Carmel Mountain Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 11895 Avenue Of Industry, San Diego, California 92128
- CMS Provider Number
- 555326
- Inspections on file
- 37
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Carmel Mountain Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control failures involving residents on Enhanced Barrier Precautions. A resident with a trach and bladder dysfunction, under orders for Enhanced Barrier Precautions for carbapenem-resistant Acinetobacter baumannii, was observed with a Foley catheter bag resting on the floor, contrary to staff statements that it should never be on the floor. For another resident with ventilator dependence and a G-tube on Enhanced Barrier Precautions, a CNA doffed PPE in the room, then took a single trash bag into the hallway and separated soiled linens and trash there instead of bagging them separately inside the room, and did not perform hand hygiene after doffing PPE. In a third case, a resident with ventilator dependence and carbapenem-resistant Acinetobacter baumannii had their bed control replaced by the Maintenance Supervisor, who entered and exited the room without performing hand hygiene, despite facility expectations and policy requiring hand cleansing to prevent transmission of infectious material.
Two residents did not receive necessary care and services when one was required to purchase his own condom catheters due to a supply shortage, and another lacked access to adequate TV channels for activity, leaving him without entertainment for an extended period. Staff confirmed the facility did not have the required supplies or consistent TV service, and the facility's policy did not address accommodation of residents' needs.
A deficiency was found when a used urinal containing urine was placed on a resident's bedside table alongside food and cleaning supplies. The resident and a family member confirmed this was a regular practice, and staff acknowledged it violated infection control protocols. The facility's policy requires standard precautions and environmental cleaning, which were not followed in this instance.
A planned power outage prevented staff from accessing the eMAR, resulting in 50 residents receiving their scheduled morning medications late. A resident with Parkinson's Disease did not receive any of their prescribed medications, including Rytary, within the required timeframe. Facility leadership confirmed the delay and acknowledged the importance of timely medication administration, as outlined in facility policy.
A resident with a history of hypothermia experienced a significant drop in body temperature, which was first reported by a CNA to an LN. The LN did not immediately assess or notify the physician, resulting in a delay of several hours before action was taken. The resident was eventually transferred to the hospital after further temperature decline and signs of distress, contrary to facility policy requiring prompt physician notification for changes in condition.
A planned power outage was not properly communicated to facility management, resulting in staff being unprepared and unable to access paper MARs in time. As a result, 50 residents received their medications late, including a resident whose family was concerned about delayed Parkinson's medication. The incident was not accurately reported to CDPH as required by facility policy.
Several residents experienced significant delays in receiving personal care and meal service, with staff failing to respond promptly to call lights and not distributing meal trays in a timely manner. Residents reported waiting extended periods for assistance with toileting and receiving cold meals due to delayed tray delivery, despite facility policies requiring prompt response and care.
Multiple resident rooms were found with dirty wall-mounted fans, broken furniture, exposed unfinished wood, scraped paint, duct tape repairs, unsanded wall patches, long extension cords, and malfunctioning closet doors or drawers. Most affected residents were non-verbal and on ventilators. Staff interviews revealed a lack of documentation and communication regarding these deficiencies, despite facility policies requiring a clean and homelike environment.
Expired food items, including shredded parmesan cheese, peaches, and yogurt, were found in both the kitchen and nursing unit refrigerators. The DSS, Nurse Manager, and RD all confirmed that staff were responsible for labeling, dating, and discarding expired foods, but these procedures were not followed, resulting in expired food remaining accessible in resident care areas.
The QAA Committee did not include surveyor-identified issues with call light response and the lack of a homelike environment in the QAPI plan. While the QAPI team focused on falls, pressure ulcers, weights, and UTI prevention, they did not address these additional concerns, and the DON was unable to identify a root cause for the call light response issue. Planned room improvements were also not incorporated into the QAPI process.
Staff did not follow infection control protocols when providing care to a resident on Enhanced Barrier Precautions, including failing to perform hand hygiene and don required PPE before entering the room. A phlebotomy technician also failed to use appropriate PPE and did not disinfect equipment after use. Additionally, ice scoops at two stations were stored in uncovered containers with standing water, leading to contamination concerns. These actions were inconsistent with facility policies and were confirmed by interviews with nursing and dietary staff.
A resident who was cognitively intact and able to express preferences did not consistently receive scheduled showers, with only two showers provided over a three-week period. Staff interviews and record reviews confirmed that the resident was not offered showers as expected, and facility policy required staff to accommodate resident preferences for personal hygiene. This resulted in the resident's choices not being honored.
A resident with sepsis and a UTI did not consistently receive IV antibiotics and PICC line care as ordered by the physician. Review of records showed missed documentation for several antibiotic doses and PICC line flushes. Interviews with an LN and the DON confirmed these omissions, and facility policy required accurate documentation and implementation of orders.
A resident with a history of cellulitis and sepsis did not consistently receive pressure ulcer care as ordered by the physician, including missed wound dressing changes and the application of only one foam boot instead of both. Staff interviews and documentation confirmed that required treatments and preventive measures were not always implemented or documented, contrary to facility policy.
Two residents did not receive appropriate bowel and bladder care as required by physician orders and facility policy. One resident with constipation did not receive the full prescribed bowel regimen after several days without a bowel movement, and another resident with a urinary catheter did not have urine output consistently documented. Staff interviews and record reviews confirmed that required monitoring and interventions were not performed or recorded.
A resident with end stage renal disease returned from dialysis with a dressing on the dialysis access site that was not removed within the recommended four to six hours. LNs were unaware of the requirement to remove the dressing and did not review the communication record from the dialysis center, resulting in the resident having a soiled dressing on the access site.
A resident with a left heel wound related to cellulitis and sepsis was incorrectly documented in weekly wound evaluations as having a wound on the right heel. This error was confirmed by both the Tx LN and DON, who acknowledged the inaccuracy and its potential to cause confusion, in violation of facility policy requiring accurate wound documentation.
Two residents did not have individualized care plans developed or implemented as required. One resident, at high risk for constipation, experienced ongoing discomfort due to the lack of a care plan and incomplete administration of physician-ordered bowel interventions. Another high fall risk resident suffered a wrist fracture after falling while using the commode without the physician-ordered knee immobilizer, which was not included in the care plan or applied by staff. Facility policies required such care plans, but they were not followed in these cases.
A resident with a history of lower extremity fractures and identified as high risk for falls was left unsupervised on a bedside commode without a gait belt or knee immobilizer during transfer. The CNA left the room for privacy and to respond to another emergency, leaving the resident alone for about ten minutes. The resident fell while attempting to stand, resulting in a fractured wrist. Staff interviews confirmed that facility policy required supervision and use of assistive devices for high fall risk residents, which were not followed in this incident.
The facility failed to follow physicians' care plans for wound treatments for three residents, leading to potential risks of worsening conditions. A resident with multiple skin injuries had missing documentation for treatments on weekends, indicating they were not performed. Two other residents with severe pressure ulcers also had lapses in documented care, suggesting treatments were not administered. The DON confirmed that undocumented treatments were considered not done, increasing infection risks.
A facility's fall evaluation tool failed to accurately assess the fall risk of three residents due to its limitations in accounting for all medications and medical diagnoses. This led to artificially low fall risk scores and subsequent falls for the residents, including a right hip fracture for one. The DON acknowledged the tool's limitations and errors by nursing staff in scoring the assessments.
A resident with multiple health issues and a history of falls was admitted to a facility without a fall risk care plan in place. Despite the facility's policy requiring a preventative plan for high-risk residents, no interventions were added until after the resident fell and sustained a right femur fracture. The deficiency was identified during an unannounced survey when the DON confirmed the lapse in care planning.
A resident with dysphagia and a prescribed pureed diet was mistakenly served non-pureed chicken soup, contrary to their dietary needs. The error was identified by a CNA, and the Director of Nursing confirmed the kitchen's mistake. Facility records and policies were reviewed, showing the resident's consistent need for a pureed diet.
The facility failed to enforce its COVID-19 mitigation plan during an outbreak, with staff and visitors not adhering to mask-wearing protocols. Front desk staff did not request masks, and an IP allowed a visitor into the COVID-19 isolation area without an N95 mask. Staff, including an LN and a CNA, were observed unmasked in patient care areas, and kitchen staff were largely unmasked during lunch preparation. A resident with significant medical conditions was exposed to COVID-19, highlighting the deficiencies' potential impact.
A resident with a high fall risk and multiple medical conditions, including hemiplegia and epilepsy, fell from a wheelchair while being assisted by a CNA, resulting in two fractured ribs. The resident's wheelchair lacked necessary supports, and the CNA failed to provide adequate supervision, contributing to the fall. Despite the resident's high fall risk and cognitive impairment, the facility's supervision and safety protocols were not properly implemented.
The facility failed to ensure proper food handling and sanitation practices, including not labeling and dating opened food items, not discarding food by use-by dates, and not changing gloves after washing a used blender. These actions led to potential foodborne illness and cross-contamination.
The facility failed to ensure proper infection control practices, including a urinary catheter bag resting on the floor, inadequate hand hygiene by staff, improper use of PPE, and insufficient cleaning of equipment. These actions were confirmed through observations and staff interviews, posing a risk for cross-contamination and infection.
The facility failed to ensure dignity for a resident by not concealing the resident's urine collection bag from public view. The resident was observed with an uncovered urine collection bag hanging on the wheelchair in the hallway. Both a Licensed Nurse and the DON confirmed that the bag should have been covered to maintain the resident's dignity, as per the facility's policy.
The facility failed to implement its policies on medication self-administration for a resident with hypertension and diabetes mellitus. The resident's son was found applying triamcinolone cream without a physician's order, and the medication was improperly left in the resident's room. The facility did not conduct the required assessment, obtain a physician's order, or develop a care plan for self-administration.
The facility failed to place a resident's call light within reach, despite the resident's need for assistance due to a fractured femur and difficulty walking. The resident expressed the inability to reach the call button, and both a Licensed Nurse and the DON confirmed that call lights should be accessible, as per facility policy.
The facility failed to ensure the POLST was signed by the physician in a timely manner for a resident who wished to be on DNR status. The resident's POLST form was not signed by the physician, rendering it invalid and defaulting the resident to full code status. Interviews with staff confirmed the requirement for the physician's signature for the POLST to be valid.
The facility failed to protect the confidentiality of two residents' medical records when computer monitors were left open and unattended in the hallway, exposing sensitive information to unauthorized persons. Both LNs and the DON acknowledged the oversight, which violated the facility's policy on safeguarding resident information.
The facility failed to ensure a homelike environment for two residents due to the poor condition of their bedrail foam coverings. One resident with a sacrum fracture and another with hemiplegia and hemiparesis had bedrails with ripped and torn foam. Both the House Keeping Supervisor and the Director of Nursing acknowledged that the foam should have been repaired or replaced.
The facility failed to develop care plans for two residents, one requiring management of psychotropic medications and another with a DNR code status. The Director of Nursing confirmed that care plans should have been developed for both residents, as per facility policy.
The facility failed to provide personal care for a resident who was observed with a white, crusty substance on her eyes. The resident required maximum assistance with bathing and had not been attended to within the expected timeframe, as confirmed by a licensed nurse and the Director of Nursing.
The facility failed to follow physician's orders for daily weight monitoring of a resident with morbid obesity and chronic kidney disease. Staff did not record weights for several consecutive days, which was confirmed through interviews and record reviews. The DON acknowledged the importance of daily weights for accurate monitoring.
A facility failed to ensure that Restorative Nursing Assistance (RNA) was conducted per the physician's order for a resident with contractures and quadriplegia. The resident received RNA less frequently than ordered, increasing the risk for further contractures. Staff interviews confirmed the deficiency.
The facility failed to label tube feeding (TF) bags appropriately for two residents, leading to a potential risk of inadequate TF administration. One resident's TF bag was missing the start time, and another resident's TF formula and water bags were not labeled with the required information. The Director of Nursing and a Licensed Nurse confirmed that the facility's policy mandates proper labeling to ensure correct TF administration.
The facility failed to ensure staff verified physician's orders before administering tube feeding (TF) to a resident with chronic respiratory failure and a tracheostomy. This oversight was confirmed through interviews with the Charge Nurse and Director of Nursing, and it contradicted the facility's policy on Enteral Feeding Administration.
A facility failed to ensure accurate medication administration when an LN administered medication to a resident without proper identification. The LN used the room number and posted name for identification instead of the resident's wristband ID or other approved methods, as required by facility policy.
A medication cart was found unlocked and unattended by an LN, who admitted to not securing it while attending to a resident. The DON confirmed that medication carts should be locked when unattended to prevent unauthorized access and ensure patient safety.
The facility failed to ensure timely inspections of fire extinguishers in the kitchen. Observations revealed that the last documented inspection was in March 2024, and interviews with maintenance staff confirmed that inspections for April and May 2024 were not recorded. The Maintenance Supervisor and Director acknowledged the need for monthly checks and proper documentation.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Practices
Penalty
Summary
The deficiency involves failures to adhere to infection prevention and control protocols for residents on Enhanced Barrier Precautions. For one resident admitted with a malfunctioning tracheostomy and neuromuscular bladder dysfunction, physician orders specified Enhanced Barrier Precautions for carbapenem-resistant Acinetobacter baumannii, with a catheter and gastrostomy tube in place. During observation, this resident’s Foley catheter bag was seen resting on the floor next to the bed. A CNA confirmed that the Foley bag should have been hung on the bed frame and stated it was not supposed to be on the floor because it was contaminated. The DSD also stated the Foley bag should never be on the floor for infection control. The facility’s IPCP Standard and Transmission-Based Precautions policy did not provide guidance on Foley catheter bag placement. A second deficiency involved handling of soiled linen and trash for a resident admitted with ventilator dependence and a gastrostomy, who had physician orders for Enhanced Barrier Precautions due to tracheostomy and G-tube placement. A CNA was observed doffing PPE inside the resident’s room, then donning a new pair of gloves and taking a clear plastic trash bag into the hallway. In the hallway, the CNA opened the bag and separated its contents, placing soiled linen into a gray bin and trash into a white bin. The CNA stated she had provided peri-care and separated the resident’s soiled briefs and dirty linens in the hallway because she only had one trash bag. The DSD stated this was not proper infection control, indicating the soiled linen and trash should have been placed in two separate bags inside the resident’s room and that the CNA should have performed hand hygiene after doffing PPE and before leaving the room. The DON stated she expected staff to contain soiled linen and trash inside the resident’s room and that separating them in the hallway could spread bacteria throughout the facility. The facility’s IPCP policy stated all linen should be handled as if highly infectious. A third deficiency involved hand hygiene for a resident admitted with ventilator dependence and care-planned for carbapenem-resistant Acinetobacter baumannii, with instructions to maintain standard precautions. The Maintenance Supervisor was observed entering this resident’s room without performing hand hygiene and replacing the resident’s hospital bed control, a high-contact device used to adjust the bed. The Maintenance Supervisor later stated that, although he was not providing resident care, he should have performed hand hygiene before entering and exiting the room, especially after touching high-contact areas such as bed controls and side rails. The DSD stated the Maintenance Supervisor should have performed hand hygiene before exiting the room and that it was her expectation for staff to perform hand hygiene before exiting any resident’s room, particularly after touching high-contact areas. The DON stated she expected staff to perform hand hygiene before entering and prior to exiting resident rooms to prevent the spread of germs. The facility’s hand washing policy stated it was the facility’s policy to cleanse hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff.
Failure to Provide Required Medical Supplies and Adequate Entertainment Options
Penalty
Summary
The facility failed to ensure that two residents had access to necessary care and services, resulting in deficiencies related to resident rights. One resident, who had neuromuscular dysfunction of the bladder and impairments in both upper and lower extremities, was required to purchase his own condom catheters after the facility ran out of supplies. Despite being alert and oriented, the resident expressed dissatisfaction with having to order these medical supplies himself, and staff confirmed that the facility did not have the necessary items available, leading to the use of supplies purchased by the resident. Another resident, admitted with a rib fracture and cognitive communication deficit but with intact cognition, did not have access to adequate television channels for entertainment. The resident's family member reported that the television in the room only had four channels, one of which was in a foreign language, and that the resident had been without entertainment for twelve days. The issue had been reported to the facility, but no resolution had occurred, and the resident did not wish to participate in group activities due to noise, leaving him without suitable activity options. Interviews with staff, including a CNA, the Maintenance Director, and the DON, confirmed ongoing issues with both the supply of medical items and the television service. The facility's policy on resident rights did not address the accommodation of residents' needs, and staff acknowledged that the residents' needs were not being met in these instances.
Used Urinal Placed on Bedside Table with Food Items
Penalty
Summary
A deficiency was identified when a used urinal containing urine was observed on top of a resident's bedside table, alongside a plastic bag of chocolate candies, cookies, and a roll of paper towel. The resident, who had intact cognition as indicated by a BIMS score of 13/15, was present in the room with a family member at the time of observation. The family member confirmed that the urinal was not rinsed and was placed on the table where the resident also ate his meals. This practice was directly observed by surveyors and confirmed through interviews with both the resident's family member and facility staff. Further interviews with a licensed nurse and the Director of Nursing confirmed that the urinal should not have been placed on the bedside table due to infection control concerns and the risk of cross contamination. The facility's infection control policy, which was reviewed, requires standard precautions and environmental cleaning to prevent the spread of communicable diseases. The observed actions were not in compliance with these established infection control procedures.
Delayed Medication Administration During Power Outage
Penalty
Summary
During a planned power outage, the facility failed to provide medications on time to 50 out of 113 residents. Nursing staff were unable to access the electronic Medication Administration Record (eMAR), resulting in delayed administration of scheduled morning medications. Interviews with the Assistant Director of Nursing and a licensed nurse confirmed that medications intended for administration between 8 A.M. and 10 A.M. were instead given after the power was restored, with some medications administered as late as 1:08 P.M. This delay was confirmed through record review and staff interviews. One resident, admitted with Parkinson's Disease and other diagnoses, did not receive any of their prescribed morning medications within the required timeframe. Medications such as Rytary, which is critical for managing Parkinson's symptoms, were administered late. The Director of Nursing acknowledged the importance of timely medication administration, especially for conditions like Parkinson's Disease, and confirmed that the facility did not meet this requirement for the resident. Facility policy requires adherence to the six rights of medication administration, including timely delivery, which was not followed during the outage.
Failure to Promptly Address and Report Resident Hypothermia
Penalty
Summary
A deficiency occurred when staff failed to promptly address and notify the physician regarding a resident's hypothermia. The resident, who had a diagnosis of hypothermia, was first noted by a CNA to have a low temperature of 92°F at 9:30 A.M. The Licensed Nurse (LN) on duty was informed but did not immediately assess the resident, instead instructing the CNA to retake the temperature. At around 11:00 A.M., the resident's temperature had dropped further to 90.2°F, and the resident was observed to be shivering with cold skin. The LN initiated a change of condition assessment and notified the physician only around 12:00 P.M., after which the resident was transferred to the hospital. Interviews with staff, including the Director of Nursing (DON) and another LN, confirmed that the resident's low temperature should have been addressed and the physician notified immediately, as hypothermia is a medical emergency. The facility's policy requires all changes in resident condition, including unusual signs and symptoms, to be promptly communicated to the physician. The delay in assessment and notification resulted in a delay of treatment for the resident.
Failure to Implement Emergency Plan and Timely Medication Administration During Power Outage
Penalty
Summary
The facility failed to implement its emergency plan for a planned power outage and did not accurately report the resulting unusual occurrence to the California Department of Public Health (CDPH). Despite being notified by the power company two weeks in advance, the Director of Maintenance only sent a text message to the management team, which was not the official communication method. As a result, key staff, including the Director of Nursing, Medical Records Director, and other managers, were not adequately prepared for the outage. On the day of the outage, staff were surprised by the loss of power and had to rely on paper Medication Administration Records (MARs), which were not available until after the power was restored. This led to delayed medication administration for 50 out of 111 residents. A resident and her family expressed concerns about the late administration of Parkinson's medication, which was particularly time-sensitive, and the resident was subsequently discharged with her family. Interviews with staff confirmed that the lack of timely communication and preparation resulted in the inability to administer medications as scheduled. The facility's report to CDPH did not accurately reflect the problems experienced during the outage, and the facility's policy required that unusual occurrences be reported accurately and completely.
Failure to Timely Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents by not providing timely personal care and meal service. Multiple residents reported significant delays in receiving assistance after activating their call lights. One resident, who was cognitively intact and required assistance with toileting, waited over an hour to be changed despite repeated requests and call light activations. Staff were observed turning off call lights without providing the requested care, and one certified nursing assistant stated that residents were not changed until after breakfast was served to avoid disturbing others. Another resident, dependent on a ventilator and requiring full staff assistance for activities of daily living, reported that staff responded to her needs only at their convenience, which increased her anxiety. A third resident, also cognitively intact and needing maximal assistance for transfers, described waiting over 30 minutes for help and sometimes experiencing even longer delays, attributing this to possible short staffing. In addition to delays in personal care, the facility did not provide meals to residents in a timely manner. Observations showed that breakfast trays were left in the hallway for an extended period before being distributed, resulting in residents receiving cold food. One resident reported that his eggs were ice cold and that trays were always cold, while another resident stated during a council meeting that meal trays were often delayed and cold when finally delivered. Staff interviews confirmed that meal trays should be distributed immediately upon arrival to the unit, but this was not consistently done. Facility policies reviewed during the investigation required that call lights be answered within a reasonable time and that incontinence care be provided while maintaining resident dignity. Staff interviews, including those with the DON and Director of Staff Development, confirmed that the expectation was for prompt response to call lights and immediate distribution of meal trays. However, the observed and reported practices did not align with these policies, resulting in unmet resident needs and delays in essential care and services.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for residents, as evidenced by observations of multiple deficiencies in resident rooms. In one nursing unit, 11 out of 24 resident areas had wall-mounted fans with a visible black coating of dirt and residue on the blades. Additionally, 13 out of 24 resident areas were found to have broken furniture, holes in the wall, scraped paint, exposed unfinished wood on shelving, duct tape covering a bathroom door latch plate, unsanded and unpainted wall repairs, long extension cords running from hallways into rooms, and closet doors or drawers that would not close. These issues were observed in rooms where most residents were non-verbal and on ventilators, with no visitors present during the survey. Interviews with facility staff revealed that housekeeping was responsible for daily cleaning, including furniture and the exterior of fans, while the maintenance department was responsible for cleaning the fans and repairing damaged items. However, there was no documentation in the maintenance log for the previous two months regarding these issues, and staff reported relying on each other to communicate needed repairs. Facility policies required a clean, comfortable, and homelike environment, but these standards were not met in the observed areas.
Expired Food Found in Facility Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food sanitation procedures by allowing expired food items to remain in both the kitchen and nursing unit refrigerators. During a kitchen tour with the Dietary Services Supervisor (DSS), a bag of shredded parmesan cheese and six containers of peaches were found with use by dates that had already passed. The DSS confirmed that these items should have been disposed of on their use by dates and acknowledged the potential for expired food to cause foodborne illness. Additionally, during an inspection of the nursing unit refrigerator with a Nurse Manager, three containers of expired yogurt were identified. The Nurse Manager stated it was her responsibility to check the refrigerator for expired items and that the yogurt should have been discarded. The Registered Dietitian (RD) further explained that staff were responsible for labeling, dating, and disposing of food items by their expiration dates, including food brought in by residents. Facility policy required daily inspection and disposal of perishable foods to ensure food safety, but this procedure was not followed, resulting in the presence of expired food in resident care areas.
QAA Committee Failed to Address Survey-Identified Deficiencies in QAPI Plan
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) did not identify or include in its Quality Assurance Performance Improvement (QAPI) plan the deficient trends found by surveyors during the recertification survey, specifically regarding call light response times and the lack of a homelike environment for residents. During an interview and review of the QAPI program, administrators and the DON confirmed that the QAPI team was primarily monitoring falls, pressure ulcer reduction, weights, and urinary tract infection prevention, but not the issues of call light response or homelike environment. The DON acknowledged that call light response was an ongoing project but was unable to identify a root cause for the issue, stating that it was challenging to do so. Additionally, although there was a budget approved for improvements to residents' rooms to address the lack of a homelike environment, this initiative was not discussed in the QAA Committee nor included in the QAPI plan. The facility's policy on QAPI indicated that the purpose of the plan is to continually assess performance in all service areas to achieve person-centered care, but the identified deficiencies were not incorporated into the facility's ongoing quality improvement processes.
Failure to Adhere to Infection Control Practices and Sanitary Storage of Equipment
Penalty
Summary
Staff failed to follow infection control practices related to Enhanced Barrier Precautions (EBP) and the sanitary storage of ice scoops. Certified Nursing Assistants (CNAs) entered a resident's room, who was on EBP due to conditions including vertebral fractures and muscle weakness, without performing hand hygiene or donning the required personal protective equipment (PPE) such as gowns and gloves. The CNAs donned gloves only after entering the room and did not perform hand hygiene after removing gloves and exiting. Both CNAs acknowledged awareness of the EBP signage and requirements but stated they forgot to follow the protocols. Additionally, a Certified Phlebotomy Technician (CPT) drew blood from a resident on EBP without wearing a gown and placed a supply container directly on the resident's bed, later moving it to a cart without disinfecting it. The CPT was unaware that drawing blood was considered a high-contact activity requiring full PPE, as clarified by the Infection Preventionist (IP). Observations also revealed that ice scoops at two different ice/water stations were stored in uncovered metal containers that lacked drainage, resulting in the scoops resting in standing water. Both the Treatment Licensed Nurse (Tx LN) and the Registered Dietitian (RD) confirmed that the scoops were considered contaminated due to their storage conditions and the risk of cross contamination. The facility's policies required that ice scoops be covered and stored in containers with drainage to prevent contamination, but these procedures were not followed. Interviews with the Director of Nursing (DON), Infection Preventionist, and other staff confirmed that the observed practices did not align with facility policies on hand hygiene, PPE use, and environmental cleaning. The DON and other staff acknowledged the expectations for proper infection control measures, including donning PPE before entering EBP rooms and ensuring sanitary storage of equipment, but these were not adhered to during the observed incidents.
Failure to Consistently Provide Showers and Honor Resident Choice
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and able to make decisions, did not consistently receive showers according to her preferences and the facility's policy. The resident reported not being offered showers and expressed discomfort with the situation, attributing it to possible understaffing. Record review showed that the resident received only two showers over a three-week period, despite the expectation of twice-weekly showers for hygiene and comfort. Staff interviews confirmed that the resident was alert, oriented, and required some assistance with showers, and that the facility's policy was to accommodate resident preferences and provide necessary hygiene services. Further review of facility policies indicated that staff are required to review and accommodate residents' preferences, including for showers, and to provide necessary services for personal hygiene. Interviews with the CNA, LPN, and DON all confirmed the expectation that residents should not miss scheduled showers and that staff should promote dignity and accommodate hygiene needs. The failure to provide showers as scheduled resulted in the resident's preferences and choices not being honored or respected.
Failure to Administer IV Antibiotics and Provide PICC Line Care per Physician Orders
Penalty
Summary
Staff failed to follow physician's orders for a resident who was readmitted with sepsis and a urinary tract infection. The physician's orders required administration of two IV antibiotics—Ertapenem once daily for 14 days and Merrem three times daily until a specified date—as well as PICC line care, including flushing the line before and after each antibiotic dose. Review of the medication administration record revealed missed documentation for several doses of both antibiotics and multiple instances where PICC line care was not documented as provided. Interviews with a licensed nurse and the Director of Nursing confirmed that there were missed entries for medication administration and PICC line care, and that if it was not documented, it was considered not given. Facility policy required implementation of physician orders and accurate documentation of all medications and treatments. The lack of documentation and missed care placed the resident at risk for delayed healing and complications related to the PICC line.
Failure to Follow Physician Orders for Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to follow physician's orders for pressure ulcer treatment and prevention for one resident with a history of cellulitis and sepsis. The resident was observed multiple times with only one foam boot applied to the left foot, despite a physician's order for foam boots on both feet every shift to address a deep tissue injury. Additionally, the resident's treatment administration record indicated that a wound dressing change was not conducted on a specified date, as required by the physician's order for daily wound care. Interviews with staff confirmed that wound treatments should not be missed and that foam boots are necessary to prevent further injury, but documentation and observations showed these interventions were not consistently implemented. The care plan for the resident included interventions such as administering treatments as ordered and applying foam boots as tolerated. However, repeated observations showed non-compliance with these interventions, and staff interviews acknowledged the importance of adhering to physician orders for wound care and prevention. Facility policies required accurate and timely documentation of treatments and implementation of physician orders, but these were not followed, as evidenced by the missed dressing change and inconsistent use of foam boots.
Failure to Follow Bowel and Bladder Care Protocols
Penalty
Summary
The facility failed to follow its bowel and bladder care protocols for two residents. For one resident with a history of cervical disc disorder and high risk for constipation due to pain medication and immobility, the facility did not implement the prescribed bowel regimen after three days without a bowel movement. Despite physician orders for a stepwise approach involving Docusate Sodium, Lactulose, and a mineral oil enema if no bowel movement occurred, the additional Lactulose and mineral oil enema were not administered as required. The resident experienced ongoing discomfort and bloating, and staff interviews confirmed that the bowel management protocol was not followed as ordered. For another resident with neuromuscular bladder dysfunction and urinary retention, the facility did not consistently document urine output as required by physician order and facility policy. The resident had an indwelling urinary catheter and was on a fluid restriction, necessitating close monitoring of urine output to prevent bladder distention. Record reviews revealed multiple missed entries for urine output across various shifts, and staff acknowledged that documentation was not completed as expected. Facility policies required licensed nurses to monitor and document bowel movements and urine output according to physician orders. However, in both cases, the required monitoring and interventions were not performed or documented, resulting in a failure to provide appropriate care for residents who were continent or incontinent of bowel and bladder.
Failure to Provide Timely Dialysis Access Site Care
Penalty
Summary
The facility failed to ensure proper care of a dialysis access site for a resident with end stage renal disease who required hemodialysis. The resident, who attended dialysis three times a week, returned to the facility with a dressing on her right upper arm dialysis access site. Observations revealed that the dressing remained soiled and was not removed within the recommended timeframe. The resident reported that licensed nurses did not remove the dressing after her return from dialysis. Interviews with licensed nurses indicated they were unaware of the requirement to remove the dialysis dressing four to six hours after treatment, as specified in the communication record from the dialysis center. The nurses also admitted to not reading the communication record for updates or new orders. The Director of Nursing confirmed that the dressing should have been removed within the specified timeframe to prevent complications. The facility's policy required adherence to standards for care of residents on renal dialysis and their vascular access sites.
Inaccurate Documentation of Wound Location in Resident Record
Penalty
Summary
The facility failed to accurately document the correct extremity involved in the weekly wound evaluation summary for one resident. Specifically, a resident who was admitted with cellulitis in the lower extremities and sepsis had a wound on her left heel, as confirmed by physician orders and the resident's own statement. However, the facility's weekly wound evaluations on two separate occasions incorrectly identified and measured the wound as being on the right heel instead of the left. This documentation error was confirmed during interviews with both the wound Treatment Nurse and the Director of Nursing, who acknowledged that the records were inaccurate and could confuse readers. The facility's own policy requires that all wounds and treatments be accurately documented in the resident's record, but this was not followed in the case of this resident.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, resulting in unmet care needs. One resident, admitted with orthopedic aftercare and at high risk for constipation due to pain medication and immobility, experienced ongoing abdominal discomfort and bloating. Despite physician orders for a bowel regimen including Docusate Sodium, Lactulose, and a mineral oil enema if needed, the care plan for constipation was not developed, and not all physician-ordered interventions were administered. Staff interviews confirmed the absence of a care plan and inconsistent application of the bowel protocol, leading to the resident's continued discomfort. Another resident, admitted with fractures to the right tibia and patella and identified as a high fall risk, did not have the physician-ordered intervention of a knee immobilizer included in the care plan. The resident subsequently fell while using the bedside commode without the immobilizer in place, resulting in a fractured left wrist. Staff interviews revealed that the knee immobilizer, which was ordered to be worn whenever the resident was out of bed, was not applied during the transfer, and the care plan did not reflect this critical intervention. Facility policies on bowel care management and fall management required individualized care plans with measurable objectives and interventions based on assessment findings. However, in both cases, the care plans were either not developed or not implemented as ordered, leading to residents experiencing pain and injury. Staff and leadership interviews confirmed the importance of care plans for communication and consistent intervention, and acknowledged that the deficiencies contributed to the residents' negative outcomes.
Failure to Supervise High Fall Risk Resident During Toileting and Omission of Gait Belt Use
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and utilize required safety devices for a resident identified as high risk for falls. The resident, who had a history of a displaced fracture of the right tibia and patella and was under partial weight-bearing orders with a knee immobilizer for out-of-bed activities, was assisted to a bedside commode by a CNA. The CNA did not use a gait belt during the transfer, did not apply the resident's knee immobilizer, and left the resident alone for privacy, despite the resident's high fall risk status as documented in the care plan and fall risk evaluation. The resident subsequently attempted to stand up from the commode, reached for a walker and the call light, and fell when the commode shifted behind her. The fall resulted in a fractured left wrist. The call light had been placed out of easy reach, and the resident was left unsupervised for approximately ten minutes. The CNA left the room to respond to another emergency and did not inform another staff member to supervise the resident during this time. Interviews with facility staff, including the CNA, treatment nurse, DSD, and DON, confirmed that facility policy required staff to remain with high fall risk residents during toileting and to use gait belts during transfers. The staff acknowledged that the required supervision and use of assistive devices were not provided, and that the resident should not have been left alone on the commode.
Failure to Document and Perform Wound Care Treatments
Penalty
Summary
The facility failed to adhere to the physicians' plan of care for skin and wound treatments for three residents, leading to potential risks of worsening skin and wound injuries. Resident 1, who was readmitted with multiple skin injuries, had several instances where wound treatments were not documented as performed on specific dates, particularly on weekends. The treatment nurse confirmed that the charge nurses were expected to perform these treatments on weekends, but the lack of documentation indicated that the treatments were not completed, putting the resident at risk of infection. Resident 2, admitted with severe pressure ulcers, also experienced lapses in documented wound care. On two consecutive days, there was no evidence that the prescribed wound treatments were performed. This lack of documentation suggests that the treatments were not administered, which could have led to further complications in the resident's condition. The care plan for Resident 2 included specific interventions to manage pressure ulcers, but the failure to document treatments indicates a gap in care delivery. Similarly, Resident 3, who had a stage 4 pressure ulcer, had missing documentation for wound treatments on two separate occasions. The treatment nurse emphasized the importance of documenting wound care to ensure continuity and effectiveness of treatment. The Director of Nursing acknowledged that if treatments were not documented, they were considered not done, which could increase the risk of infection for the residents. The facility's policies on physician orders and skin management were not followed, as evidenced by the lack of accurate transcription and implementation of treatment orders.
Inaccurate Fall Risk Assessments Lead to Resident Falls
Penalty
Summary
The facility's fall evaluation tool failed to accurately represent the fall risk status of three residents during their admission assessments. The Director of Nursing (DON) acknowledged that the tool did not allow nursing staff to include all medications and medical diagnoses that could increase fall risk, leading to artificially low fall risk scores. This deficiency was evident in the cases of three residents who had multiple medical conditions and were taking several medications that heightened their risk of falling. Despite these factors, the fall risk assessments for these residents were inaccurately scored, contributing to their falls. Resident 1, who had a history of falls and multiple medical conditions, experienced two falls shortly after admission, resulting in a right hip fracture. Similarly, Resident 2 and Resident 3, both with significant medical histories and medication regimens, were also inaccurately assessed and subsequently fell, although without serious injury. The DON admitted that the evaluation tool's limitations and errors by nursing staff led to these inaccurate assessments. The facility's policies on fall risk assessment and documentation accuracy were not effectively implemented, as evidenced by the inaccurate evaluations and subsequent falls.
Failure to Implement Fall Risk Care Plan
Penalty
Summary
The facility failed to create an admission fall risk care plan for a resident within 48 hours of admission, as required by their policy. The resident, who had a history of falling and multiple diagnoses including difficulty in walking, generalized muscle weakness, major depressive disorder, cardiac murmur, chronic kidney disease, anemia, and epilepsy, was admitted without a fall risk care plan in place. This oversight occurred despite the facility's policy to identify residents at risk for falls and initiate a preventative plan of care. The deficiency was identified during an unannounced survey when the Director of Nursing (DON) acknowledged that the care plan was opened but no interventions were added until after the resident experienced a fall. The resident subsequently fell in her room, resulting in a right femur fracture. The facility's policy clearly stated that any resident identified as high risk should have a prevention protocol initiated and documented on the care plan, which was not done in this case.
Resident Served Incorrect Diet Despite Puree Order
Penalty
Summary
A resident with a medical history of hemiplegia, hemiparesis, generalized muscle weakness, and dysphagia was admitted to the facility with a prescribed therapeutic diet of pureed food and thin liquids. On a specific date, the resident was served chicken soup with rice and carrots, which was inconsistent with the prescribed pureed diet. This incident was reported to the State Agency following a complaint, and it was confirmed through interviews and record reviews that the resident received an inappropriate diet. The Director of Nursing acknowledged that the kitchen mistakenly sent out the incorrect soup, which was identified and removed by a Certified Nursing Assistant. The facility's records, including the resident's care plan and speech therapy evaluation, consistently indicated the need for a pureed diet. The Certified Dietary Manager admitted that an error occurred when the wrong soup was placed on the resident's tray. Facility policies regarding meal tray preparation and verification were reviewed, highlighting the failure to ensure the correct diet was served to the resident.
Failure to Enforce COVID-19 Mitigation Plan
Penalty
Summary
The facility failed to adhere to its COVID-19 mitigation plan during an outbreak, as observed through multiple instances of non-compliance with mask-wearing protocols. Front desk staff did not request individuals entering the facility to wear masks, even during a COVID-19 outbreak with confirmed positive cases. Additionally, the Infection Preventionist allowed a visitor into the COVID-19 isolation area without an N95 mask, and floor staff did not stop unmasked visitors to ask them to wear masks while inside the facility. These actions were contrary to the facility's stated procedures for managing COVID-19 risks. Further observations revealed that staff members, including a Licensed Nurse and a Certified Nursing Assistant, were not wearing masks properly or at all in patient care areas. The Licensed Nurse was seen with a mask under her chin while entering a patient room, and the CNA was unmasked by the timeclock. The Receptionist was also observed unmasked in various areas, including the front desk and near the bathroom, despite the facility's policy that masks should be worn in all resident care areas. The Infection Preventionist admitted to not emphasizing mask-wearing in certain areas, acknowledging that the mitigation plan was not up to the standard of care. The report also highlighted that kitchen staff were largely unmasked during lunch preparation, with only two staff members wearing masks. The facility's COVID-19 mitigation plan required adherence to source control principles during visitation and group activities, yet this was not consistently enforced. The report included details about a resident with significant medical conditions who was exposed to COVID-19, further underscoring the potential impact of these deficiencies on vulnerable residents.
Inadequate Supervision Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in the resident suffering two fractured ribs. The resident, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, epilepsy, and a history of falls, was identified as having a high risk for falls. Despite this, the resident fell from a wheelchair while being assisted to an activity, leading to the injury. The incident occurred when a CNA was pushing the resident in a personal wheelchair without a footrest on the right side, which was necessary due to the resident's right leg paralysis. The Director of Nursing (DON) acknowledged that the resident required supervision or touching assistance to propel in the wheelchair and had a high fall risk due to poor posture and cognitive deficits. The resident's medication regimen, which included multiple black box medications, was reviewed prior to the fall with no recommendations for changes. The resident's cognitive impairment was moderate, as indicated by a BIMS score of 10. During the incident, the CNA was not looking at the resident's feet and did not notice the resident's right arm position, which contributed to the fall. Interviews and observations revealed that the resident's wheelchair lacked a high back or leg rests, and the resident had a tremor in the right arm and leg. The facility's training and policies emphasized the importance of supervision and safety precautions, but these were not adequately followed in this case. The facility's fall management system required individualized care plans for high-risk residents, but the supervision provided was insufficient to prevent the accident.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food handling and sanitation practices in the kitchen, leading to potential foodborne illness and cross-contamination. During a tour of the kitchen, it was observed that opened food items, such as pineapple slices and bread, were not labeled and dated properly. Additionally, some food items were not discarded by their use-by dates, and mold was found on a hot dog roll. The Nutrition Service Director (NSD) and Registered Dietitian (RD) confirmed that these items should have been labeled and discarded according to the facility's policies. Furthermore, a knife with food debris was found on a magnetic knife holder, and the NSD acknowledged that it should have been cleaned after use. The RD also noted the potential for foodborne illness if the knife was used to prepare food without proper cleaning. Another issue was observed with a kitchen staff member who did not change gloves after washing a used blender during food preparation. The staff member, Cook 1, wore the same gloves while pureeing vegetables, washing the blender, and then preparing pureed meat without performing hand hygiene and using new gloves. Both the NSD and RD confirmed that the staff should have changed gloves and washed hands to prevent cross-contamination. The facility's policies on labeling, dating, and sanitation were not followed, leading to these deficiencies.
Multiple Infection Control Failures
Penalty
Summary
The facility failed to ensure proper infection control practices in several instances. One resident's urinary catheter bag was observed resting on the floor, which was confirmed by multiple staff members as a risk for cross-contamination. The facility's policy and CDC guidelines both indicate that the urine drainage bag should not touch the floor to prevent infection. Despite this, the bag was found on the floor during multiple observations and interviews with staff, including the Infection Preventionist and the Director of Nursing, who acknowledged the risk of cross-contamination. Staff also failed to perform proper hand hygiene in several situations. Certified Nurse Assistants were observed not washing their hands after exiting and before entering residents' rooms, and Licensed Nurses did not perform hand hygiene between glove changes during wound care and medication administration. These actions were against the facility's hand hygiene policy, which requires hand hygiene before and after direct contact with residents, before donning sterile gloves, and after removing gloves. Interviews with the staff confirmed that they were aware of the importance of hand hygiene but failed to adhere to the policy. Additional deficiencies included improper use of personal protective equipment (PPE) and inadequate cleaning of equipment. A Certified Phlebotomy Technician did not remove PPE before exiting a resident's room and placed used supplies on a clean cart. Bedrails with damaged foam coverings were not replaced or cleaned properly, posing a risk for contamination. A resident's bipap mask was also not stored in a clean bag, as required by the facility's policy. These actions were confirmed through observations and interviews with staff, including the Infection Preventionist and Housekeeping Supervisor, who acknowledged the failures and the potential for cross-contamination and infection.
Failure to Conceal Urine Collection Bag
Penalty
Summary
The facility failed to ensure dignity for Resident 320 by not concealing the resident's urine collection bag from public view. Resident 320, who was admitted with muscle weakness and urinary retention, was observed on 5/7/24 at 11:08 A.M. with an uncovered urine collection bag hanging on the wheelchair in the facility hallway. Licensed Nurse 31 confirmed that the urine collection bag was visible to people passing by and acknowledged that it should have been covered to maintain the resident's dignity. The Director of Nursing also stated that urine collection bags must be placed inside a privacy bag to respect the resident. The facility's policy on catheter care mandates that drainage bags be covered with a privacy bag.
Failure to Implement Medication Self-Administration Policies
Penalty
Summary
The facility failed to ensure their policies on medication self-administration were implemented for Resident 101. Resident 101 was admitted with diagnoses including hypertension and diabetes mellitus. During an observation and interview, it was found that Resident 101's son was applying triamcinolone cream to the resident's skin, despite there being no physician order for this medication in the resident's record. Licensed Nurse 32 confirmed that there was no triamcinolone order and stated that an assessment, physician's order, and care plan should have been in place if the resident was to self-administer medications. The medication should not have been in the room to prevent misuse. The Director of Nursing confirmed that residents should be assessed for self-administration and that medications should not be left in the resident's room to prevent inappropriate use. The facility's policy on self-administration of medications requires an interdisciplinary team assessment and periodic re-evaluation based on changes in the resident's status. This failure to follow policy had the potential to result in unsafe medication administration.
Failure to Place Call Light Within Resident's Reach
Penalty
Summary
The facility failed to address the needs of Resident 316 by not placing the call light within reach. Resident 316, who was admitted with a displaced fracture of the right femur, a history of falling, and difficulty walking, was found to have his call light dangling on the headboard, making it inaccessible. During an observation and interview, Resident 316 expressed that he needed help but could not reach the call button. His son had to press the button for him. Both a Licensed Nurse and the Director of Nursing confirmed that call lights should be placed within residents' reach, as per the facility's policy and procedure.
Failure to Ensure Timely Physician Signature on POLST
Penalty
Summary
The facility failed to ensure the Physician Order for Life-Sustaining Treatment (POLST) was signed by the physician in a timely manner for Resident 62, who wished to be on Do Not Attempt Resuscitation (DNR) status. Resident 62 was admitted with a diagnosis of heart failure, and a review of records on 5/8/24 indicated that the POLST form was not signed by the physician, rendering it invalid. Interviews with the Social Services Director (SSD), Licensed Nurse (LN) 1, and the Director of Nursing (DON) confirmed that the physician's signature is required for the POLST to be valid, and without it, the resident would default to full code status, which includes intubation, medication, and cardio-pulmonary resuscitation. The SSD stated that the physician should have signed the POLST within 48 hours of the physician's visit and discussion with the resident. LN 1 mentioned that the physician had to sign the POLST within three days, and the DON reiterated that the POLST must be completed in all areas, including the physician's signature, to be valid. The facility's policy and procedure on Resident Assessment Advance Directives/POLST also indicated that the POLST form must be signed by a physician, nurse practitioner, or physician assistant and the patient or decision maker to be valid. The failure to obtain the physician's signature in a timely manner resulted in the POLST being invalid, thus not honoring Resident 62's DNR wishes.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records for two of the 29 sampled residents. On two separate occasions, computer monitors on Medication Cart #1 were left open and unattended in the hallway outside of resident rooms, displaying the medical records of Resident 216 and Resident 215. Resident 216 was admitted with a sacrum fracture, and Resident 215 was admitted with a right shoulder fracture. These unattended monitors had the potential to expose sensitive information to unauthorized persons. During interviews, both Licensed Nurse 11 and Licensed Nurse 4 acknowledged that the computer monitors were left open and unattended, and they admitted that they should have closed the monitors to protect the residents' confidential information. The Director of Nursing also confirmed that the computer monitors should have been closed when unattended to ensure the confidentiality of residents' medical records. The facility's policy on resident medical information emphasizes the importance of safeguarding resident records to protect their confidentiality and restricts access to authorized staff and consultants only.
Failure to Maintain Homelike Environment Due to Damaged Bedrail Foam
Penalty
Summary
The facility failed to ensure a homelike environment for two residents, Resident 50 and Resident 216, due to the poor condition of their bedrail foam coverings. Resident 216, who was admitted with a sacrum fracture, had bedrails with black foam that was ripped and torn. During an interview, Resident 216 expressed feeling uncared for because of the broken foam. Resident 216's daughter also voiced concerns, stating that the torn foam was disrespectful to the resident. Similarly, Resident 50, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, had a left-side bedrail with black foam that was falling apart and wrapped with black tape. Resident 50's spouse indicated that fixing the foam would improve his comfort level. The House Keeping Supervisor (HKS) acknowledged the poor condition of the bedrail foam and stated that it should have been reported to maintenance for repair or replacement. The Director of Nursing (DON) confirmed that the foam should have been replaced or removed, emphasizing the importance of maintaining resident equipment in good working condition to make residents feel at home. A review of the facility's policy on Environmental Conditions/Environmental Rounds indicated that the facility is required to provide a safe, functional, sanitary, comfortable, and homelike environment for residents.
Failure to Develop Care Plans for Psychotropic Medications and Code Status
Penalty
Summary
The facility failed to develop care plans for two residents, leading to potential mismanagement of their medical needs. Resident 6, who was readmitted with major depressive disorder and anxiety disorder, had psychotropic medications ordered by the physician. However, a care plan addressing these medications was not developed, as confirmed by the Director of Nursing (DON) during an interview. This oversight could result in inappropriate management of Resident 6's psychotropic medications. Similarly, Resident 62, admitted with heart failure, had a Physician Order for Life-Sustaining Treatment (POLST) indicating a Do Not Resuscitate (DNR) code status. Despite this, the code status was not incorporated into the resident's care plan. The DON acknowledged that a care plan should have been developed to reflect Resident 62's DNR status. The facility's policy mandates that the interdisciplinary team (IDT) develop a comprehensive care plan for each resident, which was not followed in these cases.
Failure to Provide Personal Care for Resident
Penalty
Summary
The facility failed to ensure personal care was provided for Resident 319, who was observed with a white, crusty substance on the inner side of her eyes. Resident 319 was admitted with diagnoses including difficulty in walking and traumatic subdural hemorrhage, and her Minimum Data Set indicated she required maximum assistance with showering and bathing. During an observation, it was noted that her eyes had not been cleaned, which was confirmed by a licensed nurse who stated that the eyes should have been attended to within two hours of the shift. The Director of Nursing also confirmed that residents dependent on staff for personal care should be promptly cared for. The facility's policy on Routine Procedure Morning Care indicated that residents should be given a moist cloth and towel for cleaning hands and face, with assistance if necessary.
Failure to Follow Physician's Orders for Daily Weight Monitoring
Penalty
Summary
The facility did not ensure staff followed physician's orders for a resident who required daily weight monitoring. Resident 41, who was admitted with diagnoses including morbid obesity and chronic kidney disease stage 3, reported that the facility sometimes failed to weigh him daily as required. This was confirmed through record reviews and interviews with staff, which revealed that weights were not recorded for several consecutive days. The physician's order dated 1/11/2022 specified daily weights, but there were no weights recorded for Resident 41 on 5/1/24, 5/2/24, 5/3/24, and 5/4/24. Both the Restorative Nursing Assistant and the Charge Nurse acknowledged the lapse in following the physician's order. The Director of Nursing also confirmed that Resident 41 should have been weighed daily to monitor weight gain and water retention accurately. The facility's policies on physician orders and routine procedures for weight assessment were reviewed and indicated the importance of accurately transcribing and implementing orders, as well as obtaining accurate weights as part of the resident's assessment. The failure to weigh Resident 41 daily as ordered had the potential to negatively impact the resident's physical and psychosocial well-being.
Failure to Conduct Restorative Nursing Assistance as Ordered
Penalty
Summary
The facility failed to ensure that Restorative Nursing Assistance (RNA) was conducted per the physician's order for a resident with limited range of motion (ROM). Resident 6, who was readmitted with diagnoses including contracture of muscle in the left upper arm and quadriplegia, was observed in bed with both upper arms contracted. The physician's order dated 4/5/24 indicated that the RNA program should be conducted three times per week for three months on both upper and lower extremities. However, the RNA flowsheet for April 2024 showed that the resident received RNA only two times during the week of 4/8, once during the week of 4/15, and not at all during the week of 4/22. Interviews with the Restorative Nursing Assistant (RNA 1), the Minimum Data Set Coordinator (MDS 1), and the Director of Staff Development (DSD) confirmed that the RNA program was not conducted as ordered. RNA 1 acknowledged that Resident 6 was in the RNA program due to contractures in both upper and lower extremities. MDS 1 stated that the RNA program should have started when the physician's order was written and that there was a risk for contractures when the RNA was not performed. The DSD confirmed that the RNA was not conducted three times a week as required by the physician's order, based on staff documentation. The facility's policy on Restorative Care emphasized that residents should receive services to attain and maintain the highest possible mental and physical functional status as defined by the comprehensive assessment and plan of care.
Failure to Label Tube Feeding Bags Appropriately
Penalty
Summary
The facility failed to ensure that tube feeding (TF) bags were labeled appropriately per the facility's policy for two residents, leading to a potential risk of inadequate TF administration. Resident 6 was readmitted with a gastrostomy and observed with a TF bag dated the previous day but lacking the time it was started. The Licensed Nurse (LN) admitted to forgetting to label the TF bag with the time, which is necessary to ensure the TF is administered correctly according to the physician's order. The Director of Nursing (DON) confirmed that the TF bag should have been labeled with the resident's name, date, time, and the initials of the administering nurse, as per the facility's policy and the six rights of medication administration. Similarly, Resident 106, admitted with pneumonitis, was observed with a TF pump set connected to a water bag and TF formula bag, both of which were not labeled with the required information. The DON reiterated that the facility's policy mandates labeling the TF formula with the resident's name, the amount to infuse, the date and time it was administered, and the initials of the administering staff. Licensed Nurse 13 also confirmed that the TF formula and water bags should be labeled with the resident's name, date, time, rate of infusion, and staff initials. The facility's undated policy and procedure for Enteral Feeding Administration clearly state the need for such labeling to ensure proper TF administration.
Failure to Verify Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to ensure that staff had the appropriate competencies to administer tube feeding (TF) correctly for Resident 20. Resident 20, who was admitted with chronic respiratory failure and a tracheostomy connected to a ventilator, required TF at 50 milliliters per hour for 20 hours. During an observation, interview, and record review, Licensed Nurse (LN) 13 was unable to verbalize the need to verify the physician's order as part of the TF administration process. This step is crucial for ensuring the resident's safety by confirming the right formula and rate, as well as checking for potential allergic reactions. Further interviews with the Charge Nurse (CN) 22 and the Director of Nursing (DON) confirmed the importance of verifying physician's orders before administering TF. The facility's policy on Enteral Feeding Administration also mandates this verification step. The failure to follow this procedure had the potential to negatively affect Resident 20's health, as it is essential for ensuring the correct administration of TF.
Failure to Properly Identify Resident Before Medication Administration
Penalty
Summary
The facility failed to ensure accurate medication administration for one of 29 sampled residents when a Licensed Nurse (LN) administered medication without properly identifying the resident. Resident 17, who was admitted with diagnoses including diverticulitis of the large intestine with perforation and abscess, did not have a wristband identification at the time of medication administration. The LN did not check for Resident 17's wristband ID or ask for the resident's identifiers such as name and date of birth before administering the medication. Instead, the LN identified the resident by checking the room number and name posted outside the room, which is not an accurate method of identification according to the facility's policy. During an interview, the LN acknowledged the failure to properly identify the resident and admitted to using the room number and posted name for identification. The Director of Nursing (DON) confirmed that the LN should have identified the resident using the wristband ID or, if unavailable, by confirming with another licensed staff member and using the photo in the patient profile. The DON emphasized the importance of proper resident identification for patient safety and stated that using the room number and posted name is not an acceptable method of identification. The facility's policy on medication administration also mandates accurate resident identification prior to administering medications.
Failure to Lock Medication Cart
Penalty
Summary
The facility failed to ensure all medications were locked for one of seven medication carts (Medication Cart #1). An observation was conducted in the hallway outside of a resident's room, where Medication Cart #1 was found to be unlocked and unattended by a Licensed Nurse (LN). During a joint observation and interview, LN 11 admitted to leaving the medication cart unlocked and unattended while attending to a resident in the room. LN 11 demonstrated that the cart could be opened without a key and acknowledged that the key lock button should have been pushed to secure the cart before leaving it unattended. An interview with the Director of Nursing (DON) confirmed that medication carts should be locked when unattended to prevent unauthorized access and ensure patient safety. The facility's policy and procedure titled Medication Access and Storage indicated that only authorized personnel should have access to medications and that medication carts should be locked or attended at all times. This failure had the potential for Medication Cart #1 to be accessed by unauthorized personnel, posing a risk to patient safety and the potential for drug diversion.
Failure to Timely Inspect Fire Extinguishers
Penalty
Summary
The facility failed to ensure that fire extinguishers in the kitchen were inspected in a timely manner. During a tour of the kitchen, it was observed that three fire extinguishers had their last documented inspection in March 2024. Interviews with the Maintenance Assistant (MA) revealed that the inspections for April and May 2024 were not recorded on the tags. The MA admitted to checking the fire extinguishers but only documenting the inspections in a notebook, which was then transferred to his boss's computer or desk. However, there was no documentation in the application used by the facility to confirm these inspections were conducted. Further interviews with the Maintenance Supervisor (MS) and Maintenance Director (MD) confirmed that the fire extinguishers should be checked monthly to ensure they are in good operating condition. The MS was unable to provide documentation to show that the inspections were conducted timely. The MD stated that the fire extinguishers' tags should be marked on the first day of the month to ensure they are ready for use in case of a fire and acknowledged that the MA needed proper education and training. The facility's document titled NFPA 10 Standard for Portable Fire Extinguishers also indicated that monthly inspections should be recorded with the date and initials of the person performing the inspection.
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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