan and obtain appropriate orders related to infection control precautions for one resident. The resident was admitted with diagnoses including diabetes mellitus, protein calorie malnutrition, and reduced mobility, and had moderately impaired cognition per the MDS. The MDS also documented that the resident had an indwelling catheter and was dependent on staff for toileting hygiene, bathing, dressing, and required assistance with oral hygiene and eating. The facility’s care plan, initiated on 7/3/24, indicated the resident was on Enhanced Barrier Precautions (EBP) due to a wound but did not reflect that the resident also had an indwelling catheter, despite this being documented elsewhere in the record. During observation, the resident was seen lying in bed with an indwelling catheter hanging on the right side of the bed. In a concurrent interview and record review with the DON, it was confirmed that the resident should be on EBP because of both wounds and the indwelling catheter, and that there was no physician order in place to initiate EBP for this resident. The DON acknowledged that the care plan should be revised and that a physician order was needed to place the resident on EBP. Facility policies stated that care plans must be reviewed and revised at least quarterly or more often as the resident’s condition warrants, and that EBP are indicated for residents with wounds and/or indwelling medical devices even if they are not known to be infected or colonized with MDROs. The failure to revise the care plan to include the indwelling catheter and to obtain a physician order for EBP had the potential to spread infection to other residents, staff, and visitors.
Failure to Safeguard and Inventory Resident-Owned Wheelchair Resulting in Loss
Penalty
Summary
The facility failed to protect a resident’s personal property and maintain an accurate inventory of belongings, resulting in the loss of the resident’s wheelchair. The resident, who had diagnoses including morbid obesity, muscle weakness, and chronic pain syndrome, was cognitively intact and used a manual wheelchair for mobility, with impaired range of motion in both lower extremities. Social services documentation showed that the resident was evaluated by a wheelchair company for a special wheelchair and that the new wheelchair was delivered to the resident, with the facility’s social service designee signing the delivery ticket. The wheelchair was paid for by the resident’s health insurance and was owned by the resident. However, the wheelchair was never added to the resident’s clothing and possessions list, despite facility policy requiring that personal belongings be inventoried upon admission and as items are replenished. When the resident was transferred to a general acute hospital and later admitted to another facility, the resident’s wheelchair was not returned. During interviews, the director of rehabilitation confirmed that the resident was wheelchair-bound, that the wheelchair was specifically fitted for the resident, and that it belonged to the resident for her own use and to take upon discharge. The administrator stated he did not know what happened to the wheelchair, acknowledged there was no invoice available, and confirmed the wheelchair was not added to the resident’s belongings list. A customer service representative from the wheelchair company confirmed that the resident’s health insurance paid for the wheelchair, that it was delivered to the facility, that the resident owned it, and that the facility was responsible for replacing the lost wheelchair. These failures resulted in the resident’s wheelchair being lost and the resident not having a wheelchair for mobility.
Failure to Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to implement its abuse policy for one of two sampled residents when it did not report an elopement incident to the State Survey Agency (SSA) and did not investigate how the resident was able to leave the premises unsupervised. The resident, who had diagnoses including low back pain, osteomyelitis of the left shoulder, and a history of mental and behavioral disorders, was cognitively intact and required varying levels of assistance with daily activities. On the date of the incident, staff discovered the resident missing at approximately 6:30 a.m. and were unable to locate him despite searching the facility and contacting local hospitals. Attempts to reach the resident by cell phone were unsuccessful, and the police were notified to assist in the search. The resident returned to the facility at 1 p.m. the same day, at which point the police were informed that the missing person case was resolved. Documentation in the nursing progress notes confirmed the timeline of the resident's absence and the actions taken by staff, including notification of the physician and police. Interviews with staff, including LVNs, the registered nurse supervisor, the DON, and the administrator, revealed that the incident was not reported to the SSA as required by facility policy. Additionally, there was no investigation into how the resident was able to elope from the facility. The facility's policies on wandering, elopement, and reporting of alleged violations require immediate reporting and investigation of such incidents, but these procedures were not followed in this case.
Failure to Maintain Functioning Locks on Exit Doors
Penalty
Summary
The facility failed to ensure that two of five exit doors, specifically the main entrance (Door 1) and the door near the kitchen (Door 2), were properly fitted with functioning locks. Multiple staff members, including an LVN, housekeeping personnel, the receptionist, the maintenance supervisor, and the DON, attempted to lock these doors using their keys but were unable to do so. Observations and interviews confirmed that both doors could not be locked, even after visiting hours, despite facility policy requiring these doors to be secured at night for safety reasons. A review of the facility's policies and procedures indicated that the maintenance director is responsible for maintaining a safe and operable environment, including ensuring that doors are locked as required. The receptionist and maintenance supervisor both stated that the doors should be locked after visiting hours, especially given the facility's location. The DON also confirmed that the doors do not latch and should be locked for safety. The lack of functioning locks on these doors was directly observed and verified through staff interviews and policy review.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating the resident's right to return and remain at the facility. The resident, who had diagnoses including schizophrenia, osteoarthritis of the knees, and generalized muscle weakness, was admitted and noted to be alert and oriented. On the morning of the incident, the resident became verbally and physically aggressive, leading staff to contact the police. The resident expressed a desire to leave against medical advice (AMA), was informed of the risks and benefits, but refused to sign the AMA form. The police subsequently took the resident to a general acute care hospital (GACH) for psychiatric evaluation. When the hospital contacted the facility to coordinate the resident's discharge and return, the facility refused re-admission, citing the resident's prior aggression and AMA departure. Facility staff, including the admission coordinator and administrator, confirmed the refusal, stating the resident was not welcome back due to the incident. There was no physician documentation indicating the facility was an inappropriate placement for the resident, and the facility's own policy permitted residents to return following hospitalization or therapeutic leave. The policy also required specific physician documentation if a transfer or discharge was necessary for safety reasons, which was not present in this case.
Failure to Obtain and Document Ordered Blood Draw
Penalty
Summary
The facility failed to ensure that a blood sample was collected from a resident as ordered by the physician. The physician had ordered a complete blood count (CBC), basic metabolic panel (BMP), c-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to be obtained on a specific date. The laboratory service log indicated that the resident refused the blood draw, and this was signed by an LVN. However, during an interview, the resident stated that he was waiting for the blood sample to be collected and was told he had refused, which he denied. There was no documentation in the nursing progress notes to confirm that the resident refused the blood draw, and the LVN stated she did not document a refusal. The registered nurse supervisor confirmed the lack of documentation and stated that such events should be recorded to clarify what occurred. The resident involved had been admitted with diagnoses including osteomyelitis of the cervical region, right ankle and foot, and diabetes mellitus, and required substantial assistance with daily activities. The facility's policies required that laboratory services ordered by a physician be completed in a timely manner and that any deviations, such as a resident refusal, be documented in the nursing notes. The director of nursing also confirmed that refusals should be documented and the physician notified. The failure to document the refusal and to obtain the blood sample as ordered constituted the deficiency.
Failure to Notify Physician and Initiate Change of Condition for Ongoing Antipsychotic Side Effects
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not notifying the physician or initiating a Change of Condition (COC) when the resident experienced continuous side effects from Quetiapine, an antipsychotic medication. The resident, who had diagnoses including schizophrenia and end stage renal disease requiring dialysis, was documented as experiencing side effects such as sedation, drowsiness, and other symptoms on multiple consecutive days, as recorded in the Medication Administration Record (MAR). Despite these ongoing side effects, there was no evidence that the physician was notified or that a COC was initiated, as required by facility policy and physician orders. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the physician should have been notified and a COC initiated due to the persistent side effects. The facility's policies required monitoring, documentation, and reporting of adverse reactions to antipsychotic medications, as well as physician notification for significant changes in a resident's condition. However, these procedures were not followed, as indicated by the lack of documentation of physician notification or COC initiation, despite clear evidence of ongoing adverse effects.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that staff did not consistently follow established protocols for pressure ulcer prevention and care, resulting in inadequate interventions for residents with existing ulcers and insufficient preventive actions for those at risk.
QAPI Committee Failed to Address CPR and Dialysis Concerns
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address concerns related to cardio-pulmonary resuscitation (CPR) and dialysis services. During an interview and record review with the Interim Director of Nursing (IDON), it was confirmed that CPR and dialysis were not discussed or included in the QAPI meeting minutes. The IDON acknowledged that if these topics were not listed in the meeting minutes, they were not addressed during the QAPI meeting. A review of the facility's QAPI policy indicated that the committee is responsible for identifying and addressing specific care and quality issues, implementing action plans, and using data to monitor performance. Despite this, the QAPI committee did not include CPR and dialysis in their discussions or evaluations, as evidenced by the absence of these topics in the meeting minutes. This omission had the potential to impact residents who receive dialysis or require CPR, as concerns in these areas were not identified or addressed by the committee.
Failure to Ensure Gradual Dose Reduction and Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary psychotropic medications and that proper procedures were followed regarding medication management. For one resident with a history of schizophrenia, cognitive communication deficit, and depression, the facility did not perform a required gradual dose reduction (GDR) for risperidone, despite a medication regimen review indicating that a GDR was due. Documentation showed that the resident had not exhibited symptoms such as hallucinations or behavioral disturbances for several months, yet the antipsychotic medication was continued at the same dosage without documented clinical justification or evidence of a GDR attempt. Additionally, the facility failed to obtain proper informed consent for the administration of alprazolam to another resident diagnosed with dementia, schizophrenia, and anxiety. Although the resident was taking anti-anxiety medication, the informed consent form was signed by the resident, who was documented as unable to make medical decisions, rather than by the responsible party (RP) designated to make such decisions. Both nursing staff and the interim director of nursing confirmed that the RP should have provided consent, and acknowledged that the lack of RP signature meant the resident and their representative may not have been fully informed about the medication being administered. Facility policy required that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications, and that documentation of this informed consent be maintained. In both cases, the facility did not adhere to its own policies and procedures regarding psychotropic medication management and informed consent, resulting in deficiencies related to medication safety and resident rights.
Incomplete Staff Competency and Certification Documentation
Penalty
Summary
The facility failed to ensure that the employee files for three of five sampled staff members, including a Licensed Vocational Nurse, a Treatment Nurse, and the Interim Director of Nursing, contained required documentation such as performance evaluations, skills competency checklists, and Basic Life Support (BLS) certifications. During interviews and record reviews with the Director of Staff Development, it was found that the Licensed Vocational Nurse's file was missing a BLS certification, skills competency checklist, and a current performance evaluation. The Interim Director of Nursing's file lacked a skills competency checklist, and the Treatment Nurse's file was missing both a skills competency checklist and a current performance evaluation. The Director of Staff Development and the Interim Director of Nursing confirmed that these documents were not present in the respective employee files and acknowledged the importance of having them to ensure staff proficiency and readiness to provide care, including resuscitative efforts. Facility policies reviewed indicated that employee job performance should be evaluated and that staff should be properly trained in CPR, but these requirements were not met for the sampled employees.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices and the resulting error rate.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals within the facility.
Failure to Follow IDDSI Level 4 Pureed Diet Standards
Penalty
Summary
The facility failed to ensure that standardized recipes for pureed diets were followed during lunch service, resulting in pureed foods that did not meet the required International Dysphagia Diet Initiative (IDDSI) Level 4 consistency. Observations during the tray line service revealed that pureed meat, corn, and potato had a thin and loose consistency, spreading out flat on the plate and failing to hold their shape. When tested, the pureed foods dripped through the fork prongs and were described as being on the liquid side. Both the Dietary Supervisor and the cook confirmed that the pureed foods were not at the correct consistency, with the cook admitting to using more liquid than the recipe specified in an attempt to make the food smoother. A review of the facility's recipes for pureed meats and vegetables indicated that foods should be pureed to a paste consistency before adding any liquid, and the finished product should be smooth, free of lumps, hold its shape, and not separate into liquid and solid. The recipes also required that the pureed foods pass IDDSI Level 4 testing methods, including the fork drip, fork pressure, and spoon tilt tests. The IDDSI guidelines further specify that Level 4 pureed foods should fall off a spoon in a single spoonful, hold their shape on the plate, and not have liquid separation. These requirements were not met during the observed meal service.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey and was based on a review of the resident's records, which did not contain a comprehensive care plan as required.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Unsanitary Trash Storage and Uncovered Bins
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas in a sanitary manner. During an observation, one large trash bin was found uncovered and two recyclable trash bins were overfilled with boxes and left uncovered. A cat was observed around the trash area in the parking lot. The dietary supervisor confirmed that trash bins needed to be covered to prevent animals from feeding and to avoid attracting flies. The maintenance supervisor also stated that trash was picked up twice a week, boxes should be broken down to allow more space, and lids should be closed to prevent animals from accessing the trash and to deter pests. A review of the facility's policy and procedures indicated that garbage and refuse containers are to be maintained in good condition and waste is to be properly contained in dumpsters or compactors with lids covered. Additionally, the FDA Food Code requires that receptacles and waste handling units for refuse, recyclables, and returnables kept outside must be covered with tight-fitting lids or doors, and stored so that they are inaccessible to insects and rodents. The facility did not adhere to these requirements, resulting in the observed deficiency.
Failure to Maintain Perineal Skin Integrity in Dependent Resident
Penalty
Summary
A resident with a history of left above-the-knee amputation, stage 2 pressure ulcer, type 2 diabetes mellitus, and schizophrenia was admitted to the facility and assessed as always incontinent of bladder and bowel, requiring substantial to maximal assistance for activities of daily living, including toileting and personal hygiene. The resident was identified as being at risk for skin injuries, with a care plan in place to keep the skin clean and dry, conduct frequent visual checks, and reposition the resident regularly. Despite these interventions, staff interviews and observations revealed that the resident received perineal care only twice during an 8-hour shift and developed redness, weeping, and excoriation in the perineal area. The resident reported pain during perineal care, and a treatment nurse confirmed the presence of Moisture-Associated Skin Damage (MASD) and dermatitis, with a denuded line and watery exudate below the coccyx, attributed to prolonged exposure to urine and feces due to incontinence. Review of facility policy indicated that exposure to urine and feces increases the risk of skin breakdown, especially in residents with impaired mobility and other comorbidities. The policy required evaluation of resident-specific risk factors and implementation of interventions to prevent skin damage. However, the findings showed that the resident's skin was not maintained in a clean and intact condition, and monitoring for incontinence was insufficient, as the resident should have been checked every two hours. This failure resulted in the development of MASD and discomfort for the resident.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's documented dietary preferences by providing food items that were specifically listed as dislikes on the resident's meal ticket. The resident, who had diagnoses including heart failure and muscle weakness and required assistance with food setup, received a lunch meal consisting of corn, mashed potatoes, and meat with gravy, despite mashed potatoes and gravy being listed as disliked foods. The resident also reported inconsistencies in receiving preferred meal options, such as receiving an omelet instead of scrambled eggs and incomplete toppings for chef's salads. The dietary supervisor confirmed that resident preferences are available to the kitchen through their diet system and acknowledged that receiving disliked foods could result in the resident being upset and not eating. The facility's policy requires that food provided accommodates resident allergies, intolerances, and preferences, but this was not followed in the case of this resident.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment was created and transmitted to the Centers for Medicare and Medicaid Services (CMS) for a resident who was discharged home. The resident had been admitted with diagnoses including urinary tract infection, dysphagia, muscle weakness, and transient cerebral ischemic attack, and was noted to be cognitively intact. Documentation showed that the resident was discharged in stable condition with her family and medications, but review of records and interviews with the MDS Coordinator confirmed that a discharge MDS assessment was not completed or transmitted as required. Facility policy states that MDS data must be encoded and transmitted to CMS within specified timeframes following a resident's discharge. The MDS Coordinator acknowledged that the discharge MDS should have been created on the day of discharge and transmitted within the required period, but this was not done. The last MDS assessment in the system for the resident was a quarterly assessment, and no discharge MDS was present. The Interim Director of Nursing also confirmed that the discharge MDS assessment was not completed or transmitted, which could potentially delay discharge care for the resident.
Resident Privacy Compromised Due to Broken Window Blinds
Penalty
Summary
A deficiency was identified when a resident's right to privacy and dignity was not maintained due to broken window blinds in her room. Observations revealed that one set of blinds had 22 broken slats out of 39, and another set had 5 broken slats out of 33, making the room visible from the main street. The resident reported that someone had measured the windows for new blinds weeks prior, but no further action had been taken, and she continued to lack privacy. The resident expressed concerns about her privacy, especially at night when staff turned on the lights during care, making her visible from outside. Staff interviews confirmed the issue, with a CNA acknowledging that the broken blinds allowed people outside to see into the room and that this could be a privacy issue affecting residents emotionally. The Interim Director of Nursing also confirmed that most rooms faced outside and that the lack of privacy could impact residents' comfort. The facility's policy on dignity emphasized care that promotes and enhances quality of life and dignity, which was not upheld in this instance.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide Required SNFABN Notification to Resident
Penalty
Summary
The facility failed to provide a required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to a resident when Medicare Part A skilled services were ending, as indicated by a review of the resident's records and staff interviews. The resident, who was cognitively intact and had multiple diagnoses including muscle weakness, dysphagia, COPD, type 2 diabetes mellitus, and chronic kidney disease, was not given the SNFABN prior to the termination of Medicare coverage, despite remaining in the facility. The SNF Beneficiary Notification Review form confirmed that the last covered day for Medicare Part A services had passed, and the resident had not exhausted benefit days, yet no SNFABN was issued. Interviews with the Admissions staff and Interim Director of Nursing revealed a lack of familiarity with the SNFABN process and uncertainty about why the notice was not provided. The facility's policy and procedure required that residents be informed of their potential liability for non-covered services and be given the SNFABN at the initiation, reduction, or termination of services. However, the responsible staff did not follow this policy, resulting in the resident not being informed of the end of Medicare coverage or their appeal rights.
Failure to Apply Prescribed Hand Splints Resulting in Worsening Contractures
Penalty
Summary
A resident with a history of right femur fracture, diabetes mellitus, and osteoarthritis was admitted to the facility and assessed as requiring supervision and maximal assistance for activities of daily living. The resident had physician orders and occupational therapy recommendations for the application of resting hand splints to both hands for two hours daily, five times a week, to address impairments and prevent contractures. However, during observations, the resident was seen without the prescribed hand splints, and both hands were noted to be in a contracted position. The Restorative Nurse Assistant (RNA) reported being unable to apply the splints because they were missing. Further review and interviews revealed that the resident experienced pain during passive range of motion exercises, and the occupational therapist determined that the right hand contracture had worsened, with a new contracture developing in the left hand. The facility's policy required the provision of specialized rehabilitative services as assessed in the comprehensive care plan, but the prescribed intervention of hand splint application was not carried out due to the unavailability of the splints.
Failure to Implement Fall Risk Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement the fall risk care plan for one resident by not providing frequent visual monitoring as required. The resident, who had a history of necrotizing fasciitis, generalized muscle weakness, lower leg osteomyelitis, and chronic ulcers on both feet, was admitted with significant mobility impairments and required supervision and assistance with activities of daily living. The care plan specifically called for frequent visual checks to prevent falls, but during observation, the resident was found with curtains drawn around the bed, making visual monitoring difficult, and was not wearing non-slip socks. The resident reported always having the curtains drawn, further impeding staff's ability to monitor her. A review of records revealed that the resident was taking multiple medications, including anticoagulants and antihypertensives, and was assessed as unable to self-transfer. Despite these risk factors, staff interviews confirmed that frequent visual monitoring was not being performed. The resident experienced a fall during the night and self-reported getting back up without injury. The facility's Fall Risk Assessment was found to be inaccurate, and the Interim Director of Nursing acknowledged the importance of following the care plan for frequent monitoring, emphasizing that it is the responsibility of all staff to ensure the resident's safety. The facility's policy required adequate supervision to prevent accidents, which was not followed in this case.
Failure to Label and Date Tube Feeding Supplies
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received appropriate treatment and services to prevent complications related to tube feeding. Specifically, during an observation, an unlabeled and undated syringe and a container of tube feeding formula were found on the resident's bedside dresser. The nurse present confirmed that both the tube feeding container and syringe should have been labeled and dated, and subsequently disposed of the items. The resident in question had diagnoses including dysphagia and gastrostomy, with severely impaired cognition, and was receiving enteral feeding as ordered by a physician. Further review of facility policy indicated that all enteral feeding containers must be labeled with the resident's name, formula type, date, and time of preparation, and that open system formulas should be discarded within eight hours. The facility's interim DON confirmed that failure to label and date tube feeding containers could result in staff not knowing how long the formula had been out, potentially leading to expired formula being administered. The lack of labeling and dating was a direct violation of the facility's policy and placed the resident at risk for gastrointestinal complications.
Failure to Implement and Communicate Proper Infection Control Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two specific deficiencies. For one resident with diagnoses including necrotizing fasciitis, osteomyelitis, and chronic foot ulcers, there was no physician order for enhanced barrier precautions (EBP) despite the presence of wounds on both feet. The Infection Prevention Nurse (IP) confirmed that EBP should have been ordered for this resident, as per facility policy, to ensure staff are aware of the necessary protective measures during care. Additionally, another resident with a history of cerebral infarction, pressure ulcer, muscle weakness, and sepsis was observed to have both contact precautions and EBP signage posted outside their isolation room. The IP stated that only the contact precautions sign should have been displayed due to the resident's MDRO status, as having both signs could cause confusion among staff regarding the appropriate personal protective equipment (PPE) to use. These findings were confirmed through observation, interview, and record review, and were not in accordance with the facility's own policies on EBP and transmission-based precautions.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to provide rooms that meet the required minimum square footage per resident. Specifically, rooms intended for multiple residents did not meet the standard of at least 80 square feet per resident, and single resident rooms did not meet the required 100 square feet. This deficiency was identified based on the physical measurements of resident rooms during the survey.
Clean Linen Stored Outside in Violation of Infection Control Policy
Penalty
Summary
The facility failed to follow its infection control policy regarding the storage of clean laundry. During two separate observations, two laundry carts containing clean linen and towels intended for residents were found stored in the facility's parking lot. Although the carts were covered with plastic, they remained outside for an extended period. The Maintenance Supervisor confirmed that the carts contained clean linen and explained that they were placed outside due to a lack of space inside the facility. The interim DON acknowledged that storing clean linen in the parking lot, even if covered, was unhygienic and constituted an infection control issue. Review of the facility's Laundry and Linen Policy indicated that clean linen should be stored and transported in a safe and aseptic manner, with carts covered and stored in designated areas inside the facility.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The facility failed to report an incident of elopement involving a resident to the state survey agency (SSA) as required by their own policy and federal or state regulations. The resident, who had diagnoses of encephalopathy and anoxic brain damage, was admitted with a documented need for close supervision due to impaired cognition and poor safety awareness, and was identified as an elopement risk. On the day of the incident, the resident eloped while a licensed vocational nurse was temporarily assisting another resident. The facility initiated a search and notified the police, the resident's family, the director of nursing, and the administrator, but did not notify the SSA. Interviews with the director of nursing and the administrator confirmed that the elopement was not reported to the SSA, with the administrator stating the event was not reported because the resident was eventually found. Review of the facility's policy on Unusual Occurrence Reporting indicated that such events, which affect the health, safety, or welfare of residents, must be reported to appropriate agencies within 24 hours. The failure to report the elopement resulted in a delay in the investigation of the incident and in ensuring the resident's safety.
Failure to Provide Required Supervision for Resident at Risk of Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was identified as an elopement risk. The resident, admitted with diagnoses including encephalopathy and anoxic brain damage, had a care plan in place that required constant monitoring and a one-to-one sitter due to impaired cognition and poor safety awareness. Despite these documented needs and interventions, the resident was left unsupervised at the facility's front entrance when the assigned staff member temporarily assisted another resident. During this period, the resident eloped from the facility and was later found at their home, 6.4 miles away. Interviews with facility staff confirmed that no one-to-one sitter was provided on the day of the incident, despite the care plan and prior assessments indicating this was necessary. The facility's policies on wandering, elopement, and resident supervision emphasized the importance of identifying at-risk residents and providing appropriate supervision, but these were not followed in this case. The deficiency resulted from the facility's failure to implement required supervision and safety measures for a resident at high risk for elopement.
Failure to Develop and Implement Nutrition Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan to address the nutritional and hydration needs of a resident who was admitted with diagnoses including Parkinson's disease, muscle weakness, and heart failure. The resident was assessed as having mild cognitive impairment, was dependent on assistance for multiple activities of daily living, and had an indwelling catheter. The nutritional assessment indicated the resident had variable oral intake, was underweight, and required additional calories. Despite these findings, no care plan was created to address the resident's nutritional needs. During interviews and record reviews, the DON confirmed that although the resident was receiving high protein supplements three times a day due to malnutrition, there was no care plan in place to monitor or evaluate the effectiveness of these interventions. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables for all residents, including those at risk for nutritional complications. The absence of a care plan meant the facility did not address or monitor the resident's nutritional and hydration needs as required.
Failure to Monitor and Address Resident's Nutritional and Hydration Needs
Penalty
Summary
The facility failed to adequately evaluate and monitor the nutritional and hydration needs of a resident with multiple medical conditions, including Parkinson's disease, muscle weakness, and heart failure. The resident was admitted with an indwelling catheter and was dependent on staff for most activities of daily living. A physician's order was in place to monitor the resident's input and output (I&O) for hydration, and the care plan included interventions to observe urine output and encourage fluid intake. However, review of documentation revealed that while fluid intake was recorded, urine output was not consistently documented every shift as required by the physician's order and facility policy. This lack of consistent documentation prevented staff from accurately assessing the resident's hydration status. Additionally, the registered dietitian (RD) initially assessed the resident's nutritional needs and recommended a fortified diet to provide additional calories due to the resident being underweight and at risk for weight loss and dehydration. Despite this recommendation, there was no evidence that the RD continued to evaluate the resident's nutritional needs after the initial assessment, and the resident was not provided with the fortified diet as recommended. The dietary supervisor confirmed that the resident did not receive the fortified diet, which could have contributed to inadequate nutritional intake. Interviews with facility staff, including the registered nurse supervisor and the director of nursing, confirmed that the required monitoring and documentation of I&O were not performed consistently. The RD also acknowledged that there was no follow-up or documentation after the initial assessment. Facility policies and job descriptions reviewed indicated that these actions were required, but they were not carried out, resulting in the facility's failure to meet the resident's hydration and nutritional needs.
Inadequate Night Shift Staffing Led to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff during the night shift on two consecutive days, resulting in a resident not receiving timely assistance with personal hygiene needs. The resident, who was admitted with muscle weakness, difficulty walking, and a high risk for falls, was dependent on staff for toileting and other activities of daily living. On the nights in question, only two CNAs were present to care for 48 residents after two scheduled CNAs called in sick and were not replaced. As a result, the resident had to wait for hours after activating the call bell before receiving help to change her pull-ups, leading to distress and dissatisfaction. The resident reported feeling annoyed and angry due to the long wait times for assistance. The facility's staffing policy requires sufficient numbers of staff to meet residents' needs according to their care plans, but this was not met on the nights in question. The Director of Staff Development acknowledged that the reduced staffing negatively affected the quality of care and contributed to staff burnout. The deficiency directly impacted the resident's psychosocial and physical well-being, as timely care was not provided.
Failure to Monitor Nutritional and Fluid Needs
Penalty
Summary
The facility failed to follow physician orders to evaluate a resident's nutritional and fluid needs, specifically for a resident with dysphagia, gastrostomy, and dementia. The resident was admitted with a high risk for aspiration, dehydration, and weight loss, and the care plan included nutritional assessment and follow-up by a registered dietitian (RD). However, the RD did not assess the resident in January and February, despite a significant weight loss of 11 pounds in five days. The RD acknowledged the lack of weekly weight variance interdisciplinary team meetings, which should have been conducted to discuss the resident's needs and laboratory results. Additionally, the facility did not monitor the resident's intake and output as ordered by the physician. The physician had ordered monitoring for 30 days, but the registered nurse supervisor could not find documentation of this monitoring. The director of nursing confirmed that the resident was receiving gastrostomy tube feeding with water flushes and emphasized the importance of monitoring intake and output to ensure proper absorption and adjustment to the feeding. The facility's policies and procedures required the RD to conduct comprehensive nutrition assessments and monitor residents' weight trends and hydration status. However, the RD failed to maintain accurate and timely documentation in the resident's medical records, as required by state and federal regulations. The facility's policies also required the dietitian to follow up with residents receiving enteral nutrition and make appropriate recommendations, which was not done in this case.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to provide necessary interventions to prevent complications for a resident receiving enteral nutrition through a gastrostomy tube (GT). The resident, who had diagnoses including dysphagia, gastrostomy, and dementia, was at high risk for aspiration related to tube feeding. The facility did not adhere to the physician's order to keep the resident's head of the bed elevated at 30 degrees or higher during feeding and for one hour after feeding had stopped. Additionally, the facility failed to check the tube placement before the initiation of formula, medication administration, and water flushing at least every eight hours. The deficiency was identified during a review of the resident's care plan and physician orders, which indicated the need for specific interventions to prevent aspiration. The director of nursing acknowledged the lack of documentation confirming adherence to these orders, with the last recorded instance of proper head elevation occurring several days prior. The nurse practitioner confirmed that improper positioning could lead to aspiration pneumonia, highlighting the importance of maintaining the prescribed head elevation during GT feeding. The facility's policy on enteral nutrition also emphasized the need for these precautions to mitigate the risk of aspiration.
Failure to Document Care Meeting in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically by not documenting a care meeting held with the resident's responsible parties. The resident, who had been admitted with conditions including dysphagia, a gastrostomy, and dementia, was assessed to have severely impaired cognitive skills and required substantial assistance with daily activities. Despite a meeting occurring on February 27, 2025, involving the resident's responsible party and facility staff, including a registered nurse supervisor, activity director, licensed vocational nurse, and social service designee, no documentation of this meeting was recorded in the resident's medical record. Interviews with facility staff confirmed that the meeting took place and included discussions about the resident's care plan and medications. However, the social service designee stated that the meeting was considered informal and thus was not documented. The director of nursing acknowledged that the meeting should have been documented as a care conference, in line with the facility's policy and procedures, which require all services and changes in a resident's condition to be recorded in the medical record. This oversight resulted in an incomplete and inaccurate medical record for the resident.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Behavioral Assessment
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident 1, who had a diagnosis of schizoaffective disorder and moderate cognitive impairment, exhibited new aggressive behavior by punching a staff member. Despite this incident, the facility did not implement its policy for behavior assessment, intervention, and monitoring, which required a thorough evaluation by the interdisciplinary team (IDT) to address Resident 1's changing behavioral symptoms. Five days after the initial aggressive incident, Resident 1 sexually abused Resident 2, a roommate with severe cognitive impairment and hemiparesis, by removing Resident 2's incontinent brief and inappropriately touching her. This incident was witnessed by a certified nursing assistant (CNA), who intervened and reported the abuse. The facility's failure to conduct a psychosocial evaluation and provide emotional support for Resident 1 after the initial aggressive behavior contributed to the subsequent abuse of Resident 2. Interviews with facility staff, including the Director of Nursing (DON), Social Service Director (SSD), and Quality Assurance Nurse (QA), revealed that the IDT did not meet to evaluate Resident 1's new behavior or develop individualized interventions. The SSD was unaware of Resident 1's aggressive behavior and did not conduct a psychosocial visit. The QA acknowledged the importance of IDT meetings to ensure the safety of residents and staff. The facility's policies on abuse prevention and behavior assessment were not followed, resulting in a failure to protect Resident 2 from abuse.
Failure to Timely Assess and Follow Up on Resident Fall
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who reported a fall. The resident, who was cognitively intact and had a history of respiratory failure, chronic pain syndrome, and anxiety disorder, reported falling from his bed at 4 a.m. on 12/8/24. Despite the resident's report of the fall and subsequent back pain, the facility did not assess the resident immediately, nor did they notify the resident's physician promptly. The resident had to contact his own doctor, who ordered an MRI, but the facility did not carry out this order in a timely manner. The resident's fall was initially reported to an LVN, who noted the incident but failed to document any assessment or follow-up actions in the progress notes. The LVN stated that she notified the resident's physician via text, but there was no documentation of this communication. The resident continued to experience back pain and expressed concerns about his condition, yet the MRI ordered by the physician was delayed by 19 days due to issues with obtaining authorization from the resident's health insurance. The facility's policies on change in condition and assessing falls were not followed, as the resident's fall was not properly assessed, documented, or communicated to the physician. The delay in conducting the MRI and the lack of immediate assessment and notification of the physician were significant deficiencies in the care provided to the resident, potentially delaying necessary treatment for injuries resulting from the fall.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide a safe and accident-free environment for a resident with visual impairment, a left above the knee amputation, and a history of falls. The facility did not follow the physician's order for visual hourly safety checks for fall prevention, nor did they review and update the resident's At Risk for Falls Care Plan after a fall and change in condition. This lack of adherence to the care plan and physician's orders contributed to the resident experiencing another fall, resulting in a laceration to the forehead and subsequent admission to the intensive care unit for an acute stroke. The resident was admitted to the facility with multiple diagnoses, including schizophrenia and visual impairment, and had a care plan initiated to minimize the risk of falls. However, the care plan had not been updated since its initiation, despite the resident's fall on a previous occasion. On the night of the incident, the resident was left unattended and fell from the bed, despite a warning from the roommate to the LVN that the resident was at risk of falling. The LVN failed to reposition the resident or conduct the required visual checks, as documented incorrectly in the Medication Administration Record (MAR). Interviews with staff and review of records revealed that the resident's care plans were outdated and did not reflect the resident's current high risk for falls. The facility's policies and procedures for fall risk assessment and care plan updates were not followed, leading to inadequate supervision and failure to implement necessary interventions, such as floor mats, which could have prevented the injury. The documentation errors and lack of timely updates to the care plan contributed to the resident's fall and subsequent injury.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of quetiapine fumarate (Seroquel), an antipsychotic medication, to a resident. The resident was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood and muscle weakness. The care plan indicated the resident was to be informed about the risks and benefits of the medication regimen. However, the resident's informed consent was not obtained before the administration of the medication, as evidenced by the missing signature on the informed consent form. The resident, who was cognitively intact, reported not being informed about the medication and not signing any consent form. The Medication Administration Record showed that the resident was administered Seroquel multiple times without the necessary informed consent. The Director of Nursing confirmed the absence of the resident's signature on the informed consent form and acknowledged that consent should have been obtained prior to starting the medication. The facility's policy required documentation of informed consent before initiating psychotherapeutic drugs, which was not adhered to in this case.
Failure to Indicate and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to provide proper indication and monitoring for a resident who was started on the psychotropic medication Seroquel. The physician's order for Seroquel did not include the indication for its use or the targeted behavior and manifestation. Additionally, the informed consent form was incomplete, lacking the diagnosis and behavior for which the medication was ordered. The resident, who was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, was not monitored for adverse reactions such as lethargy, as required by the facility's policy. Interviews with facility staff revealed that the licensed vocational nurse (LVN) who obtained the Seroquel order from the psychiatrist acknowledged the omission of the indication and diagnosis in the order. The director of nursing (DON) confirmed that the reason for starting the resident on Seroquel and the targeted behavior were missing from the order, and that the resident should have been monitored for adverse reactions. The facility's policy on antipsychotic medication use mandates that residents receive such medications only when necessary and that nursing staff monitor and report any side effects or adverse consequences to the attending physician.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident with a high risk of falls, leading to a significant injury. The resident, who had a history of falls and was dependent on staff for toilet transfers, attempted to go to the bathroom unassisted and fell, resulting in a displaced intertrochanteric fracture of the right femur. The care plan for bowel and bladder incontinence, which required assistance every two hours, was not followed, and the resident was not provided with the necessary supervision. The resident's care plans were not updated or revised as required, contributing to the deficiency. The At Risk for Fall care plan had been resolved without a new plan in place, and the quarterly care plans were missing. The Director of Staff Development and the MDS coordinator acknowledged the lack of updates and revisions to the care plans, which were crucial for providing accurate guidance to staff and meeting the resident's needs. Interviews with staff revealed that the resident was confused, dependent on staff for mobility, and did not consistently use call lights. The facility's policy required frequent rounds and assistance, but these were not documented, and the two-hourly rounds for toileting assistance were not part of the facility's process. The Director of Nursing confirmed that the facility did not document the required rounds, which contributed to the resident's fall and subsequent injury.
Failure to Monitor and Evaluate Resident's Bladder Habits Leads to Fall and Injury
Penalty
Summary
The facility failed to properly monitor and evaluate a resident's bladder habits, leading to a deficiency in care. The resident, who was incontinent and dependent on staff for toilet transfer, was not monitored at regular intervals as required by the care plan. The care plan, initiated in March 2023, included interventions to assist the resident to the bathroom every two hours and to encourage participation in a bowel and bladder re-training program. However, there was no evidence of regular monitoring or evaluation of the resident's continence status, and the care plan was not reviewed or revised as needed. The resident, who had severe cognitive impairment and was dependent on staff for toileting and personal hygiene, attempted to go to the bathroom independently and fell, resulting in a displaced intertrochanteric fracture of the right femur. The facility's documentation indicated that the resident had a history of falls and was at high risk for potential falls, yet the care plan was not updated to address these risks adequately. The facility's policy required regular monitoring and evaluation of bladder habits, but this was not implemented, and the resident's continence status was not checked at regular intervals. Interviews with facility staff revealed that the resident did not have a routine toileting schedule, and staff conducted random checks instead of the required two-hour intervals. The Director of Nursing acknowledged that the facility did not document the two-hour rounds as required by the care plan. The MDS coordinator also confirmed that there was a deficiency in updating the resident's care plans, which contributed to the resident's fall and subsequent injury.
Failure to Update Resident Care Plans Quarterly
Penalty
Summary
The facility failed to review, revise, and update the care plans quarterly for a resident, specifically addressing risks for falls, incontinence, and activities of daily living (ADL). The resident, who was readmitted with diagnoses including generalized muscle weakness, cognitive communication deficit, and chronic kidney disease, was found to be moderately confused and dependent on staff for mobility and toileting. Despite having a history of falls and incontinence, the care plans were not updated as required, with the last revision noted in September 2024, and no updates recorded for June 2024. Interviews with the Director of Staff Development, MDS Coordinator, and Director of Nursing confirmed the deficiency in updating the care plans. The facility's policy requires quarterly updates in conjunction with the Minimum Data Set (MDS) assessment, but this was not adhered to for the resident in question. The lack of updates in the care plans potentially exposed the resident to risks of recurrent falls, urinary tract infections, and a decline in functional ability.
Failure to Investigate and Report Alleged Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident who alleged being slapped by the CNA. This allegation was supported by another resident who heard the slap and the victim's subsequent question about the slap. Additionally, another CNA reported hearing the slap and the resident's scream to a Registered Nurse (RN), who then reported it to the Director of Nursing (DON). Despite these reports, the facility did not properly acknowledge or investigate the allegations, nor did they report the incident to the necessary authorities such as the police, ombudsman, or Department of Public Health. The resident involved had moderate cognitive impairments and was mostly dependent on staff for activities of daily living. The facility's failure to investigate and report the incident was acknowledged by the RN, the Social Services Director, and the Facility Administrator, who admitted that the incident should have been treated as suspected abuse. The facility's policy on abuse prevention requires thorough investigation and reporting of such incidents, but there was no documented evidence of an investigation. The Facility Administrator, who was also the abuse coordinator, believed the DON had investigated the incident, but this was not substantiated with documentation.
Inadequate Supervision and Equipment Inspection Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe operation of a hoyer lift during a resident transfer, resulting in an injury. Certified Nursing Assistant (CNA) 2 did not properly control the hoyer lift, causing it to lower quickly and hit Resident 2 in the face, leading to a bruise on the right eye. The incident occurred while transferring Resident 2, who was mostly dependent on staff for activities of daily living, from the bed to a wheelchair. Resident 2, who was cognitively intact and had the capacity to understand and make decisions, reported the incident, but the facility did not conduct a thorough investigation or inspect the hoyer lift for malfunctions. Additionally, the facility did not adequately follow up on the incident. Registered Nurse (RN) 1 observed the bruise but did not investigate further, relying on existing progress notes. The Facility Administrator also did not probe the incident further, assuming that the nursing staff had investigated. This lack of follow-up and failure to inspect the hoyer lift for malfunctions after the incident contributed to the deficiency in ensuring a safe environment free from accident hazards.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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