Camellia Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1920 N. Fair Oaks Avenue, Pasadena, California 91103
- CMS Provider Number
- 056316
- Inspections on file
- 46
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Camellia Gardens Care Center during CMS and state inspections, most recent first.
A resident with COPD, neuropathy, back muscle spasms, and dependence for all ADLs, who received both scheduled and PRN pain meds, reported severe pain rated 10/10 and was observed searching for a call light and then yelling for a nurse. Surveyors found the call light placed on the side rail behind a trash bag, out of the resident’s reach, despite care plan directives to anticipate and promptly respond to pain and a facility policy requiring call lights to be within easy reach when a resident is in bed or a chair. The RN Supervisor and DON both acknowledged that the call light should not have been behind the trash bag and should have been accessible to the resident.
A resident with COPD, neuropathy, and back muscle spasms was cognitively independent but dependent on staff for all ADLs, including toileting and personal hygiene. The resident’s care plans for MASD risk and UTI required staff to keep the skin clean and dry, check for incontinence at least every two hours, and wash, rinse, and dry soiled areas. A CNA reported the resident’s last brief change was at 8 a.m., found the brief wet late in the morning, and delayed changing the resident until after lunch, with the RN Supervisor later confirming the resident was changed at 1 p.m. The RN Supervisor acknowledged that the care plan directives for two-hour incontinence checks and maintaining cleanliness and dryness were not followed, despite facility policy and the DON’s statement that such care plan instructions should be implemented by staff.
CNAs did not complete required Stop and Watch Early Warning Tool forms when a resident with COPD, acute respiratory distress, dysphagia, and severe cognitive impairment exhibited congestion, coughing, phlegm, difficulty swallowing, fever-like warmth to touch, and diarrhea over multiple shifts. Facility policy and staff interviews confirmed that such symptoms represent an acute condition change and that CNAs are expected to document these changes on Stop and Watch forms and provide them to nursing and the DSD, yet review of the Stop and Watch binder showed no forms were completed for this resident.
A resident with severe cognitive impairment, ventilator dependence, and a tracheostomy developed dark purple discoloration and later greenish-yellow bruising with a linear red mark around one eye, with no known cause. Multiple staff, including an RN supervisor, TN, LVN, and CNA, observed the eye discoloration and described it as redness, light purple discoloration, and a “black eye,” but the TN only notified the physician and responsible party and did not initiate abuse reporting. The DON and ADM confirmed that, under facility policy, this unexplained bruise met the definition of an injury of unknown origin and should have been treated as potential abuse and reported to CDPH, law enforcement, and the Ombudsman within two hours, which did not occur, resulting in a delayed investigation.
A resident with severe cognitive impairment and requiring contact isolation for Candida auris was not admitted to the first available bed after a hospital stay, despite meeting all readmission criteria and the facility having an open bed. The Admissions Coordinator did not communicate the resident's status or bed needs to nursing leadership, resulting in a lack of internal coordination and a delayed return to the facility.
A resident remained in a room with an active ceiling leak and no safety signage or relocation, despite being at risk for falls and requiring assistance with daily activities. Additionally, a Hoyer lift and shower chair were left in a hallway for several hours, creating trip hazards for residents and staff. Staff and the DON confirmed these practices did not follow facility safety policies.
A resident with multiple pressure ulcers experienced significant changes in wound size and condition that were not documented or communicated using the SBAR tool as required by facility policy. Staff interviews confirmed that these changes were not reported or acted upon according to established procedures, resulting in a failure to provide care consistent with professional standards of practice.
Two residents with IV access did not receive appropriate monitoring or dressing changes as required by facility policy. One resident had a visibly soiled and blood-stained peripheral IV dressing that was not changed, and there was no documentation of IV site assessment or care for several days. Another resident was left with an unused peripheral IV line without monitoring or a physician's order for removal, and no documentation of IV site assessment was found. Facility policy requiring regular assessment and documentation of IV sites and dressings was not followed.
A resident with hemiplegia and cognitive impairments was not provided adequate ADL care in a LTC facility. The resident was found soaked in urine, indicating a failure to follow the care plan for incontinence checks every two hours. Additionally, a physician-ordered tongue scraping was not documented or performed, as it was not transcribed into the MAR. The DON confirmed the need for proper documentation and adherence to care plans.
The facility failed to provide a safe, clean, and homelike environment for two residents, leading to unsanitary conditions with used gloves on the floor and an overflowing trashcan with gowns. Both residents were severely impaired and dependent on staff for care. Interviews confirmed the inappropriate conditions, and the facility's policies for cleanliness and infection control were not followed.
Two residents in an LTC facility were not properly monitored for the use of physical restraints, as required by physician orders. The facility failed to document the release and monitoring of hand mittens and a soft elbow splint every two hours, leading to a deficiency in care. Incomplete informed consent and lack of adherence to facility policies contributed to the issue.
A facility failed to accurately document a resident's use of restraints in the MDS, despite physician orders for a left-hand mitten and soft elbow splint to prevent removal of invasive lines. The MDS Nurse acknowledged the omission, and the DON highlighted the importance of accurate MDS for care planning.
The facility failed to maintain proper hygiene and grooming for three residents, all of whom were dependent on staff for personal care. These residents, with conditions such as traumatic brain injury and quadriplegia, were found with long, untrimmed fingernails, posing risks of infection and skin breakdown. Staff acknowledged the need for regular nail care, which was not provided, contrary to the facility's policy on supporting activities of daily living (ADLs).
The facility failed to follow infection control practices, including improper handling of a foley catheter drainage bag, inadequate glove changes, and hand hygiene during medication administration for several residents. Additionally, a feeding pump was found unclean, increasing infection risks.
A resident with severe impairments was left exposed during a sponge bath due to a CNA's failure to close the privacy curtain, violating the facility's dignity policy. The resident's privacy was compromised as they were visible to their roommate and through an open door.
A facility failed to provide a resident with adequate notice regarding the termination of Medicare Part A coverage. The resident, with conditions including dementia and muscle weakness, did not receive a signed Notice of Medicare Non-coverage, and the Skilled Nursing Facility Advance Beneficiary Notice lacked an estimated cost for non-covered services. The Business Office Manager was unaware of the requirement to include cost estimates, and the facility's policy of notifying residents in writing was not followed.
A resident's medical records were left exposed on an unattended computer screen, violating confidentiality policies. The resident, who was alert and oriented, had diagnoses including sepsis and hypertension. Staff interviews confirmed the breach and the facility's policy on safeguarding records.
A resident with hearing loss and cognitive impairment did not have a comprehensive care plan addressing communication needs. Despite staff using effective methods like writing and speaking louder, these were not documented in the care plan, leading to potential delays in care.
A facility failed to properly implement pressure ulcer prevention for a resident with a Stage 4 ulcer. The resident's LAL mattress was not set to the correct pressure according to their weight, as required by the care plan and physician's orders. Observations showed the mattress was set incorrectly, which could worsen the resident's condition. A nurse confirmed the settings were wrong, indicating a failure to follow the facility's policy for pressure ulcer management.
A resident with hemiplegia and limited ROM did not receive necessary RNA services after readmission from a hospital. The facility failed to evaluate and continue RNA services, leading to a lapse in care for three weeks. Staff acknowledged the oversight, which was against the facility's policy to maintain or improve mobility.
A resident was not properly informed about a binding arbitration agreement they signed, which included giving up the right to a court trial. The resident, who was cognitively intact, was left with documents to sign without a thorough explanation or knowledge of their right to rescind the agreement within 30 days. The Admission Coordinator admitted the facility's responsibility to explain the agreement, which was not fulfilled.
The facility failed to complete antibiotic stewardship protocols for two residents, leading to a deficiency. One resident with chronic conditions was prescribed Ciprofloxacin for pneumonia without complete infection surveillance documentation. Another resident with hemiplegia and other conditions was prescribed Amoxicillin-Pot Clavulanate, also without complete documentation. The Infection Preventive Nurse confirmed the oversight, which could lead to inappropriate antibiotic use.
The facility failed to provide timely care for two residents dependent on staff for ADLs. One resident was found with a soiled towel and pad, while another had a soiled incontinence brief. Both residents had severe cognitive impairments and were always incontinent. The facility's protocol required regular rounds for cleaning, but care was delayed, violating the policy to maintain resident hygiene.
A resident with chronic respiratory failure did not receive continuous oxygen therapy as prescribed due to a disconnection of the T-bar from the oxygen tubing, which was found on the floor. The contaminated tubing was improperly handled and reconnected, violating infection control protocols. Staff interviews confirmed the failure to follow facility protocols for oxygen administration and infection prevention.
A resident with multiple health issues experienced delayed dental services due to the facility's failure to follow up on a dental referral. The resident was dependent on staff for oral care, and a dental exam indicated the need for a deep cleaning. However, the referral was not communicated or acted upon in a timely manner, resulting in a deficiency.
A resident with hemiplegia and hemiparesis experienced a delay in receiving PT and OT services after physician orders, resulting in a decline in joint mobility. The services were approved to start but were delayed due to the rehab department's uncertainty about session authorization, contrary to facility policy.
The facility failed to label opened packages of ground coffee with the date of opening and did not discard expired food items in the walk-in refrigerator. During inspections, three unlabeled coffee packages and several expired items, including apple cider vinegar, oatmeal cookies, and fried beans, were found. The DM and DON confirmed that these practices do not comply with safe food handling standards.
A CNA entered a contact isolation room without PPE, violating the facility's infection control policy. Two residents, one with cerebral infarction and metabolic encephalopathy, and another with hemiplegia, were under contact isolation for unspecified dermatitis. Despite clear signage and policy requirements, the CNA failed to wear gloves and a gown, as confirmed by staff interviews. The facility's policy mandates PPE to prevent infection spread.
A facility failed to ensure a safe and homelike environment for a resident by placing two pillows and a wedge between the mattress and bedframe, causing discomfort and safety risks. The resident had severe cognitive impairments and was dependent on staff for daily living activities. No assessments or interdisciplinary team meetings were documented regarding the use of the pillows and wedge.
A resident with severe cognitive and physical impairments was found in bed with unpadded siderails and improper mattress setup, contrary to care plan and doctor's orders. The facility's failure to follow safety precautions and hazardous equipment policies put the resident at risk for physical harm and injury.
Failure to Keep Call Light Within Reach for Resident in Pain
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach so the resident could request assistance and pain medication. The resident had diagnoses including COPD, hereditary and idiopathic neuropathy, and back muscle spasms, and was dependent on staff for all ADLs such as eating, toileting hygiene, bathing, dressing, and personal hygiene. The resident’s MDS dated 3/13/2026 documented that she received both scheduled and PRN pain medications and had experienced moderate pain within the last five days. Her care plans for acute left arm/shoulder pain and for potential excessive weakness, tiredness, weight loss, pain, and depression directed staff to anticipate her need for pain relief, respond immediately to any complaint of pain, and provide pain medication as ordered. Physician orders dated 2/23/2026 included Tramadol 50 mg via PEG tube every six hours as needed for moderate to severe pain. On 3/4/2026 at 10:40 AM, during observation and interview in the resident’s room, the resident stated she was in a lot of pain with a pain level of 10/10 and was observed looking for her call light, stating she did not have one. The call light was then observed on the side rail behind a trash bag, out of the resident’s reach, and the resident was observed yelling for the nurse. In interviews, the RN Supervisor stated it was not acceptable for the call light to be hidden behind a trash bag because the resident would not be able to ask for assistance when needed and receive proper treatment for her pain. The DON stated the call light should be within the resident’s easy reach and not behind a trash bag, and confirmed that per the facility’s “Answering the Call Light” policy, revised 3/2021, when a resident is in bed or confined to a chair, the call light must be within easy reach.
Failure to Follow Resident-Centered Incontinence and Skin Integrity Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow an individualized, resident-centered care plan for a resident with multiple medical conditions, including COPD, hereditary and idiopathic neuropathy, and back muscle spasms. The resident’s MDS dated 3/13/2026 showed that the resident was cognitively independent for daily decision-making but dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The resident’s care plan for potential/actual impairment to perineal skin integrity related to MASD, initiated 11/20/2025, directed staff to keep the resident’s skin clean and dry. A separate care plan for a UTI, revised 2/14/2026, directed staff to check the resident for incontinence at least every two hours and to wash, rinse, and dry soiled areas. On 3/4/2026 at 11:45 a.m., a CNA reported that the resident’s last brief change had been at 8:00 a.m. and, upon checking, found the resident’s brief to be wet but stated the resident would be changed after the CNA’s lunch. The RN Supervisor later stated the resident was changed at 1:00 p.m., indicating the resident remained in a wet brief beyond the two-hour incontinence check interval specified in the care plan. During interviews and record review at 2:00 p.m., the RN Supervisor confirmed that, according to the resident’s care plans, staff were required to keep the resident clean and dry and to check for incontinence every two hours, and acknowledged that the care plan was not being followed. The facility’s policy on Comprehensive Person-Centered Care Plans, revised 3/2022, stated that the comprehensive care plan describes services to attain or maintain the resident’s highest practicable well-being. The DON stated residents should be changed every two hours and that if the care plan indicated to keep residents clean and dry and to check every two hours for incontinence, it should be implemented by staff.
Failure to Use Stop and Watch Tool for Resident Change in Condition
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to complete required Stop and Watch Early Warning Tool forms when a resident experienced observable changes in condition on two consecutive days. The resident had a history of COPD, acute respiratory distress, and dysphagia, and was severely cognitively impaired per the MDS dated 2/2/2026, requiring substantial to total assistance with most ADLs. On one morning shift, a CNA observed that the resident was congested, had a lot of phlegm, and was having difficulty swallowing food. On another shift that same day, a different CNA noted the resident was hot to the touch and had diarrhea. The resident’s responsible party also reported the resident felt hot to the touch that day. On the following day, another CNA observed the resident coughing and congested during the day shift. Facility policy and staff interviews established that when CNAs notice a change of condition, they are to complete a Stop and Watch form describing what they observe and provide copies to the licensed nurse and the Director of Staff Development, with the nurse acknowledging the form. The DON confirmed that symptoms such as congestion, significant phlegm, difficulty swallowing, and diarrhea constitute an acute condition change under the facility’s Acute Condition Changes policy, and that CNAs are expected to use the Stop and Watch tool to communicate such changes. Review of the Stop and Watch binder with the DSD revealed there were no Stop and Watch forms completed for this resident, despite the observed changes in condition and the expectation that such forms should be present even if the resident was discharged.
Failure to Timely Report Injury of Unknown Origin as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin as potential abuse in accordance with its Abuse Investigation and Reporting policy. A resident with severe cognitive impairment, ventilator dependence, a history of nontraumatic intracerebral hemorrhage, and a tracheostomy was admitted with significant functional dependence for toileting hygiene, personal hygiene, and bed mobility. On 1/27/2026, a Change of Condition (COC) documented that the resident was noted with discoloration on the right eye, further described as dark purple discoloration with intact but discolored skin. The Director of Nursing (DON) later observed greenish to yellowish discoloration with a small linear red mark at the right corner of the eye and acknowledged that the cause of the bruise was unknown. Staff interviews showed that multiple staff members observed the discoloration but did not initiate or complete required abuse reporting. The Treatment Nurse (TN) stated he first saw the right eye discoloration on 1/27/2026 after being informed by the RN Supervisor (RNS), describing it as light purple discoloration. TN reported the discoloration only to the physician and responsible party and did not measure the area or report it as suspected abuse. The RNS reported seeing redness under the resident’s eyes on 1/27/2026 but was not informed of TN’s assessment of dark purple discoloration and stated that, had she been informed, it should have been reported to the Administrator and then to CDPH, police, and Ombudsman as suspected abuse. A CNA reported that on 1/28/2026 she entered the room, turned on the light, and saw what she described as a “black eye,” with purple discoloration under and to the right side of the eye. The Administrator and DON confirmed that the facility’s policies required that injuries of unknown source be treated as potential abuse and promptly reported to local, state, and federal agencies, including immediate notification of law enforcement, and that “promptly” meant within two hours of observing suspected abuse. The Administrator stated that, under the Investigating Resident Injuries policy, an injury of unknown source should trigger the abuse reporting and investigation protocols. The DON stated she was not informed of the resident’s right eye dark purple discoloration when it was first noted and that the injury met the definition of an injury of unknown origin that should have been reported within two hours. The LVN also acknowledged noticing discoloration on the right side of the resident’s eye on 1/27/2026 and not reporting it to CDPH, Ombudsman, or police. As a result, the injury of unknown origin was not reported to CDPH, local law enforcement, or the Ombudsman within the required two-hour timeframe, delaying the investigation.
Failure to Admit Resident to Available Bed Following Hospitalization
Penalty
Summary
The facility failed to admit a resident to the first available bed following a hospital stay, despite the resident meeting all criteria for readmission and an available bed being present. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, required contact isolation due to a positive test for Candida auris. The resident's discharge from the hospital was delayed from 12/18/2025 to 12/24/2025 because the facility did not facilitate timely readmission. Record review and interviews revealed that the hospital's case manager repeatedly contacted the facility's Admissions Coordinator (AC) regarding bed availability for the resident, but the AC consistently reported no available isolation bed. The AC did not communicate with the Director of Nursing (DON) or the Infection Preventionist Nurse (IPN) about the need for an isolation bed or the resident's readiness for discharge. Both the DON and IPN stated they were unaware of the situation and indicated that they could have arranged for an isolation bed by moving other residents if they had been informed. Further review of the facility's daily census reports confirmed that there were open beds available in a four-bed room during the relevant period. The facility's policy required priority readmission for residents returning from the hospital, and the job description for the AC included maintaining updated bed availability and communicating with nursing leadership. The failure to coordinate and communicate internally resulted in the resident remaining unnecessarily in the hospital despite the facility's ability to accommodate the resident's needs.
Failure to Maintain Safe Environment Due to Water Leak and Improper Equipment Storage
Penalty
Summary
The facility failed to provide a safe environment in accordance with its own policies and procedures in two specific instances. First, a resident with a history of hypotension and anxiety disorder, who was dependent on assistance for most activities of daily living but able to walk to the bathroom independently, remained in a room where water was leaking from the ceiling during heavy rain. The resident's roommate was moved out due to the leak, but the resident was not relocated. Staff interviews confirmed that a tall bucket was placed to catch the water, but no safety cones or hazard signs were present, and the resident could have slipped on the wet floor or tripped over the bucket. The Director of Nursing acknowledged that the resident should have been moved and that additional safety measures, such as floor mats and signage, were not implemented. Second, a Hoyer lift and a shower chair were left in the hallway outside a resident's room for several hours, with the Hoyer lift's legs expanded and facing the hallway and the shower chair placed directly across from it. Staff interviews indicated that these items should have been stored in designated areas, such as the rehabilitation department or shower room, to prevent them from becoming trip hazards. The Director of Nursing confirmed that leaving these items in the hallway created accident hazards for residents and staff. Facility policies reviewed indicated a requirement to maintain a safe environment and minimize accident hazards, which was not followed in these instances.
Failure to Document and Communicate Significant Pressure Ulcer Changes
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the worsening of pressure ulcers for one resident. Specifically, staff did not assess and document detailed observations using the SBAR (Situation, Background, Assessment, Recommendation) communication tool when there were significant changes in the resident's skin and wound conditions on the left trochanter and sacral areas on multiple occasions. These changes in wound size and condition were not communicated through the required SBAR process, as confirmed by interviews with the wound treatment nurse, registered nurse supervisor, infection preventionist nurse, and director of nursing. The facility's policy required that significant changes in a resident's condition, such as those observed in wound size and severity, be documented and communicated using SBAR to ensure timely interdisciplinary review and care plan revision. The resident involved was an 84-year-old female with a history of encephalopathy, essential hypertension, and pulmonary embolism, who was admitted with multiple pressure ulcers and altered mental status. The resident was assessed as being at risk for developing pressure ulcers and was dependent on staff for several activities of daily living. Despite documented changes in the size and severity of stage 4 pressure ulcers on the left trochanter and sacrococcyx, there was no evidence that these changes were communicated using the SBAR tool or that a change of condition form was initiated as required by facility policy. Interviews with facility staff revealed a lack of awareness and follow-through regarding the responsibility to initiate SBAR communication for significant wound changes. The wound treatment nurse, who was new to the position, was unaware of the resident's wounds and did not initiate SBAR documentation. The infection preventionist nurse and director of nursing both confirmed that the observed changes in wound size were significant and should have triggered SBAR communication and care plan review, but this did not occur. The facility's own policy outlined the need for detailed observation and communication for significant changes, which was not followed in this case.
Failure to Monitor and Maintain IV Sites and Dressings
Penalty
Summary
The facility failed to properly monitor and maintain intravenous (IV) sites and change heplock dressings for two residents, as required by facility policy. For one resident with a history of vancomycin-resistant enterococci (VRE) and diabetes mellitus, observations revealed a peripheral IV site with a visibly soiled, blood-stained dressing and dried blood on the tape. Multiple staff interviews confirmed that the IV site was not clean or well secured, and the dressing should have been changed due to visible soiling. Record reviews showed that there was no physician's order for IV site monitoring or dressing changes, and no documentation of IV site assessment or care in the medical record for several days. The resident's care plan also contained incorrect information, listing a PICC line instead of a peripheral IV, and lacked interventions for IV site monitoring. For the second resident, who had diagnoses including sepsis, pneumonia, and COPD, the facility did not have a physician's order for IV site monitoring or discontinuation of the IV site when it was no longer in use. Progress notes lacked documentation of IV site monitoring, and staff interviews revealed that the IV site was not assessed or monitored after IV medications were changed to oral. The resident was left with an unused peripheral IV line, and staff failed to obtain an order for monitoring or removal. The care plan did not address IV site care, and there was no documentation of assessment or intervention for the IV site during the relevant period. Facility policy required that IV dressings be changed if soiled or compromised and that peripheral IV sites be assessed at least every four hours, with more frequent checks for residents with cognitive impairment. The policy also required documentation of dressing changes and any complications. These requirements were not met for either resident, as evidenced by the lack of monitoring, documentation, and appropriate care of the IV sites.
Deficient ADL Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care assistance for a resident, leading to deficiencies in incontinence care and oral hygiene. The resident, who was admitted with conditions such as hemiplegia, hemiparesis, and cognitive impairments, was found soaking wet with urine, indicating a failure to adhere to the care plan that required checking every two hours for incontinence. The resident's care plan, revised on 3/25/2025, specified interventions for bowel and bladder incontinence, which were not followed as the resident was not checked for nearly four hours. Additionally, the facility failed to provide tongue scraping as ordered by the physician. The order for tongue scraping was not transcribed into the Medication Administration Record (MAR), and there was no documentation indicating that the procedure was performed. Interviews with nursing staff confirmed that the tongue scraping was not documented, suggesting it was not completed, despite the physician's order being in place since 3/12/2025. The Director of Nursing acknowledged that the physician's orders should have been documented in the MAR and signed once the treatment was completed. The facility's policy on supporting ADLs, revised in 3/2018, mandates appropriate care and services for residents unable to perform ADLs independently, which includes hygiene and elimination support. The failure to adhere to these policies and care plans resulted in deficient practices that compromised the resident's care.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents, resulting in unsanitary conditions that placed them at risk for infection and discomfort. Observations revealed that the room shared by the two residents had used gloves left on the floor and an overflowing trashcan filled with used disposable gowns. Both residents were severely impaired in cognitive skills for daily decision-making and were dependent on staff for personal care activities, including hygiene and dressing. Interviews with the Housekeeping Manager and the Infection Prevention Nurse confirmed that the conditions observed were inappropriate and posed a risk of spreading germs or bacteria. The facility's policies and procedures for cleaning and maintaining a homelike environment were not followed, as evidenced by the failure to properly dispose of personal protective equipment and maintain cleanliness in the residents' room. The facility's policy emphasized the importance of a clean, sanitary, and orderly environment, which was not upheld in this instance.
Failure to Monitor and Document Physical Restraints
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of physical restraints for two residents, leading to a deficiency in care. Resident 28, who was admitted with chronic respiratory failure, seizures, and quadriplegia, was ordered to have bilateral hand mittens to prevent pulling out invasive tubing. However, the facility did not document the monitoring of these mittens every two hours as required by the physician's orders. Additionally, the informed consent for the use of these mittens was incomplete, lacking necessary signatures and verification of consent, rendering it invalid. Similarly, Resident 49, who had chronic respiratory failure, anemia, and type 2 diabetes, was ordered to have a left hand mitten and a soft elbow splint to prevent pulling out life-sustaining tubes. The facility failed to document the release and monitoring of these restraints every two hours, as per the physician's orders. The care plan for Resident 49 included interventions to assess skin condition and circulation, but there was no documentation to confirm these actions were performed. Interviews with nursing staff and record reviews revealed that the facility's policy and procedures for the use of physical restraints were not followed. The lack of documentation in the Medication Administration Record (MAR) for both residents indicated that the required monitoring and release of restraints were not consistently performed. This deficiency in documentation and adherence to physician orders had the potential to compromise the residents' safety and well-being.
Inaccurate MDS Documentation of Restraints
Penalty
Summary
The facility failed to ensure the accurate documentation of a resident's assessment on the Minimum Data Set (MDS), specifically regarding the use of restraints. Resident 49, who was admitted with chronic respiratory failure, anemia, and type 2 diabetes mellitus, was observed with a left-hand mitten and a soft elbow splint to prevent the removal of invasive lines and a tracheostomy tube. However, the MDS assessment dated 2/4/2025 did not reflect the use of these restraints, which were ordered by a physician on 11/24/2024. This omission was confirmed during an interview with the MDS Nurse, who acknowledged the failure to include the restraints in the assessment. The Director of Nursing emphasized the importance of an accurate MDS as it forms the basis for the resident's plan of care. The facility's policy and procedure, as well as the MDS Coordinator's job description, require that the MDS and all supporting documentation accurately represent the resident and meet regulatory requirements. The inaccurate MDS assessment had the potential to negatively affect Resident 49's plan of care and the delivery of necessary services.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for three residents, specifically in maintaining good grooming and personal hygiene. Resident 27, who has contracted hands, was observed with long, untrimmed fingernails pressing into his palms. This resident was admitted with conditions including seizures, traumatic brain injury, and hypertension, and was assessed as severely impaired in cognitive skills and dependent on staff for personal care. Resident 36, who suffers from chronic respiratory failure and traumatic brain injury, was also found with long, untrimmed fingernails. This resident was similarly assessed as severely impaired in cognitive skills and dependent on staff for various ADLs, including personal hygiene. Observations on multiple occasions confirmed the lack of nail care, which was acknowledged by a Certified Nursing Assistant (CNA) who stated that nails should be trimmed every 2 to 3 weeks to prevent infection. Resident 37, diagnosed with chronic respiratory failure, quadriplegia, and a Stage 4 pressure ulcer, was found with long, untrimmed fingernails on contracted hands. The Treatment Nurse confirmed the necessity of keeping nails short to prevent self-injury and infection. The Infection Prevention Nurse emphasized the importance of maintaining short and clean nails, especially for residents with hand contractures, to prevent skin breakdown and infection. The facility's policy on ADLs, revised in 2019, mandates appropriate care and assistance for residents unable to perform ADLs independently, which was not adhered to in these cases.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to standard infection prevention control practices for several residents, leading to potential contamination and infection risks. Resident 57's foley catheter drainage bag was observed touching the floor, which is against the facility's policy and procedure for catheter care. This oversight was confirmed by the Registered Nurse Supervisor and the Infection Prevention Nurse, who acknowledged that such a practice could lead to contamination and nosocomial infections. In multiple instances, staff members failed to change gloves and perform hand hygiene between tasks during medication administration. Licensed Vocational Nurse 3 did not change gloves or perform hand hygiene after assisting Resident 122 with an oxygen cannula and before administering medications. Similarly, LVN 4 and Registered Nurse 1 did not change gloves or perform hand hygiene between tasks while administering medications to Residents 9 and 11, respectively. These actions were acknowledged by the staff involved, who admitted that they should have followed proper infection control procedures to prevent cross-contamination. Additionally, the facility did not ensure that Resident 120's feeding pump was clean, as it was observed with visible stains. The Certified Nursing Assistant confirmed the pump's unclean state, and the Infection Prevention Nurse emphasized the importance of cleaning and disinfecting medical equipment to prevent infection spread. The facility's policy on cleaning and disinfection of resident care equipment was not followed, contributing to the potential risk of infection for Resident 120.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident 37, during personal care. Resident 37, who was admitted with chronic respiratory failure, quadriplegia, and a Stage 4 pressure ulcer, was observed receiving a sponge bath from a Certified Nursing Assistant (CNA 3) while laying naked on the bed. The privacy curtain was not fully closed, leaving Resident 37 exposed to their roommate and the open door, which compromised their privacy and dignity. CNA 3 acknowledged forgetting to close the privacy curtain completely during the care session, which was against the facility's policy on dignity revised in February 2021. This policy mandates that staff must promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures. The oversight in closing the privacy curtain led to a deficiency in maintaining the resident's dignity and privacy as per the facility's established guidelines.
Failure to Provide Adequate Notice of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide adequate notice to a resident regarding the termination of Medicare Part A coverage, which is a requirement to ensure residents are informed about their potential financial liabilities. Specifically, Resident 12, who was admitted with conditions including muscle weakness, dementia, and hypothyroidism, did not receive a signed Notice of Medicare Non-coverage (NOMNC) indicating the end of coverage. The NOMNC, dated 11/29/2024, stated that coverage would end on 12/2/2024, but it lacked the signature of the resident or their representative, which is necessary to confirm receipt and understanding of the notice. Additionally, the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for Resident 12, also dated 11/29/2024, was incomplete as it did not include an estimated cost for services that would not be covered after the termination of Medicare Part A benefits. The Business Office Manager (BOM) admitted to not knowing the requirement to include an estimated cost on the SNFABN. Furthermore, the facility's policy and procedure, as well as the adopted guidelines, were not followed, as they require the resident or their representative to be notified in writing about the potential liability for non-covered services, and the SNFABN should not be communicated via phone, which was done in this case according to the Social Services Director's documentation.
Breach of Resident's Medical Record Confidentiality
Penalty
Summary
The facility staff failed to maintain the privacy and confidentiality of a resident's medical records, specifically for Resident 219. On March 5, 2025, a computer at Nurse Station 1 was left unattended with Resident 219's medical information visible on the screen. This incident was observed by a Registered Nurse Supervisor, who was unable to identify who left the computer screen on. The facility's policy requires staff to log off or turn off the computer screen before leaving it unattended to prevent unauthorized access to residents' medical records. Resident 219 was admitted to the facility with diagnoses including sepsis, degeneration of the nervous system due to alcohol, and essential hypertension. The resident was alert, oriented, and able to communicate effectively. Interviews with facility staff, including the Minimum Data Set Nurse and the Director of Nursing, confirmed that the medical records are confidential and should not be accessible to unauthorized individuals. The facility's policy, revised in October 2017, emphasizes safeguarding the personal privacy and confidentiality of all resident records, limiting access to authorized personnel only.
Failure to Develop Comprehensive Communication Care Plan
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, identified as Resident 52, who had significant communication challenges due to hearing loss and cognitive impairment. The resident was admitted with diagnoses including dysphagia, cognitive communication deficit, and unspecified bilateral hearing loss. Despite these challenges, the care plan did not include specific interventions to effectively communicate with the resident, such as writing on paper or speaking louder, which were methods found to be effective by the staff. This lack of a detailed communication strategy in the care plan was identified during a review of the resident's records and interviews with facility staff. Observations and interviews revealed that the resident's hearing loss worsened after cancer treatment, and the staff had to adapt their communication methods accordingly. However, these adaptations were not documented in the care plan, which should have been resident-centered and comprehensive. The facility's policy requires that care plans include measurable objectives and timetables to meet residents' needs, but this was not adhered to in the case of Resident 52. The deficiency was noted during a survey, highlighting the potential for delayed or inadequate care due to the lack of a proper communication plan.
Failure to Implement Correct Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement appropriate pressure ulcer prevention and management for a resident with a Stage 4 pressure ulcer in the sacral region. The resident, who was admitted with chronic respiratory failure, quadriplegia, and a Stage 4 pressure ulcer, was at moderate risk for skin breakdown according to the Braden Scale. The resident's care plan included the use of a low air loss (LAL) mattress to manage skin integrity, with specific settings based on the resident's weight of 132 pounds. However, observations revealed that the LAL mattress was not consistently set to the correct pressure of 132 mmHg, as required by the resident's weight and physician's orders. During observations, the LAL mattress was found to be set at 120 mmHg and later at 80 mmHg, which was not in accordance with the facility's policy and procedure or the manufacturer's operating instructions. A Licensed Vocational Nurse confirmed that the incorrect settings could lead to worsening of the resident's pressure ulcers. The facility's policy required monitoring of pressure ulcer risk factors and appropriate interventions, which were not adequately followed, leading to the potential for the resident's condition to deteriorate.
Failure to Provide Restorative Nursing Services for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion (ROM) and mobility, as per the facility's policy and procedure. The resident, identified as Resident 218, was initially admitted with conditions including hemiplegia affecting the right dominant side, aphasia, and essential hypertension. The resident was assessed with functional limitations in ROM on both upper and lower extremities and was dependent on assistance for various daily activities. Upon readmission from a General Acute Care Hospital (GACH), Resident 218 did not receive the necessary Restorative Nursing Assistant (RNA) services for passive range of motion (PROM) exercises, which were previously ordered before hospitalization. Observations and interviews revealed that the resident had not been assisted with exercises since returning from the hospital, and the RNA services were on hold. The facility's staff, including the Restorative Nurse Assistant, Registered Nurse Supervisor, Director of Nursing, and Director of Rehabilitation, acknowledged that the resident should have been evaluated and continued with RNA services to prevent further decline in ROM and mobility. The facility's policy indicated that residents with limited ROM should receive treatment to prevent further decrease, and those with limited mobility should receive appropriate services to maintain or improve mobility. However, the resident was not screened by a physical therapist after readmission, and no active order for RNA services was in place, resulting in the resident not receiving RNA services for three weeks. This oversight placed the resident at risk for further decline in ROM and potential contractures.
Failure to Inform Resident of Arbitration Agreement Details
Penalty
Summary
The facility failed to ensure that a resident was properly informed and understood the binding arbitration agreement they were asked to sign. The resident, who was cognitively intact and required a walker or wheelchair for mobility, was admitted with conditions including hemiplegia, hemiparesis, and hyperlipidemia. During the admission process, the resident was left with a stack of papers to sign, including the arbitration agreement, without a thorough explanation of its contents or the resident's right to rescind the agreement within 30 days. The Admission Coordinator acknowledged that it was the facility's responsibility to explain the arbitration agreement to residents and inform them of their right to rescind. However, the resident reported that the arbitration agreement was not explained, and they were unaware of the 30-day rescission period. The facility's arbitration agreement form clearly stated that signing the contract meant giving up the right to a jury or court trial, and that the agreement could be rescinded within 30 days. This oversight had the potential to result in the resident unknowingly forfeiting their right to resolve disputes through a court of law.
Incomplete Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to complete the antibiotic stewardship program protocols for prescribing antibiotics for two residents, leading to a deficiency. Resident 6, who was admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and muscle weakness, was prescribed Ciprofloxacin for pneumonia. However, the Surveillance Data Collection Form for Resident 6 was incomplete, as the McGeer Criteria for infection surveillance was not fully filled out, with symptoms left unchecked. Similarly, Resident 218, who had diagnoses including hemiplegia, hypertension, and hyperlipidemia, was prescribed Amoxicillin-Pot Clavulanate for pneumonia. The Surveillance Data Collection Form for Resident 218 also had the McGeer Criteria incomplete, with symptoms not documented. During an interview, the Infection Preventive Nurse confirmed that the McGeer Criteria was incomplete for both residents before they received antibiotics. The facility's policy on antibiotic stewardship, revised in December 2016, requires that antibiotics be prescribed and administered under the guidance of the stewardship program, with signs and symptoms documented when a nurse communicates a suspected infection to a physician. The failure to complete the McGeer Criteria could lead to inappropriate antibiotic use, potentially resulting in antibiotic-resistant organisms.
Failure to Provide Timely ADL Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents, who were dependent on staff for activities of daily living (ADLs), were kept clean and provided with appropriate care. Resident 1, who was admitted with diagnoses including benign prostatic hyperplasia, hemiplegia, and hemiparesis, was found to have severely impaired cognitive skills and was always incontinent of urine and bowel. The care plan indicated that Resident 1 was totally dependent on staff for personal hygiene, yet during an observation, Resident 1 was found with a wet towel and absorbent pad soiled with urine, indicating a lack of timely care. Similarly, Resident 2, who had severe cognitive impairments and was always incontinent, was observed with a soiled incontinence brief. The facility's protocol required staff to round every two hours for cleaning and repositioning, but CNA 1 admitted to delaying care due to arriving late to work. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene, but this was not adhered to, resulting in delayed services for both residents.
Failure to Maintain Continuous Oxygen Therapy and Infection Control
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not administering the prescribed continuous oxygen therapy. The resident, who was admitted with chronic respiratory failure and other serious conditions, was supposed to receive continuous oxygen therapy at 2 liters per minute. However, during an observation, the resident's T-bar was found disconnected from the oxygen tubing, and the tubing was observed on the floor, indicating a lapse in the administration of the prescribed oxygen therapy. Additionally, the facility did not maintain infection control protocols when the oxygen tubing became contaminated. The tubing, after falling on the floor, was picked up by a CNA and placed in the resident's nightstand drawer instead of being discarded as per facility protocol. Later, the contaminated tubing was handed to an LVN for reconnection to the resident, which posed a risk of infection due to the resident's immunocompromised status. Interviews with facility staff, including the LVN, Respiratory Therapist, Infection Preventionist Nurse, and Director of Nursing, confirmed that the facility's protocol was not followed. The staff acknowledged that the contaminated tubing should have been replaced immediately to prevent infection and ensure the resident received the necessary continuous oxygen therapy. The facility's policies on cleaning and disinfection, as well as oxygen administration, were not adhered to, leading to this deficiency.
Delayed Dental Services Due to Lack of Follow-Up
Penalty
Summary
The facility failed to ensure timely dental services for a resident, resulting in delayed dental care. The resident, who was admitted with multiple diagnoses including GERD, hemiplegia, and hemiparesis, was dependent on staff for personal hygiene and oral care. A dental exam conducted by a Doctor of Dental Medicine indicated the need for a deep cleaning by the facility's in-house hygienist. However, the Licensed Vocational Nurse was unaware of this referral until a later date, indicating a lack of communication and follow-up on the dental services required. The Social Services Director (SSD) acknowledged the delay in following up on the dental exam and referral, which was not acted upon until a family member requested a dental exam. The SSD admitted to not sending the referral for the hygienist immediately after the exam, as per facility policy. The facility's policies on dental and ancillary services require coordination and documentation of such services, which were not adhered to in this case, leading to the deficiency.
Delay in Therapy Services for Resident
Penalty
Summary
The facility failed to provide timely physical therapy (PT) and occupational therapy (OT) services for a resident after these services were ordered by the physician. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, was approved to receive PT and OT services starting on November 12, 2024. However, the services did not commence until December 2, 2024, for PT and December 3, 2024, for OT, resulting in a delay. This delay occurred despite the facility's policy that therapeutic services should be provided upon the written order of the resident's attending physician. The resident's condition included severely impaired cognitive skills and dependence on assistance for daily activities. During the period of delay, the resident experienced a decline in joint mobility, with assessments indicating increased limitations in shoulder, hand, hip, and knee mobility. Interviews with facility staff revealed that the delay was due to the rehab department's uncertainty about the number of sessions authorized, which contradicted the facility's process of initiating rehab services immediately upon authorization. The facility's policies emphasized the importance of timely therapeutic services to prevent further decline in residents' range of motion and mobility.
Failure to Label and Discard Expired Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling opened packages of ground coffee with the date they were opened. During an observation in the facility's kitchen, three 8-ounce packages of ground coffee were found on a rolling cart without any labels indicating when they were opened. The Dietary Manager (DM) confirmed that all opened items should be labeled with the date of opening to ensure they are safe for consumption. The absence of such labels creates uncertainty about the freshness and safety of the coffee. Additionally, the facility did not discard expired food items found in the walk-in refrigerator, which is against safe food handling practices. During an inspection, several expired items were identified, including a gallon of apple cider vinegar, two boxes of oatmeal cookies, and a container of fried beans, all past their used-by dates. The DM acknowledged that expired items should not be stored in the refrigerator as they could be mistakenly served to residents, potentially causing illness. The Director of Nursing (DON) reiterated the importance of discarding expired food and labeling items with open and used-by dates to prevent foodborne illnesses.
Infection Control Breach in Contact Isolation Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices as outlined in their policy and procedure, specifically in the case of two residents who were under contact isolation precautions. Certified Nursing Assistant 1 (CNA 1) entered the room of these residents without donning the required personal protective equipment (PPE), which includes gloves and a gown. This action was observed despite the presence of a contact isolation precautions sign outside the room, which clearly indicated the necessity for PPE to prevent the spread of infection. Resident 1 was admitted with diagnoses including cerebral infarction and metabolic encephalopathy, and was moderately impaired in cognitive skills for daily decision-making. Resident 2, also admitted with cerebral infarction and hemiplegia, was severely impaired in cognitive skills and dependent on assistance for most activities. Both residents were placed on contact isolation precautions due to unspecified dermatitis, yet there was no physician order for these precautions until after the incident was observed. Interviews with staff, including CNA 1, Licensed Vocational Nurse 1 (LVN 1), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed the expectation that PPE should be worn in contact isolation rooms. The facility's policy, revised in October 2018, mandates the use of gloves and gowns for staff and visitors entering such rooms. The failure to follow these protocols was identified during a survey, highlighting a lapse in infection control measures intended to protect residents and staff from the transmission of infections.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe and homelike environment for one of three sampled residents by placing two pillows and a wedge between the resident's mattress and bedframe. This setup was observed during multiple instances, including an observation with a Certified Nurse Assistant (CNA) and the Director of Nursing (DON). The DON confirmed that the pillows and wedge should not have been placed there as they caused an elevation of the feet, limiting the resident's movement and creating a safety risk. The DON also noted that this arrangement could be unsafe and uncomfortable for the resident. The resident involved had severe cognitive impairments and was dependent on staff for various activities of daily living. The facility's records showed no documented evidence of an assessment, interdisciplinary team meeting, or nursing assessments and monitoring related to the use of the pillows and wedge. The facility's policies on Resident's Rights and Homelike Environment were reviewed, indicating that residents should be treated with respect and provided with a safe and comfortable environment. However, these policies were not followed in this instance, leading to the deficiency.
Failure to Provide Safe Environment for Resident
Penalty
Summary
The facility failed to provide an environment free of accident hazards for a resident with severe cognitive and physical impairments. The resident, who has a history of seizures, Parkinson's disease, bipolar disorder, and schizophrenia, was observed in bed with unpadded bilateral upper siderails, contrary to the care plan and doctor's orders. The Director of Nursing (DON) confirmed the absence of padding, acknowledging that this oversight put the resident at risk for physical harm and injury due to potential head and limb injuries during a seizure or other movements. Additionally, the resident was found lying in bed with two pillows and a wedge cushion improperly placed between the mattress and bed frame. This setup was observed by both a Certified Nurse Assistant (CNA) and the DON, who confirmed that the pillows and wedge should not have been there for safety reasons. The Maintenance Director (MD) identified the mattress as a prime mattress from Mattress Company 1, and the manufacturer's manual indicated that improper use could result in damage or injury. The facility's policies on safety precautions and hazardous equipment were not followed, contributing to the unsafe environment. The resident's Minimum Data Set (MDS) and History & Physical (H&P) records indicated severe impairments in decision-making and physical abilities, requiring maximal assistance for daily activities. Despite these documented needs, the facility did not adhere to the prescribed safety measures, thereby failing to mitigate accident hazards and ensure the resident's safety as per the care plan and facility policies.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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