Chapman Global Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, California.
- Location
- 2601 East Chapman Avenue, Orange, California 92869
- CMS Provider Number
- 555709
- Inspections on file
- 19
- Latest survey
- October 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Chapman Global Medical Center D/p Snf during CMS and state inspections, most recent first.
The facility failed to prevent LVNs from performing respiratory care tasks outside their scope of practice following regulatory changes, as evidenced by continued LVN involvement in tracheostomy care and respiratory assessments for a resident. Facility policies and procedures were not updated to reflect the new scope limitations, and staff interviews confirmed that LVNs continued these practices due to inadequate RT staffing and lack of updated guidance.
Multiple residents did not receive required monitoring for pain and injury, and physician-ordered PT, OT, and RNA services were missed or undocumented. Staff interviews confirmed that assessments and treatments were not consistently performed, and therapy was deprioritized due to staffing shortages.
Two residents dependent on ventilators experienced lapses in respiratory care, including inadequate monitoring of ventilator circuits and improper handling of oxygen therapy and disposable equipment by non-qualified personnel. One resident was found unresponsive and disconnected from the ventilator without timely intervention or documentation of required checks, while another had emergency interventions performed by a CNA outside their scope of practice. The absence of a dedicated RT and inconsistent adherence to facility policies contributed to delayed care and non-compliance.
A resident with multiple pressure injuries was found on an air mattress set to static mode, contrary to the physician's order for an alternate mode setting. An LVN incorrectly confirmed the static mode as correct, despite the order specifying a five-minute cycle for pressure redistribution.
The facility failed to provide ordered RNA services to two residents with contractures and quadriplegia, as documented in their RNA Flowsheets. The absence of daily ROM exercises and application of orthotic devices, as ordered by physicians, was confirmed by staff interviews and could lead to worsening contractures and muscle stiffness.
The facility failed to properly place low air loss mattress pumps for two residents, leaving them on the floor instead of hanging them on the footboard as recommended. Additionally, a resident with impaired cognition and mobility was observed with only one floor mat beside the bed, despite a physician's order for mats on both sides to prevent falls. Staff acknowledged these deficiencies.
The facility failed to maintain the required head of bed (HOB) elevation for two residents receiving enteral feeding via gastrostomy tubes (GT). Both residents had physician orders to keep the HOB elevated at 30 to 45 degrees during feeding, but observations showed the HOB was not elevated to the required angle. Staff interviews revealed a lack of tools and knowledge to ensure compliance with these orders, posing a risk for complications.
A facility failed to maintain proper IV access for a resident, as they did not obtain a physician's order for IV care and maintenance, nor develop a care plan for the IV access on the resident's lower extremity. The resident, with moderately impaired cognitive skills, was on IV hydration due to abnormal lab results. The absence of a physician's order for IV assessment, dressing change, and site change frequency was confirmed by RN 2 and the CNO.
A facility failed to follow its P&P for pharmaceutical waste disposal when an LVN improperly disposed of a half tablet of fludrocortisone in a sharps container instead of the designated pharmaceutical waste container. The incident involved a resident prescribed fludrocortisone for hypotension, and the LVN was observed during a medication administration session.
The facility did not act on a pharmacist's recommendations for a resident, including discontinuing chlorhexidine and performing a hemoglobin A1c test. The physician's orders remained unchanged, and there was no follow-up by nursing staff, as confirmed by the Director of Pharmacy and RN 1.
A resident did not receive medications as prescribed, resulting in a medication error rate of 8% at the facility. The resident was given an incorrect dose of lactulose and did not receive a scheduled clonidine patch. The LVN acknowledged the errors, which were contrary to the facility's medication administration policies.
The facility failed to properly store medications on two medication carts, leading to potential medication administration errors. Medications such as loperamide liquid, Carboxymethylcellulose eye drops, and Insulin Lantus were found stored together without partitions, contrary to the facility's policy. LVNs verified the findings and acknowledged the need for separate storage.
The facility failed to ensure food safety and sanitation in the kitchen, with issues including unsanitary utensils, staff's personal food in the kitchen refrigerator, and lack of hair restraints. These deficiencies were confirmed by the RD, Dietary Supervisor, and CNO.
The facility's infection control committee failed to meet for one quarter in 2024 due to the absence of the Infection Control Chair, leading to a lapse in discussing infection control statistics and posing a risk for disease transmission.
The facility's assessment was outdated and did not involve direct care staff, residents, or their representatives. It lacked a plan for staffing resources, recruitment, retention, and contingency for staffing needs, as confirmed by the CNO.
The facility lacked a full-time, dedicated Infection Preventionist (IP) to oversee its Infection Prevention and Control Program. The position was vacant since January 2024, and the Director of Infection Prevention/Acting IP was primarily stationed at the acute care unit, spending only limited time at the facility. The CNO confirmed the facility shared IP personnel with the acute care unit and was actively seeking to fill the position.
A resident's protected health information was left visible on an unattended staff computer in a hallway accessible to visitors. The computer, used by a Respiratory Therapist, displayed the resident's name and medications, violating confidentiality policies. An LVN confirmed the breach during an observation.
The facility failed to properly dispose of garbage and refuse, with two waste dumpsters observed overflowing and not closed, potentially causing unsanitary conditions. This was confirmed by the RD, Dietary Supervisor, and CNO, and violated the facility's sanitation policy requiring tightly closed containers to prevent pests.
The facility failed to maintain a homelike environment for four residents, as observed in two rooms with walls in disrepair, including holes, scratches, and unfinished patchwork. The residents were cognitively impaired and not interviewable. The CNO acknowledged the need for repairs.
A facility failed to provide restorative nursing assistant (RNA) services as ordered for a resident with contractures, leading to a potential decline in range of motion (ROM) functions. The resident received inconsistent RNA services due to staffing challenges, with RNA staff often reassigned to CNA duties. The Director of Nursing acknowledged the issue and was working on recruiting additional RNA staff.
LVNs Performed Respiratory Care Outside Scope After Regulatory Change
Penalty
Summary
The facility failed to ensure that Licensed Vocational Nurses (LVNs) performed their duties within their legal scope of practice when providing care to patients, specifically those with tracheostomies. Despite regulatory changes from the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) effective 10/1/25, which restricted LVNs from performing certain respiratory care tasks, LVNs continued to conduct activities such as pre- and post-nebulizer treatment assessments, tracheostomy care, suctioning, and manipulation of ventilators. These actions were documented in patient records and confirmed through staff interviews, indicating that LVNs were performing tasks outside their authorized scope. The facility's policies and procedures (P&Ps) related to respiratory care and tracheostomy management had not been updated to reflect the new BVNPT regulations. Multiple P&Ps, including those for tracheostomy tube suctioning, speaking valve cleaning, and tracheostomy care, did not specify the limitations imposed on LVNs. Staff interviews revealed that LVNs were aware of the regulatory changes but continued to perform restricted tasks due to insufficient respiratory therapist (RT) staffing. Some LVNs stated they performed these tasks out of necessity when RTs were unavailable, and documentation showed that these practices persisted after the effective date of the new regulations. Interviews with the Director of Nursing (DON), RT Manager, and other staff confirmed that the facility was aware of the changes in LVN scope of practice but had not yet fully implemented the necessary staffing adjustments or policy updates. The DON acknowledged that LVNs were performing respiratory care outside their scope and that the facility's job descriptions and policies were outdated. The RT Manager also noted that the number of RTs was insufficient to meet patient needs, leading to continued reliance on LVNs for restricted respiratory care tasks.
Plan Of Correction
Chapman Global Medical Center Plan of Correction Scope changes of LVN staff, including what respiratory care they can provide and instructing them to notify the charge nurse of any respiratory care needed that falls within the limitations defined by the BVNPT so that an RN can complete these duties. Resident #1 was assessed by the RN to ensure no adverse effects were present from the LVN providing the care to the patient. No issues were identified. By 11/15/25, all LVNs will be educated on the changes to the LVN scope of practice for providing respiratory care from the BVNPT effective 10/1/25 by their supervisor. The education will be done during unit huddles, staff meetings, or online. The DON reviewed the LVN JD and found it outdated. By 11/15/25, the Facility will revise the Job Description, Scope of Practice Policies, and Procedures in accordance with the California Vocational Nursing Practice Act and The Respiratory Care Board Regulations. All LVNs will be educated on the revised JD and will sign the new JD to ensure understanding of the changes.
Failure to Provide Necessary Care, Therapy, and Restorative Services
Penalty
Summary
The facility failed to provide necessary care and services to ensure residents maintained their highest physical well-being, as evidenced by multiple deficiencies in monitoring, documentation, and adherence to physician orders for five sampled residents. For one resident with a right upper arm fracture, there was no consistent monitoring for pain, redness, swelling, or warmth of the extremities, despite care plan interventions requiring such assessments. Documentation was lacking for musculoskeletal assessments and CNA care during specific shifts, and there was no evidence that pain observed by PT staff was reported to nursing. Interviews with staff confirmed that assessments were not completed and that signs of injury were not always checked or documented. The facility also failed to follow physician orders for physical therapy (PT) and occupational therapy (OT) treatments for two residents. Records showed missed PT and OT sessions over several weeks, with the rehabilitation department prioritizing other hospital patients over those in the skilled nursing facility. The Director of Nursing acknowledged the lack of therapy documentation and confirmed that required treatments were not consistently provided as ordered. Additionally, the facility did not provide daily Restorative Nursing Assistant (RNA) services as ordered for four residents. Medical records revealed multiple dates where RNA services, including range of motion exercises and application of orthotic devices, were not performed or documented. Staff interviews indicated that on days with staffing shortages, the RNA was reassigned to CNA duties, resulting in missed restorative care. The Director of Nursing verified that these services were not provided on the specified dates due to staffing issues.
Failure to Provide Safe and Appropriate Respiratory Care for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents who were dependent on ventilators with tracheostomy tubes. For one resident, the ventilator circuit was not effectively monitored, resulting in the resident being found disconnected from the ventilator and unresponsive. Documentation showed that after being readmitted, the resident was alert and oriented, but there was no evidence of required ventilator checks or suctioning as per physician orders and facility policy. The resident was later found unresponsive, disconnected from the ventilator, and required manual ventilation and a Code Blue response. The ventilator alarm log was found to have inaccurate time settings, and it was unclear if the alarm sounded during the incident. Interviews revealed that there was no dedicated respiratory therapist (RT) in the facility, and the RT assigned was also responsible for the acute care unit, leading to lapses in monitoring and care. For the second resident, the facility failed to ensure that policies and procedures for respiratory care were followed when oxygen therapy and parts of the disposable ventilator circuit were replaced and rinsed by a non-qualified staff member. The resident, who had severely impaired decision-making capacity, experienced a sudden change in condition, turning blue and requiring an increase in FiO2. During the event, a CNA replaced the HME filter and rinsed the T-adapter, and also increased the FiO2, actions that were outside the CNA's scope of practice. The RT was not present at the time, and the nurse on duty did not immediately intervene, instead asking the CNA to assist. The RT manager confirmed that CNAs were not permitted to perform these tasks and that the T-adapter should not have been rinsed. Both incidents were compounded by the lack of a dedicated RT in the facility, with RTs being shared with the acute care hospital. This led to delays in care and interventions, as well as non-compliance with facility policies and procedures regarding ventilator management, suctioning, and equipment handling. Documentation and interviews confirmed that required assessments, monitoring, and interventions were not consistently performed or documented, directly contributing to the deficiencies identified.
Failure to Follow Physician's Order for Air Mattress Setting
Penalty
Summary
The facility failed to provide the necessary care and services to promote the healing of pressure injuries for a resident. The resident, who was admitted with several wounds including a Stage 3 pressure injury to the sacrum and Stage 4 pressure injuries to the left and right hips and right ankle, was observed lying on an air mattress set to the static mode. This setting was contrary to the physician's order, which specified that the air mattress should be set to the alternate mode with a cycle of five minutes to aid in pressure redistribution. During an observation and interview, an LVN incorrectly confirmed that the static mode was the correct setting, despite the physician's order indicating otherwise. This discrepancy was later verified during a follow-up interview and medical record review with the same LVN.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 9 and 11, received Restorative Nursing Assistant (RNA) services as ordered by their physicians. Resident 9, who had a history of contractures and quadriplegia, was supposed to receive daily passive range of motion (ROM) exercises and have specific splints and orthotic devices applied for certain durations. However, the RNA Flowsheet for February 2025 showed no documented evidence that these services were provided on specific days. Similarly, Resident 11, also with a history of contractures and quadriplegia, had orders for daily ROM exercises and the application of orthotic devices, but the RNA Flowsheet indicated missing documentation for several days in February 2025. Interviews with RNA 1 and RN 1 confirmed the absence of documentation and acknowledged that the lack of RNA services could lead to worsening contractures and muscle stiffness. The Chief Nursing Officer (CNO) also verified the missing RNA signatures in the RNA Flow Sheets and expressed expectations for the RNA services to be performed as ordered to prevent further contractures. The failure to provide these services as ordered had the potential to negatively impact the residents' ROM function and overall physical condition.
Improper Equipment Placement and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the proper placement of low air loss mattress pumps for two residents, as per the manufacturer's recommendations. For one resident, the pump was observed on the floor under the bed, contrary to the user manual's instructions to hang it on the footboard. A Licensed Vocational Nurse (LVN) confirmed the incorrect placement and acknowledged it was not supposed to be under the bed. Similarly, another resident's low air loss mattress control unit was also found on the floor, with a Registered Nurse (RN) stating that the hook did not fit the footboard, preventing proper placement. The Chief Nursing Officer (CNO) was informed and acknowledged these findings. Additionally, the facility did not implement the physician's order for floor mats on both sides of a resident's bed, which was necessary for fall prevention. The resident, who had severely impaired cognition and was dependent on staff for mobility, was observed with a floor mat on only one side of the bed. An LVN verified the absence of the second mat and recognized the resident's risk for falls, confirming the need for mats on both sides as per the physician's order.
Failure to Maintain Proper HOB Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure appropriate care and services for the use of gastrostomy tubes (GT) for two residents. Resident 3, who had severe cognitive impairment and difficulty swallowing, was observed on multiple occasions with the head of the bed (HOB) not elevated at the required 30-degree angle or higher while receiving enteral feeding. Despite physician orders to maintain the HOB at 30 to 45 degrees during and after feeding, the bed lacked a device to measure the elevation, and staff were unable to confirm the correct angle. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), revealed a lack of knowledge and tools to ensure compliance with the physician's orders. Similarly, Resident 13, who also had difficulty swallowing and was on tube feeding, was observed with the HOB not elevated to the required angle during feeding. The resident's care plan and physician orders specified the need for the HOB to be elevated at 30 to 45 degrees, yet observations showed it was only at a 15-degree angle. Staff interviews confirmed the absence of a device to measure the HOB elevation and acknowledged the failure to comply with the physician's orders. These deficiencies posed a risk for complications related to the use of GT for both residents.
Failure to Maintain IV Access for a Resident
Penalty
Summary
The facility failed to provide the necessary care and services for the maintenance of intravenous (IV) access for a resident, identified as Resident 21. The deficiency was observed when the facility did not obtain a physician's order for the care and maintenance of the IV access, nor did they develop a plan of care for the resident's IV access to the lower extremity. This oversight was noted during an observation on February 10, 2025, when Resident 21 was seen with an IV fluid infusing at 70 ml per hour, but the IV access was not visible due to bed covers. Further investigation revealed that the resident had moderately impaired cognitive skills and was on IV hydration due to abnormal laboratory results. Upon reviewing the medical records, it was found that there was no documented evidence of a physician's order for the IV access assessment, dressing change, or the frequency of changing the peripheral IV access site. Additionally, the resident's plan of care did not address the use and maintenance of the IV access site. Interviews with RN 2 and the Chief Nursing Officer (CNO) confirmed these findings, with RN 2 acknowledging the absence of a physician's order for the necessary IV care and the lack of a developed care plan for the resident's IV use.
Improper Disposal of Medication
Penalty
Summary
The facility failed to properly dispose of unused medication in accordance with its policy and procedures (P&P). During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen disposing of a half tablet of fludrocortisone, a corticosteroid medication, in a sharps container instead of the designated pharmaceutical waste container. The facility's P&P, dated October 2022, specifies that all unusable medications, including partially used tablets, should be disposed of in pharmaceutical waste containers. The incident involved a resident who was prescribed fludrocortisone 0.05 mg daily for hypotension. The LVN obtained a 0.1 mg tablet, cut it in half, administered the required dose, and improperly disposed of the remaining half tablet.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations from the monthly drug regimen review (MRR) were acted upon for Resident 13, who was reviewed for unnecessary medications. The pharmacist recommended discontinuing chlorhexidine, an antiseptic medication, as it was not recommended for residents on a ventilator, and also suggested performing a hemoglobin A1c level test due to the resident's diagnosis of diabetes. These recommendations were documented in the MRR dated 12/31/24 and 1/28/25, respectively, and were signed by the physician. However, there was no documented response from the physician regarding the approval or disapproval of these recommendations. The medical record review revealed that the physician's order to administer chlorhexidine 0.12% oral rinse twice a day remained active and had not been discontinued. Additionally, there was no evidence that the laboratory order for the hemoglobin A1c level was obtained from the physician. Interviews with the Director of Pharmacy and RN 1 confirmed that the charge nurses failed to follow up with the physician about the MRR recommendations. The Chief Nursing Officer (CNO) was also informed and verified these findings, indicating a lapse in the facility's process for addressing pharmacist recommendations in a timely manner.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. This deficiency was identified through the case of a resident who did not receive their medications as prescribed. Specifically, the resident was supposed to receive lactulose 30 grams via GT daily for elevated ammonia levels and clonidine 0.3 mg/24 hours transdermal patch weekly for muscle spasticity. However, during a medication administration observation, it was noted that the resident was only given 20 grams of lactulose instead of the prescribed 30 grams, and the clonidine patch was not applied at all. The facility's policies and procedures for medication administration, which require verification of the correct medication and adherence to the administration schedule, were not followed. The LVN responsible for administering the medications acknowledged the errors during an interview and review of the resident's medical records. These failures in medication administration had the potential to negatively impact the resident's health, as the prescribed treatments were not delivered as ordered by the physician.
Improper Medication Storage on Facility's Medication Carts
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications on two of its medication carts, posing a risk for medication administration errors. During an observation of Medication Cart A, it was found that a bottle of loperamide liquid, Carboxymethylcellulose 0.5% eye drops, and an Albuterol Sulfate inhaler were stored together in one tray without partitions. Additionally, a vial of Insulin Lantus and a bottle of Calcitonin Sodium Nasal spray were also stored together in another tray without partitions. These findings were verified by LVN 5, who acknowledged that the medications should have been stored separately. Similarly, an observation of Medication Cart B revealed that a vial of Insulin Lantus and a bottle of Carboxymethylcellulose 0.5% eye drops were stored together in one tray without partitions. LVN 6 confirmed these findings and stated that the medications should have been stored separately with partitions. The facility's policy on medication storage and security, as outlined in their Pharmacy Manual, requires that medications be stored in segregated and secure conditions to minimize the potential for errors, theft, or diversion. The failure to adhere to these policies resulted in the identified deficiencies.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. The deficiencies included the use of food preparation utensils and equipment that were not in good, sanitary, and cleanable working conditions. Specifically, a spatula was found with brown discoloration and heavily worn, two scoops had melted handles and were heavily worn, and three white cutting boards were heavily marred with black discoloration. These findings were verified by the Registered Dietitian (RD) during an observation and interview. Additionally, the facility did not ensure that staff's personal food items were kept out of the kitchen refrigerator, as a dietary aide's personal salad was found stored in the kitchen's reach-in refrigerator. Furthermore, the kitchen staff failed to wear appropriate hair restraints, as observed with a staff member who had sideburns and a mustache without a beard restraint. These issues were acknowledged by the RD, Dietary Supervisor, and Chief Nursing Officer (CNO) during interviews, confirming the facility's non-compliance with food safety standards.
Infection Control Committee Meeting Lapse
Penalty
Summary
The facility failed to implement appropriate infection control practices as required by their policies and procedures. Specifically, the infection control committee did not meet for one quarter in 2024 to discuss infection control within the subacute unit. This lapse occurred because the Medical Doctor, who also served as the Infection Control Chair, was out of the country until January 30, 2025, resulting in the committee missing the November 2024 quarterly meeting. The absence of this meeting prevented the discussion of quarterly infection control statistics, posing a risk for the transmission of disease-causing microorganisms.
Facility Assessment Lacks Comprehensive Staffing Plan
Penalty
Summary
The facility failed to ensure that the Facility Assessment was comprehensive and up-to-date, as required by the revised CMS guidance. The assessment did not actively involve direct care staff, residents, or their representatives in its development. Additionally, it lacked a detailed plan for staffing resources necessary to care for residents, particularly during weekends, and did not include strategies for recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and document review, the Chief Nursing Officer (CNO) confirmed that the Facility Assessment was outdated and did not reflect the latest CMS updates. The CNO acknowledged the absence of involvement from key stakeholders in the assessment process and the lack of necessary resources and plans to address staffing needs. This oversight had the potential to impact the facility's ability to meet residents' care needs effectively.
Lack of Dedicated Infection Preventionist
Penalty
Summary
The facility failed to have a full-time, dedicated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The organizational chart updated in February 2025 showed the position for Infection Control Supervisor/Infection Control was vacant. According to the QSO-22-19 dated June 29, 2022, Skilled Nursing Facilities (SNFs) are required to have an IP with specialized training onsite at least part-time. However, the Director of Infection Prevention/Acting IP was primarily stationed at the acute care unit and only spent one to two hours at the facility, confirming that there had been no dedicated IP personnel since January 2024. The Chief Nursing Officer (CNO) also verified that the facility shared IP personnel with the acute care unit and was actively interviewing to fill the position.
Resident Health Information Confidentiality Breach
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information, specifically for one resident. On two separate occasions, a staff computer located in the residents' hallway was left unattended with the resident's personal health information displayed on the screen. This information included the resident's name and scheduled medications, and the computer was accessible to residents' family members and visitors who used the hallway. During an observation and interview, a Licensed Vocational Nurse (LVN) confirmed that the computer was unattended and displaying the resident's personal health information. The LVN noted that the computer was used by a Respiratory Therapist, who should have either logged out or used a paper cover to protect the screen when not present. Despite this expectation, the computer was again found unattended with the resident's information visible, confirming a breach of confidentiality as outlined in the facility's policy and procedures.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by two of eight waste dumpsters being observed overflowing with trash and not properly closed. This was identified during an observation and interview with the Registered Dietitian (RD) on February 11, 2025, at 0942 hours. The RD confirmed that the waste dumpster lids should be closed to prevent attracting pests and rodents. Further interviews with the RD, Dietary Supervisor, and Chief Nursing Officer (CNO) on February 13, 2025, confirmed the findings. The facility's policy and procedure on sanitation, dated August 2024, requires food waste to be kept in leakproof, nonabsorbent, tightly closed containers and disposed of as frequently as necessary to prevent nuisance or unsightliness. The failure to adhere to these guidelines had the potential to cause unsafe sanitary conditions and harbor pests and rodents.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for four residents, as observed in Rooms A and B. Resident 23, residing in Room A, was found in a room with a wall behind the bed that had a hole, scratches, and unfinished patchwork. Similarly, Residents 10, 14, and 18, residing in Room B, were observed in a room where the wall behind their beds was in disrepair, with holes, scratches, unfinished patchwork, and peeled paint. These observations were made during a survey, and the residents were not interviewable due to cognitive impairment. The Chief Nursing Officer (CNO) was shown photos of the disrepair and acknowledged the need for repairs in these rooms.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered for a resident, leading to a potential decline in the resident's range of motion (ROM) functions. The resident, who had a history of contractures, muscle wasting, and atrophy, was supposed to receive daily ROM exercises and the application of bilateral hand splints and PRAFOs as per the physician's orders. However, the RNA services were inconsistently provided, with the resident receiving these services on only a few days throughout the month. Interviews with facility staff revealed that the RNA was often reassigned to work as a certified nursing assistant (CNA) due to staffing challenges, which contributed to the inconsistency in providing the ordered RNA services. The Director of Nursing (DON) acknowledged the issue and stated that the facility prioritized residents' hygiene and activities of daily living (ADL) assistance over RNA services, while also working on recruiting additional RNA staff. This failure to adhere to the physician's orders had the potential to negatively impact the resident's ROM status and increase stiffness in the resident's extremities.
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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