Chatsworth Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chatsworth, California.
- Location
- 10610 Owensmouth, Chatsworth, California 91311
- CMS Provider Number
- 056351
- Inspections on file
- 69
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Chatsworth Park Health Care Center during CMS and state inspections, most recent first.
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.
Two residents with severely impaired cognition and dependence on staff for personal hygiene were observed with long, untrimmed fingernails that extended past the fingertips, with one resident's nails noted as brown and dirty underneath and the other's described by the ADON as dry, long, uneven, and sharp. An LVN and the ADON acknowledged the condition of the nails during observations and interviews, and the ADON stated that nail care should be provided weekly and nails kept short to prevent injury. The facility's nail care policy, which calls for promoting cleanliness, safety, and a neat appearance, was not followed for these residents.
A resident with severe cognitive impairment and multiple neurological diagnoses developed redness on the right lateral abdomen that was reported by a CNA to the treatment nurse as a change in condition. Although a physician’s order was obtained to apply triple antibiotic ointment to the area, the treatment nurse did not measure the redness, despite acknowledging that treatment nurses are responsible for assessing and measuring skin changes. A later change-in-condition note stated the irritation had increased in size, but no measurements were documented, and the nurse could not explain how the increase was determined. The ADON confirmed the absence of measurements and that facility policy requires licensed nurses to measure and describe all skin injuries as part of the skin and wound assessment.
Surveyors found that direct care staff did not comply with the facility’s infection control and employee handbook requirements for fingernail length. A CNA and an LVN providing hands-on care were observed with long fingernails extending beyond their fingertips, despite the LVN acknowledging awareness of the policy. The ADON and IP both confirmed that staff who provide direct resident care are required to keep fingernails short and trimmed as part of the facility’s infection prevention and control program and as specified in the employee handbook.
A resident with impaired cognition and high care needs reported being physically and verbally abused by multiple staff members. Although the ADON promptly notified leadership, the ADM did not ensure the allegation was immediately reported to authorities as required by policy and regulations, instead relying on a prior investigation and failing to meet mandated reporting timelines.
Surveyors found that the facility did not develop or implement appropriate person-centered care plans for three residents. One resident on antibiotic therapy lacked a care plan for monitoring complications, another had an oxygen therapy care plan that did not match physician orders, and a third resident with a language barrier did not have a timely communication care plan. These deficiencies were confirmed by facility staff and documented in resident records.
Eight medication emergency kits containing controlled medications were not reconciled at each shift change in a medication room, as required by facility policy and regulations. Both nursing staff and the DON confirmed that accountability logs were not maintained for these kits, resulting in a lack of proper documentation and control over the inventory of controlled substances.
A resident with limited mobility and multiple health conditions did not have heel protectors applied while in bed as ordered by the physician. Staff observed the resident's heels in direct contact with the mattress, and both a CNA and the DON confirmed that the physician's order for heel protectors was not followed, contrary to facility policy for pressure injury prevention.
A resident with severe cognitive impairment and a medium fall risk was found in bed with the bed brake lock not engaged after ADL care, contrary to facility policy. The bed was observed unlocked by maintenance staff and subsequently locked. Facility policy requires staff to ensure beds are locked after care to promote safety.
A resident dependent on staff for care and with a history of UTIs was found with an indwelling catheter tubing that was looped and nearly kinked, contrary to facility policy and staff expectations. Both the TN and DON confirmed the tubing should be kept straight to prevent backflow and potential infection.
A resident with multiple complex medical conditions received an IV antibiotic at a faster rate than ordered by the physician, as a nurse manually set the flow regulator above the prescribed rate. The nurse acknowledged the error, and the DON confirmed that this was a medication administration error and not in accordance with facility policy.
A resident with end stage renal disease did not have proper post-dialysis assessments documented, as the facility failed to follow up with the dialysis center when post-dialysis weights were missing or when weights did not decrease after treatment. Staff interviews confirmed that required communication and documentation with the dialysis center did not occur, despite facility policy and care plan requirements.
A resident with complex medical needs received an IV antibiotic at a faster rate than ordered due to a nurse setting the flow regulator incorrectly. The nurse admitted to the error, and the DON confirmed that staff must follow physician orders for medication administration, including the rate.
An open vial of Aplisol used for TB testing was found in a medication room refrigerator without a label indicating the date it was opened. Both an RN and the DON confirmed the vial was not labeled as required by manufacturer instructions and facility policy, making it impossible to determine if the medication was still within its safe usage period. Facility policy mandates that multi-dose vials be labeled with the date opened and discarded after 28 or 30 days, but this was not followed, resulting in the vial being considered expired.
A resident receiving oxygen therapy was found with their nasal cannula tubing lying on the floor, which was confirmed by the ADON to be contaminated and in need of replacement. Facility policy and CDC guidelines note that floors can quickly become contaminated, posing an infection risk when care equipment touches them.
A resident with severe cognitive impairment and a diagnosis of osteomyelitis was prescribed IV Vancomycin for an infection, but the required infection surveillance form was not completed within the facility's specified timeframe. The infection control nurse confirmed the delay, which did not align with the facility's antibiotic stewardship policy requiring timely assessment and documentation when antibiotics are initiated.
Six multiple-resident rooms were found to be below the required 80 square feet per resident, with measurements ranging from 73.2 to 79.2 square feet. Despite the shortfall, residents did not report concerns and were observed to have adequate space for movement and care equipment.
The facility failed to ensure timely documentation of the History and Physical (H&P) by the attending physician for three residents, as required by facility policy. The H&Ps were completed beyond the 72-hour window, potentially affecting care coordination. The ADON confirmed the delays, which involved residents with conditions such as fractures, respiratory failure, and chronic kidney disease.
A resident with major depressive disorder and hypertension reported missing jewelry, but the facility failed to document the loss as required by its theft and loss policy. The Social Services Assistant did not inform the Administrator or document the incident, citing the resident's forgetfulness as a reason. The facility's policy requires documentation and reporting of losses over $25, which was not followed in this case.
A resident's Discharge Summary was found to be incomplete and inaccurate, failing to reflect the resident's request for discharge and missing contact information for the Home Health agency. The resident, admitted with a fracture and other conditions, insisted on being discharged home, but the summary incorrectly cited health improvement as the reason for discharge.
A resident with a fracture and other conditions was overmedicated due to the facility's failure to follow physician's orders for pain management. Despite reporting mild pain, the resident received a dosage intended for moderate pain, as confirmed by the ADON. This discrepancy highlights a failure to adhere to the facility's medication administration policies.
A resident did not receive a prescribed antibiotic in a timely manner due to a failure to check the emergency medication kit and a lack of awareness of the medication's delivery. The resident, admitted with conditions including a fracture and pneumonitis, was prescribed amoxicillin-pot clavulanate for aspiration pneumonia. The medication was available in the facility's emergency kit, but the LVN did not administer it as required by the physician's order.
A resident did not receive their daily probiotic as prescribed due to an error in transcription by an LVN, who entered the order for 30 days instead of daily. The resident, with conditions including Parkinson's disease and bipolar disorder, was affected by this oversight. The DON confirmed the error and noted that the facility's policy for order transcription was not followed.
A resident's representative requested clinical records, including medication administration records and blood pressure readings, but the LTC facility failed to provide them within the required timeframe. The Medical Records Director misunderstood the request, leading to a delay in fulfilling the request, which violated the facility's policy and the resident's rights.
A resident with severe cognitive impairment and dependency on staff was found with their call light out of reach, contrary to the facility's policy. The resident confirmed the need for the call light in emergencies, and staff acknowledged the oversight.
A resident with Huntington's disease and a history of falls was not provided with bilateral floormats as per their care plan, leading to a deficiency in care. The facility failed to monitor and document the use of floormats due to a missing physician's order, resulting in potential negative impacts on care delivery and team communication.
A resident with polyneuropathy, schizoaffective disorder, and bipolar disorder missed a pain management appointment due to the facility's failure to provide transportation. Despite having intact cognition and independence in daily activities, the resident was not picked up as scheduled. The Social Services Assistant arranged transportation but was off duty on the appointment day. The facility staff did not document any attempts to arrange alternative transportation, and the Administrator acknowledged the absence of a Social Services Director to assist.
The facility failed to conduct post-dialysis assessments for two residents with end-stage renal disease, as required by their policy. One resident did not receive an assessment on a specific date, while another resident's dialysis access site was not assessed on two occasions. The MDS Nurse confirmed the lack of documentation for these assessments, which are crucial for ensuring resident safety.
A facility failed to report an allegation of physical abuse within the required two-hour timeframe to the SSA. A resident with severe cognitive impairment and end-stage renal disease was found with unexplained facial injuries. Despite the resident's inability to communicate the cause, the facility delayed reporting the incident by 24 hours, contrary to its policy requiring immediate reporting of such allegations.
A resident with significant weight loss was not weighed weekly as required by the facility's policy, despite being at risk due to conditions like orthostatic hypotension and Parkinson's disease. The Registered Dietician confirmed that this failure could delay necessary nutritional interventions.
A resident with chronic respiratory failure and COPD experienced a skin reaction from a blood pressure cuff and refused Furosemide medication. Despite the resident's clear communication of these issues, the LVN did not notify the physician, contrary to facility policy. This oversight risked the resident's health by potentially leading to fluid retention and increased blood pressure.
A resident with Parkinson's disease and orthostatic hypotension did not receive their medications, Sinemet and Midodrine, at the scheduled times. The MAR audit showed multiple instances of late administration, with the LVN citing reasons such as the resident being asleep or not present. The ADON confirmed the findings, noting that the facility's policy requires timely medication administration.
A resident with severe cognitive impairment and incontinence received inadequate perineal care, increasing the risk of urinary tract infection. CNAs used a single towel without rinsing the area, contrary to facility policy. The resident, with a history of UTIs, was transferred to a hospital where a UTI was diagnosed. The facility's policy required separate towels and thorough rinsing, which was not followed.
The facility failed to ensure proper hand hygiene during perineal care for a resident with a history of UTIs. Two CNAs did not perform hand hygiene or change gloves after providing care, contrary to the facility's infection control policy. This oversight was confirmed by the Director of Staff Development and had the potential to spread infection.
A resident received Physical Therapy (PT) services without a physician's written order, contrary to the facility's policy. The resident, who required assistance for daily activities and had chronic obstructive pulmonary disease, received PT from March to June based on personal request rather than a medical order. The Director of Rehabilitation acknowledged the oversight, confirming that a physician's order should have been obtained.
An LVN failed to perform hand hygiene after touching a resident's wrists to check their identification band and blood pressure, then touched the medication cart without cleaning their hands. The resident had heart failure and hypertension, requiring significant assistance from staff. The DON confirmed this was against the facility's infection control policy.
A resident with dementia and severely impaired cognition pulled another resident's hair, causing the latter to fall and sustain injuries. The incident was identified as physical abuse by facility staff, and it was noted that the event could have been prevented with proper intervention. The facility's policy defines abuse as a willful infliction of injury, which was applicable in this case.
The facility failed to inform residents on how to contact the State Survey Agency to file complaints. During a Resident Council Meeting, six residents with various medical conditions were unaware of the process. An observation revealed that the information was posted too high and in small print, contrary to the facility's policy requiring prominent display.
A resident with type 2 diabetes mellitus and heart failure received insulin injections repeatedly in the same area, contrary to the facility's policy requiring site rotation. This practice was identified through record reviews and confirmed by a registered nurse, highlighting a failure to adhere to professional standards of care.
A resident did not receive morning medications on time, and two residents had discrepancies between Controlled Drug Records and Medication Administration Records. The facility failed to administer medications within the prescribed time frame and did not accurately document controlled drug administrations, risking medication errors and drug diversion.
A LTC facility failed to prevent unnecessary use of psychotropic drugs for residents. One resident received duplicate Zyprexa therapy for 41 days, another was given haloperidol without non-pharmacological interventions, and a third received lorazepam without proper behavioral monitoring. The facility's policies on medication administration and non-pharmacological interventions were not followed.
The facility failed to label opened medication packages for two residents, potentially compromising their effectiveness. An LVN and the ADON confirmed the lack of labeling for albuterol sulfate and ipratropium bromide/albuterol sulfate, contrary to facility policy. Additionally, a discontinued Haldol vial for a resident was not discarded, risking drug diversion. The facility's policy requires immediate disposal of discontinued medications.
A facility failed to document wound care treatments for a resident in the Treatment Administration Record (TAR) for January 2024. The resident, with severe cognitive impairment and requiring a gastrostomy tube, had missing documentation for physician-ordered treatments, including G-tube care and skin tear management. Interviews with staff confirmed the lack of documentation, which is required by the facility's policy.
The facility failed to obtain informed consent for medication changes for two residents, violating their rights to be informed about their treatment. One resident had their Seroquel dosage increased without a new consent, and another had their Zyprexa dosage increased without a new consent. The facility's policy required informed consent for medication changes, which was not followed, posing a risk to the residents due to potential side effects of the medications.
A resident admitted with COVID-19 did not have a baseline care plan developed within 48 hours, as required by facility policy. Despite being under transmission-based precautions, the absence of a care plan for the resident's COVID-19 diagnosis was confirmed by the RN Supervisor, highlighting a failure to ensure proper care and adherence to isolation protocols.
A facility failed to develop a timely care plan for a resident at risk for constipation. The resident, with diagnoses including hip dislocation and osteoarthritis, was readmitted and identified as at risk for constipation. Despite a physician's order for treatment, the care plan was not initiated until weeks later. The ADON confirmed the delay, which was against the facility's policy requiring timely, comprehensive care plans.
A resident's diclofenac sodium gel was improperly left on their bedside table, discovered during an observation by a Restorative Nurse Assistant and the DON. The medication was identified by an LVN, who admitted it was not the correct practice to leave it there, as it could lead to other residents accessing it. No assessment was conducted to determine if the resident could self-administer the medication, violating facility policy.
A resident with a history of falling and hypertension received incorrect pain medication dosage for their pain level. The resident's MAR showed acetaminophen 500 mg was given for a pain level of 5/10, contrary to physician's orders for mild pain levels of 1-3/10. The DON confirmed this was inappropriate, highlighting a failure to follow the facility's pain management policy.
A facility failed to complete a post-hemodialysis assessment for a resident with end-stage renal disease, as required by their policy. The resident's post-dialysis assessment form was left blank, indicating that vital signs and access site monitoring were not performed. A registered nurse confirmed the oversight, which placed the resident at risk for dialysis-related complications.
A facility failed to implement a consultant pharmacist's recommendation to administer prednisone with food for a resident with GERD. Despite the pharmacist's advice, the order was not updated, increasing the risk of stomach irritation. The ADON confirmed the oversight, which violated the facility's policy requiring timely action on medication regimen reviews.
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 Maintain Proper Nail Care and Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene care by not ensuring that two dependent residents had their fingernails properly trimmed. One resident, readmitted with diagnoses including metabolic encephalopathy, Alzheimer's disease, blindness in the right eye, history of TIA, and cerebral infarction without residual deficits, was documented on the MDS as having severely impaired cognition and being dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. During an observation in this resident's room, the resident's fingernails were noted to be long and untrimmed. In a concurrent observation and interview, an LVN confirmed that the resident's fingernails were long, extended past the fingertips, and that the undersides of the nails were brown and dirty, and stated she would ask the resident's CNA to trim the nails. Another resident, readmitted with diagnoses including Parkinson's disease without dyskinesia, functional quadriplegia, and lack of coordination, was also documented on the MDS as having severely impaired cognition and being dependent on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. During an observation in this resident's room, the resident's fingernails were observed to be long and untrimmed. In a concurrent observation and interview, the ADON described the resident's fingernails as dry, long, and uneven with sharp edges, and stated that nail care should be provided once a week and that fingernails should be kept short to prevent injury such as residents scratching themselves. Review of the facility's Nail Care policy, last reviewed on 1/15/2026, indicated it is the facility's policy to promote cleanliness, safety, and a neat appearance of residents, which was not followed in these instances.
Failure to Measure and Document Skin Redness per Wound Monitoring Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its Skin and Wound Monitoring and Management policy by not measuring a documented skin change for a resident. The resident was readmitted with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, right eye blindness, history of TIA, and cerebral infarction without residual deficits, and had an MDS indicating severely impaired cognition and dependence on staff for oral, toileting, personal hygiene, and movement. On the morning of 2/5/2026, a CNA reported redness on the resident’s right lateral abdomen to the treatment nurse, and a Change in Condition (COC) form was completed documenting this skin issue. Later that same day, a physician’s order was obtained to apply triple antibiotic ointment daily to the right lateral abdomen for irritation/scratch. During interview and record review, the treatment nurse acknowledged being notified of the skin-related COC on 2/5/2026 and stated that treatment nurses are responsible for assessing the area, measuring it, notifying the physician, and informing the resident or responsible party. However, the treatment nurse admitted not measuring the redness at that time, explaining they did not think it was necessary and did not believe the condition was serious. A subsequent COC dated 2/8/2026 documented that the irritation had increased in size, but the treatment nurse could not explain how this was determined without measurements. The Assistant DON confirmed there were no measurements documented for the 2/5/2026 skin COC and stated the treatment nurse should have measured the affected area, noting that the facility’s policy requires licensed nurses to assess and evaluate each pressure and non-pressure injury, including measuring the skin injury and describing its nature, location, and characteristics.
Failure to Enforce Fingernail Length Standards for Direct Care Staff
Penalty
Summary
The facility failed to implement its infection prevention and control program and employee handbook requirements regarding fingernail length for direct care staff. During an observation with the Assistant Director of Nursing (ADON), a certified nursing assistant (CNA) was noted to have long, uneven fingernails that extended past the fingertips. The ADON stated that staff who provide direct resident care should keep their fingernails short and trimmed for infection control and resident safety. In a separate observation and interview, a licensed vocational nurse (LVN) who provided direct resident care acknowledged that her fingernails were long and extended past her fingertips. The LVN stated she was aware that staff fingernails were required to be kept short for infection control purposes but explained that she had just had her nails done. In an interview, the Infection Preventionist (IP) confirmed that nursing staff who provide direct resident care should not have long fingernails and that fingernails should not extend past the fingertips, stating that short, trimmed fingernails help decrease the risk of infection and promote resident safety by protecting skin integrity. Review of the facility’s Infection Control policy indicated the infection prevention and control program is a facility-wide effort addressing detection, prevention, and control of infections among residents and personnel. Review of the Skilled Nursing Facility Employee Handbook showed that, for safety and infection control, dietary employees and those providing direct resident care must keep fingernails clean and trimmed, and that fingernails must not extend beyond the end of each finger.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its policy and procedures for reporting a reasonable suspicion of a crime, specifically regarding the immediate reporting of an allegation of staff-to-resident physical and verbal abuse. A resident with mildly impaired cognition and significant care needs reported to a third-party Clinical Evaluator that he was held down by five staff members and subjected to verbal aggression. The Assistant Director of Nursing (ADON) was informed of the allegation and notified the Director of Nursing (DON) and the Administrator (ADM) within minutes. However, the ADM stated that the incident had already been investigated and did not ensure that the allegation was immediately reported to the State Agency and local law enforcement as required by both facility policy and state regulations. Record review and interviews confirmed that the facility's policy required immediate reporting of any alleged or suspected abuse, neglect, or exploitation. Despite this, the ADM relied on a prior investigation and did not report the new allegation in a timely manner. This failure to report could have delayed necessary protective actions for residents, as the required notifications to authorities were not made within the mandated timeframe.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed the specific needs of three residents. For one resident with a urinary tract infection and a history of falls, the care plan did not include interventions or monitoring related to the prescribed antibiotic therapy, despite physician orders for cephalexin. The Assistant Director of Nursing confirmed that a care plan for antibiotic therapy should have been initiated to monitor for complications such as nausea, vomiting, diarrhea, and dehydration, but this was not done. Another resident, admitted with acute respiratory failure, congestive heart failure, and pneumonia, had a care plan for oxygen therapy that did not match the physician's orders. The care plan incorrectly indicated the use of humidified oxygen, while the physician's order specified continuous oxygen at two liters per minute without humidification. The Director of Nursing acknowledged that the care plan was inaccurate and should have reflected the physician's order to ensure proper care. A third resident, who spoke Armenian and had moderate cognitive impairment, did not have a communication care plan created upon admission, despite the need for an interpreter being identified in the assessment. The care plan addressing the language barrier was only created after a delay, and both the MDS Nurse Consultant and the Director of Nursing confirmed that the communication care plan should have been established earlier to facilitate effective communication and care.
Failure to Reconcile Controlled Medications in Emergency Kits
Penalty
Summary
The facility failed to reconcile eight medication emergency kits (eKITs) containing controlled medications (CMs) in one medication room for the month of April 2025. During an observation, four eKITs stored in a cabinet and four eKITs stored in a refrigerator, all containing CMs, were found without accountability logs documenting reconciliation of CM inventory at every shift change. Both a registered nurse and the Director of Nursing confirmed that these eKITs were not reconciled at each shift change as required, and acknowledged the importance of this process for accountability and prevention of CM diversion or accidental exposure. A review of the facility's policies and procedures indicated that all controlled substances, including those in emergency kits and under refrigeration, must be reconciled by two licensed nurses and documented at each shift change. The lack of reconciliation and documentation for these eight eKITs did not comply with the facility's own policies or with federal and state regulations regarding the handling, storage, and recordkeeping of controlled medications.
Failure to Apply Heel Protectors as Ordered for Pressure Injury Prevention
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for a resident who was at risk for developing pressure injuries. The resident, who had diagnoses including palliative care, polyneuropathy, and heart failure, required maximal assistance with hygiene and was dependent on staff for toileting and bathing. The resident's care plan included a physician's order for bilateral heel protectors to be applied while in bed as a preventative measure for skin maintenance. During an observation, it was noted that the resident's heels were in direct contact with the mattress and heel protectors were not in place, contrary to the physician's order. A CNA confirmed that the resident should have been wearing heel protectors to prevent skin breakdown. The DON also acknowledged that staff did not follow the physician's order and emphasized the necessity of such interventions for residents with limited mobility. The facility's policy required the use of pressure-relieving devices to prevent pressure injuries, which was not adhered to in this instance.
Failure to Lock Bed Brakes After ADL Care
Penalty
Summary
A deficiency was identified when staff failed to ensure that a resident's bed brake lock was engaged, resulting in the bed being left unlocked. The resident in question had been admitted and readmitted with diagnoses including failure to thrive, and was assessed as severely cognitively impaired, requiring staff assistance for activities of daily living such as showering, toileting, dressing, and personal hygiene. The resident's care plan indicated a need for assistance with ADLs due to poor balance and gait instability, and the resident was determined to be at medium risk for falls. During an observation, it was noted that the brake at the foot of the resident's bed was not locked, and this was confirmed and corrected by the maintenance resource at the time. Interviews and policy reviews revealed that facility policy requires all staff to ensure that resident beds are locked and in a safe position after providing ADL care, and that beds should be returned to the lowest position with wheels locked unless otherwise indicated in the care plan. The Director of Nursing confirmed that bed brakes should be locked to prevent movement. The failure to follow these procedures resulted in the resident being placed at risk for injury due to the unsecured bed.
Failure to Maintain Proper Catheter Tubing Position
Penalty
Summary
A resident with a history of palliative care, dementia, and previous urinary tract infection (UTI)/sepsis was observed to have an indwelling catheter with a large loop and two coils in the tubing, one of which was nearly kinked. The resident was dependent on staff for hygiene, dressing, toileting, and bathing, and had a physician order for an indwelling catheter. During observation, the catheter bag was hanging on the bedframe, and the tubing was not maintained in a straight position as required. Staff interviews confirmed that the catheter tubing should not be looped or coiled, as this could cause backflow of urine. The Treatment Nurse acknowledged that the observed condition of the tubing was inappropriate and could lead to complications. The Director of Nursing also stated that the tubing must remain straight to ensure proper drainage and prevent infection, especially given the resident's history of UTIs. Facility policy required that catheter and drainage tubing be free of loops and kinks to achieve a free flow of urine.
Failure to Administer IV Antibiotic at Prescribed Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer an intravenous (IV) antibiotic, Vancomycin, at the rate ordered by the physician for a resident. The physician's order specified that 270 ml of Vancomycin should be infused over 2 hours at a rate of 135 ml/hr. However, during observation, the nurse set the manual flow regulator to 200 ml/hr, resulting in the medication being administered more rapidly than prescribed. The nurse acknowledged not following the physician's order and stated that IV medication rates must always be double-checked to ensure accuracy. The resident involved had multiple diagnoses, including dysphagia, heart failure, unspecified dementia, and dependence on supplemental oxygen, and was dependent on staff for all activities of daily living. The facility's policy required that IV medications and fluids be administered as prescribed and that the label be verified against the prescriber's order. The Director of Nursing confirmed that administering the medication at a faster rate than ordered constituted a medication error.
Failure to Ensure Post-Dialysis Assessment and Communication
Penalty
Summary
The facility failed to ensure appropriate post-dialysis care and communication for a resident with end stage renal disease who required hemodialysis. Specifically, there was no follow-up with the dialysis center when post-dialysis weights were missing or when the resident's weight remained the same or increased after dialysis sessions, as documented on several occasions. The facility's care plan required obtaining vital signs and weights per protocol, and the facility's policy indicated ongoing communication and documentation with the dialysis center. However, there was no evidence that the facility contacted the dialysis center to clarify missing or abnormal weight documentation. Interviews with facility staff, including a registered nurse and the DON, confirmed that licensed nurses should have communicated with the dialysis center regarding missing or abnormal post-dialysis weights, but no such documentation or communication was provided. The DON acknowledged that the facility is responsible for monitoring and verifying dialysis information, even if it is documented by the dialysis center, and that failure to do so could result in unidentified complications for the resident.
IV Antibiotic Administered at Incorrect Rate
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including heart failure, dementia, and dependence on supplemental oxygen, was administered an intravenous antibiotic (Vancomycin) at a rate faster than prescribed by the physician. The physician's order and the IV medication label specified that the Vancomycin should be infused at 135 ml/hr over two hours. However, during an observation, it was found that the registered nurse manually set the flow regulator to 200 ml/hr, contrary to the prescribed rate. The nurse acknowledged the error during an interview, stating that the medication should have been administered at the ordered rate to prevent potential side effects. The Director of Nursing confirmed that licensed nurses are required to follow physician orders regarding medication administration, including the rate. Facility policy also requires that medications be administered as prescribed and that the label be verified against the order. The error was identified during a random observation and confirmed through interviews and record review.
Failure to Label and Store Multi-Dose Aplisol Vial per Policy
Penalty
Summary
Surveyors observed that an open vial of Aplisol, a medication used for tuberculosis testing, was stored in the medication room refrigerator without a label indicating the date it was opened. Both the registered nurse and the director of nursing confirmed during interviews that the vial was not labeled with the date of first use, which is required to track the 30-day usage period as per the manufacturer's instructions and facility policy. The staff acknowledged that without this labeling, it is not possible to determine if the medication is still within its effective and safe usage period. A review of the facility's policy and procedures confirmed that multi-dose vials must be labeled with the date opened and the corresponding expiration date, in accordance with manufacturer recommendations and pharmacy guidance. The policy also specifies that such vials should be discarded after 28 or 30 days, depending on the guidelines referenced. The failure to label the Aplisol vial as required led to the medication being considered expired and necessitated its removal from use.
Oxygen Tubing Found on Floor During Resident Care
Penalty
Summary
A deficiency was identified when a resident's nasal cannula oxygen tubing was observed lying on the floor while the resident was in bed. The Assistant Director of Nursing (ADON), present during the observation, confirmed that the tubing was contaminated and needed immediate replacement. The facility's policy on oxygen therapy requires safe administration, and the infection prevention and control program includes surveillance of staff practices related to resident care and infection control. The resident involved had a history of dysphagia and anemia, was cognitively intact, and required varying levels of assistance with daily activities. Physician orders indicated the resident was to receive oxygen via nasal cannula as needed to maintain oxygen saturation above 90%. Facility policy and CDC guidelines reviewed indicated that floors can become rapidly contaminated, increasing the risk of infection when medical equipment comes into contact with them.
Failure to Timely Complete Infection Surveillance for Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not conducting timely infection surveillance and not completing the required infection control reporting form after a resident was prescribed an antibiotic. Specifically, a resident with a history of osteomyelitis in the sacral and sacrococcygeal region, who was severely cognitively impaired and dependent on staff for daily activities, was admitted and later readmitted to the facility. Upon readmission, the resident was prescribed intravenous Vancomycin for an infection, and the care plan included administration of the antibiotic as ordered by the physician. According to the facility's policy, an infection surveillance form should be created within 48 to 72 hours of starting an antibiotic, using McGeer's criteria to determine if the resident meets the definition of a true infection. However, the infection surveillance form for this resident was not completed until 12 days after the antibiotic was started. The Infection Control Nurse confirmed that the resident met the criteria for infection, but the delay in completing the surveillance form meant that the physician was not promptly informed if the criteria were not met, as required by the facility's antibiotic stewardship policy.
Failure to Meet Minimum Room Size Requirements for Multiple-Resident Rooms
Penalty
Summary
The facility failed to meet the required room size of 80 square feet per resident for six out of sixty multiple-resident rooms, specifically rooms 108, 109, 208, 209, 215, and 216. Measurements showed that these rooms ranged from 73.2 to 79.2 square feet per resident, which is below the federal requirement for two-bed rooms. The deficiency was identified through observation, interviews, and record review, including a review of a waiver request letter submitted by the Administrator acknowledging the shortfall in room size. During the survey, it was observed that residents in these rooms had sufficient space to move freely, and there were no concerns raised by residents regarding room size during the Resident Council meeting. The rooms were equipped with beds, side tables, and care equipment, and the space was deemed adequate for resident care and services by staff.
Delayed Physician Documentation of H&P
Penalty
Summary
The facility failed to ensure that the attending physician documented the History and Physical (H&P) for residents in a timely manner according to the facility's policy. This deficiency was identified for three residents, each of whom had their H&P completed beyond the 72-hour window required by the facility's policy. Resident 2 was admitted with conditions including a fracture of the right femur and pneumonitis, but their H&P was documented five days after admission. Similarly, Resident 4, admitted with acute respiratory failure and COPD, also had their H&P completed five days post-admission. Resident 5, who was admitted with chronic kidney disease and syncope, had their H&P documented six days after admission. The Assistant Director of Nursing (ADON) confirmed during interviews and record reviews that the H&Ps for these residents were not completed within the required timeframe. The facility's policy mandates that the attending physician provide a current H&P within 72 hours of admission to ensure proper care coordination and timely creation of the residents' care plans. The delay in documentation had the potential to lead to inconsistent care coordination due to incomplete records for the affected residents.
Failure to Document Resident's Lost Jewelry
Penalty
Summary
The facility failed to implement its theft and loss policy by not documenting a resident's lost jewelry on the facility's theft and loss report form. This deficiency involved a resident who was admitted with diagnoses of major depressive disorder and essential hypertension. The resident, who had intact cognition according to the Minimum Data Set, reported missing seven pieces of jewelry in May 2024 to the Social Services Assistant (SSA). However, the SSA did not document this report on the Theft and Loss Log or the Theft and Loss Report form, as required by the facility's policy. The SSA acknowledged during interviews that she did not inform the Administrator of the missing items and failed to document the incident because a psychologist had mentioned that the resident was forgetful. The facility's policy mandates that any loss or theft of property worth more than $25 should be documented and reported to the Administrator for investigation. The Administrator confirmed that the SSA should have documented the missing jewelry to allow for proper follow-up. The facility's policy also requires that thefts of property valued over $100 be reported to local law enforcement within 24 hours.
Incomplete and Inaccurate Discharge Summary
Penalty
Summary
The facility failed to ensure the Discharge Summary for a resident was accurate and complete, which could lead to confusion about the resident's discharge status and delay in post-discharge services. The resident was admitted with diagnoses including a fracture of the right femur, presence of a right artificial hip joint, and pneumonitis. The resident had intact cognition and expressed a strong desire to be discharged home. Despite the resident's insistence on leaving, the Discharge Summary inaccurately stated that the discharge was due to health improvement, omitting the resident's request as the reason. Additionally, the Discharge Summary and Post-Discharge Plan of Care lacked essential contact information for the Home Health agency responsible for the resident's post-discharge care. This omission was identified during a review with the Assistant Director of Nursing, who acknowledged the inaccuracies and the missing information. The facility's policy requires maintaining complete and accurately documented clinical records, which was not adhered to in this case.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as per the physician's orders for a resident, leading to a potential risk of overmedication. Resident 2, who was admitted with a fracture of the right femur, presence of a right artificial hip joint, and pneumonitis, had intact cognition according to the Minimum Data Set. The physician's orders specified that for mild pain (1-3/10), the resident should receive one tablet of acetaminophen 500 mg, and for moderate pain (4-6/10), two tablets of acetaminophen 325 mg should be administered. However, on a specific date, Resident 2 reported a pain level of three, which falls under the mild pain category. Despite this, the resident was given two tablets of acetaminophen 325 mg, which is intended for moderate pain levels. This discrepancy was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the resident received more medication than prescribed. The facility's policies on pain management and medication administration emphasize adherence to physician orders, which was not followed in this instance.
Failure to Administer Prescribed Antibiotic Timely
Penalty
Summary
The facility failed to ensure timely administration of a prescribed antibiotic, amoxicillin-pot clavulanate, for a resident admitted with conditions including a fracture of the right femur, presence of a right artificial hip joint, and pneumonitis. The physician's order required the antibiotic to be administered every 12 hours for aspiration pneumonia, starting on the day of admission. However, the resident did not receive the scheduled dose on the evening of admission because the facility was waiting for the medication delivery, despite the antibiotic being available in the facility's emergency medication kit. The Assistant Director of Nursing (ADON) confirmed that the medication was delivered within the administration time frame, but the Licensed Vocational Nurse (LVN) on duty did not administer it. The LVN admitted to not checking the emergency kit for the medication and was unaware of its delivery. The facility's policy requires medications to be administered as per physician's orders, but this was not adhered to, resulting in a delay in the resident receiving the necessary antibiotic treatment.
Failure to Administer Probiotic as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with the physician's order by not continuing the resident's daily probiotic as prescribed. The resident, who was admitted with diagnoses including Parkinson's disease, bipolar disorder, and post-surgical aftercare, had a physician's order for a daily probiotic. However, the order was incorrectly transcribed by a Licensed Vocational Nurse (LVN), who placed the order for 30 days instead of daily, leading to the resident not receiving the probiotic as intended. The resident's Medication Administration Record (MAR) indicated that the probiotic was administered for 30 days, with the last dose given on December 15, 2024. This discrepancy was discovered during an interview with the LVN, who acknowledged the error in transcription. The LVN had received the order from an outside physician and confirmed it with the resident's primary care physician, but failed to ensure the order was correctly entered for daily administration. The Director of Nursing (DON) confirmed the error upon review of the resident's physician orders and acknowledged that the correct process was not followed. The facility's policy requires that all orders be specific and complete, and that licensed nurses are responsible for accurate transcription. The failure to adhere to these procedures resulted in the resident not receiving the prescribed probiotic, which had the potential to affect the resident's health.
Failure to Provide Timely Access to Resident's Clinical Records
Penalty
Summary
The facility failed to provide a resident's representative with copies of the resident's clinical records upon written request, violating the resident's rights. The resident, who was admitted with Parkinson's disease and bipolar disorder, had moderately impaired cognitive skills and required assistance with daily activities. The resident's representative submitted an Authorization for Release of Information (AFROI) form, requesting clinical records, including medication administration records and blood pressure readings. Despite the request, the facility did not provide the requested documents until nearly a month later. The Medical Records Director (MRD) was on vacation when the request was submitted and misunderstood the representative's needs, believing that clarification provided over the phone was sufficient. The facility's policy required that such requests be fulfilled within 48 hours, excluding weekends and holidays, but this was not adhered to. The Administrator confirmed that the facility's policy was not followed, resulting in the delay of providing the requested clinical records to the resident's representative.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a device used by residents to signal their need for assistance from staff. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including dementia and cerebral infarction. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for various activities of daily living. The care plan for the resident included an intervention to encourage the use of the call light for assistance. During an observation, the resident was found in bed with the call light placed on the floor, out of reach, which the resident confirmed was needed for emergencies. The Director of Staff Development acknowledged that the resident could not use the call light in an emergency due to its placement. The Director of Nursing stated that call lights should always be within reach to ensure residents can use them when needed. The facility's policy requires that call lights be placed within reach before staff leave the room.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement and revise a comprehensive person-centered care plan for a resident diagnosed with Huntington's disease, epilepsy, and a history of falling. The resident was admitted on 11/25/2024, and the care plan initiated on 12/2/2024 included the use of floormats to prevent injuries from falls. However, the facility did not ensure the resident was provided with bilateral floormats, as only one floormat was placed on the left side of the bed. This oversight was observed during a visit on 12/10/2024, where it was noted that the nursing staff did not monitor or document the use of floormats due to the absence of a physician's order. The Director of Nursing and Assistant Director of Nursing acknowledged that the intervention was not implemented as indicated in the care plan, and the floormats' placement was not monitored or documented. The facility's policy requires that care plans be updated to reflect assessment results, but the care plan for the resident's floormat use was not individualized or person-centered. The deficiency in implementing the care plan had the potential to negatively affect the delivery of care and services to the resident and led to miscommunication among the care team regarding the resident's needs.
Failure to Provide Transportation for Resident's Appointment
Penalty
Summary
The facility failed to provide transportation for a resident who had a scheduled pain management appointment. The resident, who has diagnoses including polyneuropathy, schizoaffective disorder, and bipolar disorder, was admitted to the facility in 2018 and readmitted in 2020. The resident's Minimum Data Set indicated intact cognition and independence in daily activities. A physician's order and a transportation notification form confirmed the appointment and transportation arrangements. However, on the day of the appointment, the resident was not picked up as scheduled, resulting in the missed appointment. Interviews with the resident, Social Services Assistant (SSA), Registered Nurse Supervisor (RNS), Assistant Director of Nursing (ADON), and Administrator (ADM) revealed that the SSA had arranged the transportation but was off duty on the appointment day. The SSA was informed by the facility staff that the transportation company was late and that the resident allegedly canceled the transportation, which the resident denied. The facility staff did not document any attempts to arrange alternative transportation, and the ADM acknowledged the lack of a Social Services Director at the time to assist. The facility's policy on transportation assistance was reviewed, indicating a failure to adhere to it.
Failure to Conduct Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for two residents, leading to deficiencies in their care. Resident 2, who was admitted with end-stage renal disease and dependent on dialysis, did not receive a post-dialysis assessment on a specified date. The MDS Nurse confirmed that there was no documented evidence of this assessment, which should have included checking vital signs and the dialysis access site for bleeding, bruit, and thrill to ensure the resident's safety. Similarly, Resident 3, also diagnosed with end-stage renal disease and dependent on dialysis, did not have their dialysis access site assessed after returning from dialysis on two separate occasions. The MDS Nurse noted the absence of documented assessments for these dates, emphasizing that it is the charge nurses' responsibility to perform these assessments to ensure resident safety. The facility's policy requires such assessments to maintain the patency of the dialysis access and to document any unusual findings, but this was not adhered to in these cases.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedures for reporting a reasonable suspicion of a crime, specifically an allegation of physical abuse, in accordance with Section 1150B of the Act. This failure involved not reporting an incident concerning a resident within the required two-hour timeframe to the State Survey Agency (SSA). The resident in question, who had end-stage renal disease and was dependent on renal dialysis, was found with unexplained injuries, including a purplish discoloration on the left eyelid brow and a dry scab on the nose bridge. Despite the resident's severe cognitive impairment and inability to communicate the cause of these injuries, the facility delayed reporting the incident to the SSA by 24 hours. The incident was initially reported by a Certified Nursing Assistant to a Registered Nurse, who then informed the Director of Nursing (DON). The DON, however, did not consider the injuries as resulting from physical abuse and thus did not report them within the mandated two-hour period. The facility's policy requires immediate reporting of any allegations or suspicions of abuse, neglect, or mistreatment, including injuries of unknown origin, to the appropriate authorities. The delay in reporting potentially hindered the timely investigation by the SSA and posed a risk of unidentified abuse within the facility.
Failure to Monitor Resident's Weight Weekly
Penalty
Summary
The facility failed to adhere to its policy and procedure for monitoring the nutritional status of a resident, identified as Resident 2, who was experiencing significant and severe weight loss. Resident 2, who was admitted with diagnoses including orthostatic hypotension, intestinal obstruction, and Parkinson's disease, was cognitively impaired and required assistance with daily activities. The facility's policy required weekly weight checks for residents at risk of weight loss, but Resident 2 was not weighed weekly as mandated. This oversight was identified during a review of Resident 2's weight records, which showed a weight decrease from 146 pounds in March to 131 pounds by early September, indicating a 10.3% weight loss over six months. The Registered Dietician (RD) confirmed during an interview that Resident 2 should have been weighed weekly to ensure accurate nutritional assessment and timely intervention. The RD acknowledged that the lack of weekly weight monitoring could lead to delays in addressing nutritional needs and weight loss. The facility's policy, titled Nutritional Status Management, emphasized the importance of weekly weight checks for residents meeting weight loss criteria, but this was not followed for Resident 2, placing the resident at increased risk for undetected weight loss.
Failure to Notify Physician of Resident's Skin Reaction and Medication Refusal
Penalty
Summary
The facility failed to notify the physician when a resident experienced a skin reaction from a blood pressure cuff and when the resident refused to take prescribed Furosemide medication. The resident, who was admitted with chronic respiratory failure and COPD, reported skin irritation from the blood pressure cuff to a Licensed Vocational Nurse (LVN). Despite the resident's intact cognitive skills and ability to communicate her preferences, the LVN did not inform the physician about the resident's concerns or the refusal of medication. The resident's electronic Medication Administration Record and Progress Notes indicated multiple instances where the resident refused to have her blood pressure checked and refused to take Furosemide. The LVN acknowledged the failure to notify the physician about these refusals, which was against the facility's policy requiring documentation and physician notification of medication refusals. This oversight placed the resident at risk for complications related to fluid retention and increased blood pressure.
Failure to Administer Medications on Time
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident diagnosed with Parkinson's disease and orthostatic hypotension. The resident was prescribed Sinemet and Midodrine, with specific administration times to manage their conditions effectively. However, the Medication Administration Record (MAR) audit revealed multiple instances where these medications were not administered at the scheduled times, potentially affecting the resident's treatment. The MAR audit records indicated that Sinemet was frequently administered late, with delays ranging from over an hour to several hours past the scheduled times. Similarly, Midodrine was also administered late on several occasions. The Licensed Vocational Nurse (LVN) responsible for administering these medications acknowledged the delays, citing reasons such as the resident being in deep sleep, not present in the room, or out with a responsible party during medication rounds. The Assistant Director of Nursing (ADON) confirmed the findings of the MAR audit and acknowledged that the medications should have been administered as scheduled. The facility's policy on medication administration emphasizes the importance of administering medications within a specific time frame to ensure safety and accuracy, which was not adhered to in this case.
Inadequate Perineal Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate perineal care for a resident who was incontinent of bowel and bladder, leading to a potential risk of urinary tract infection. The resident, who was severely cognitively impaired and dependent on staff for toileting hygiene, was observed receiving inadequate perineal care on two separate occasions. On both occasions, Certified Nursing Assistants (CNAs) used a single towel to clean the resident's perineal area without rinsing it, contrary to the facility's policy and procedures. The CNAs used the same towel to wipe both the front and back areas, which could leave soap residue and increase the risk of skin irritation and infection. The resident had a history of urinary tract infections and was transferred to a hospital with abnormal vital signs, where a UTI was diagnosed. The facility's policy required the use of soap and warm water, with separate towels for each stroke, and thorough rinsing and drying of the perineal area. However, these procedures were not followed, as confirmed by the Director of Staff Development. The failure to adhere to these protocols was observed during interviews and reviews of the facility's policies, highlighting a deficiency in the care provided to the resident.
Inadequate Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to implement proper infection control practices, specifically in hand hygiene, during the provision of perineal care to a resident. Two certified nursing assistants (CNAs) were observed not performing hand hygiene after providing perineal care and before repositioning the resident. This was noted during separate observations of perineal care provided by CNA 2 and CNA 3. Both CNAs acknowledged that they did not perform hand hygiene or change gloves, which was against the facility's infection control policy. The resident involved had a history of urinary tract infections and was dependent on staff for toileting hygiene and mobility. The facility's policy on hand hygiene, last reviewed in December 2023, requires staff to perform hand hygiene between contaminated and clean body sites during resident care. The Director of Staff Development confirmed that the staff should have performed hand hygiene and changed gloves as per the infection control prevention practices. The failure to adhere to these practices had the potential to spread infection among residents, staff, and visitors.
Failure to Obtain Physician's Order for Physical Therapy
Penalty
Summary
The facility failed to obtain a written order from a physician to provide Physical Therapy (PT) for a resident, which is a requirement according to the facility's policy. The resident, who was admitted with chronic obstructive pulmonary disease and was cognitively intact, required supervision or assistance for various activities of daily living. Despite this, the facility provided PT services to the resident from March to June without a physician's written order, as the resident expressed a desire for the therapy. The Director of Rehabilitation confirmed that PT services were administered continuously without the necessary physician's order, acknowledging that the order should have been obtained prior to providing the treatment. The facility's policy clearly states that specialized rehabilitative services must be ordered by a licensed physician, yet this protocol was not followed, leading to the deficiency.
Failure to Perform Hand Hygiene After Resident Contact
Penalty
Summary
The facility failed to implement proper infection control practices when a Licensed Vocational Nurse (LVN) did not perform hand hygiene after direct contact with a resident. During a medication pass observation, the LVN touched the resident's wrists to check their identification band and blood pressure without wearing gloves. After this contact, the LVN returned to the medication cart and touched it without performing hand hygiene, which is against the facility's infection control policy. The resident involved had a history of heart failure and hypertension and was dependent on staff for various activities of daily living due to moderately impaired cognition. The Director of Nursing confirmed that the staff should perform hand hygiene after touching a resident and before touching other objects to prevent contamination. The facility's policy emphasizes the importance of hand hygiene as a critical measure to prevent the spread of infection.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when Resident 106 pulled the hair of Resident 100, causing Resident 100 to fall to the floor. This incident resulted in Resident 100 sustaining bleeding to the scalp and pain in the left ankle. Resident 100 had a history of falling, difficulty in walking, and hypertension, and was cognitively intact at the time of the incident. The event occurred on 4/7/2024, and was documented in Resident 100's Change in Condition Form and Fall Committee Interdisciplinary Care Team Note. Resident 106, who had severely impaired cognition due to dementia, was identified as the aggressor in the incident. Interviews with facility staff, including LVN 2 and RN 2, confirmed that the interaction was considered physical abuse. The Director of Nursing and the Administrator acknowledged that the incident could have been prevented if staff had intervened by taking Resident 106 back to their room. The facility's policy on abuse prevention, last reviewed in 10/2022, defines abuse as a willful infliction of injury, which was applicable in this case as the act was deliberate.
Residents Unaware of Complaint Filing Process
Penalty
Summary
The facility failed to ensure that six residents were aware of how to contact the State Survey Agency to file a complaint, as observed during a Resident Council Meeting. These residents included individuals with various medical conditions such as end-stage renal disease, arthrogryposis multiplex congenita, unspecified open wound, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. The residents had varying levels of cognitive and physical abilities, with some requiring assistance for activities of daily living. During an observation and interview with the Administrator and Director of Nursing, it was noted that the information on how to contact the State Survey Agency was posted in a manner that was not easily accessible or visible to residents. The print was too small, and the posting was placed too high on the consumer board, making it difficult for residents to see and read. The facility's policy on Resident Rights and Responsibilities indicated that such information should be posted in a prominent area, but this was not effectively implemented.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating the subcutaneous injection sites for insulin administration for a resident with type 2 diabetes mellitus and heart failure. The resident was admitted to the facility with these diagnoses and had the capacity to understand and make decisions. The facility's policy required the rotation of injection sites to prevent skin irritation and other complications. Upon reviewing the resident's records from early April 2024, it was found that insulin was repeatedly administered in the same area, specifically the right arm, on numerous occasions. This practice was inconsistent with the facility's policy and the standard medical practice of rotating injection sites to prevent adverse effects such as lipodystrophy and cutaneous amyloidosis. During an interview, a registered nurse acknowledged that the licensed nurses were not rotating the injection sites as required. The facility's policy on diabetic management, last reviewed in January 2024, clearly indicated the need for site rotation and documentation, which was not followed in this case.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure timely administration of medications for Resident 67, who was admitted with diagnoses including hypertension, atrial fibrillation, and depression. On a specific day, Resident 67 did not receive her morning medications scheduled for 9 a.m. until 11:15 a.m., as confirmed by an interview with the resident and observation of the medication administration by LVN 6. This delay in medication administration was acknowledged by LVN 6, who stated that the medications were given late. Additionally, the facility did not maintain accurate Controlled Drug Records (CDR) that matched the Medication Administration Records (MAR) for two residents, Resident 44 and Resident 48. For Resident 44, tramadol was removed from the medication cart on several occasions, but these administrations were not documented in the MAR. Similarly, for Resident 48, oxycodone was removed multiple times without corresponding documentation in the MAR. Interviews with LVN 5 and the Director of Nursing (DON) confirmed these discrepancies, highlighting a failure to follow the facility's procedures for documenting controlled drug administration. The facility's policies require that medications be administered within a specific time frame and that all administrations be documented accurately in the MAR. The failure to adhere to these policies resulted in potential medication errors and the risk of drug diversion. The discrepancies in documentation for controlled substances like tramadol and oxycodone underscore the importance of maintaining accurate records to ensure resident safety and compliance with regulatory standards.
Unnecessary Use of Psychotropic Drugs in LTC Facility
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for several residents. One resident received duplicate therapy of Zyprexa for 41 days due to a failure to discontinue a previous order, leading to potential overdose and altered mental function. The Director of Nursing acknowledged the error, which was a result of not verifying medication orders properly. Another resident was administered haloperidol for physical and verbal aggression without attempting non-pharmacological interventions first. The resident's aggression was due to complaints about the room being too cold, but there was no documentation that the issue was addressed by maintenance. The Director of Nursing confirmed that non-pharmacological interventions should have been attempted before administering medication. Additionally, a resident received prn lorazepam frequently without corresponding behavioral monitoring documentation. This discrepancy could affect the psychiatrist's ability to order a gradual dose reduction. The facility's policy requires that non-pharmacological interventions be attempted before administering psychotropic medications, but there was no documentation of such attempts for this resident.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to properly label medications for two residents, which could compromise the therapeutic effectiveness of the medications. For Resident 48, an opened package of albuterol sulfate vials was found without an open date label during an observation of Medication Cart A. Both the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) acknowledged that the medication should have been labeled with an open date, as per the facility's policy requiring beyond-use dating of 60 days or the manufacturer's expiration date if less than 60 days. Similarly, for Resident 44, an opened package of ipratropium bromide and albuterol sulfate was also found without an open date label during the same observation. The LVN and ADON confirmed that this medication should have been labeled with an open date, in accordance with the facility's policy. Both residents had intact cognition and required varying levels of assistance with activities of daily living. Additionally, the facility failed to discard a discontinued vial of Haldol for Resident 106, which could lead to potential drug diversion. The LVN stated that the Haldol injection used for Resident 106 was obtained from a leftover vial from a previous incident, despite the order being discontinued. The facility's policy mandates that discontinued medications be marked and destroyed immediately to avoid inadvertent administration. The Emergency Kit Pharmacy Log showed no records of Haldol being retrieved for Resident 106, indicating a lapse in proper medication disposal procedures.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 12, by not documenting wound care treatments in the Treatment Administration Record (TAR) for January 2024. This deficiency was identified during a review of Resident 12's medical records, which revealed missing documentation for specific dates in January. The absence of documentation pertained to treatments ordered by the physician, including the cleansing and dressing of a gastrostomy tube and a skin tear on the left elbow, as well as the use of a low air loss mattress for wound management. Resident 12 was admitted to the facility with diagnoses including dysphagia and required a gastrostomy tube for medication and nutrition. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment and dependency on staff for personal hygiene and dressing. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nurses, confirmed the lack of documentation in the TAR, which is a legal document indicating the dates treatments were conducted. The facility's policy on charting and documentation, last reviewed in January 2024, mandates that treatments and services performed must be documented in the resident's medical record.
Failure to Obtain Informed Consent for Medication Changes
Penalty
Summary
The facility failed to obtain informed consent for medication changes for two residents, violating their rights to be informed about their treatment. Resident 106, who was admitted with dementia and had severely impaired cognition, had their Seroquel dosage increased from 50 mg at bedtime to 50 mg every 12 hours without obtaining a new informed consent. The facility's Minimum Data Set Nurse confirmed that the only informed consent on record was for the initial dosage, and the Director of Nursing acknowledged the oversight, emphasizing the importance of informed consent for medication changes. Similarly, Resident 56, who was admitted with low back pain, dementia, and psychosis, had their Zyprexa dosage increased from 2.5 mg to 3.75 mg at bedtime without obtaining a new informed consent. The Director of Nursing confirmed that the last informed consent was obtained verbally for the initial dosage and acknowledged the need for a new consent when the medication order changed. The facility's policy required informed consent prior to medication use and upon changes in medication orders, which was not followed in these cases. These deficiencies highlight the facility's failure to adhere to its policy on informed consent for psychotropic medications, resulting in a violation of the residents' rights to be informed about their treatment. The lack of informed consent for the increased dosages of antipsychotic medications Seroquel and Zyprexa posed a risk to the residents, as these medications can have significant side effects and adverse effects.
Failure to Develop Baseline Care Plan for COVID-19 Positive Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who tested positive for COVID-19. The resident was admitted with a diagnosis of COVID-19 and was placed under transmission-based precautions, including respiratory, droplet, and contact precautions, requiring isolation in a single room. Despite these measures, the facility did not create a baseline care plan to address the resident's COVID-19 diagnosis, which is essential for ensuring that all staff follow the necessary isolation precautions. During an interview, the Registered Nurse Supervisor confirmed that there was no initial care plan for the resident's COVID-19 treatment, which should have been developed according to the facility's policy. The policy mandates that an interdisciplinary team must create a baseline care plan within 48 hours of admission, including initial goals and physician orders. The absence of this care plan could potentially impact the resident's health and safety, as well as the quality of care provided.
Failure to Develop Timely Care Plan for Constipation Risk
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident identified as being at risk for constipation. The resident, who was initially admitted on 11/30/2023 and readmitted on 5/19/2024, had diagnoses including right hip dislocation and osteoarthritis. The resident's Minimum Data Set (MDS) indicated intact cognition and dependence on staff for toileting hygiene and mobility. Despite a physician's order dated 5/19/2024 for polyethylene glycol 3350 powder to treat constipation, the care plan addressing the risk of constipation was not initiated until 6/6/2024. During a review on 6/6/2024, the Assistant Director of Nursing (ADON) confirmed that the facility did not develop a care plan for the resident's constipation until that morning, despite the resident being identified as at risk on 5/19/2024. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case. This oversight had the potential to result in a failure to deliver necessary care and services.
Medication Mismanagement at Resident's Bedside
Penalty
Summary
The facility failed to ensure that a medicine cup containing diclofenac sodium gel was not left on the bedside table of a resident, identified as Resident 330. This oversight was discovered during an observation and interview with a Restorative Nurse Assistant (RNA 1) and the Director of Nursing (DON), who found the cream on the resident's bedside table. The DON instructed a Registered Nurse (RN 1) to investigate the situation further. It was confirmed by a Licensed Vocational Nurse (LVN 5) that the cream was indeed Resident 330's medication for pain, which had been left at the bedside during the morning medication pass. LVN 5 acknowledged that leaving medication at the bedside was not the correct practice, as it could lead to other residents taking the medication, potentially causing adverse effects. Further investigation revealed that there was no assessment conducted to determine if Resident 330 was capable of self-administering the medication, as required by the facility's policy. RN 1 confirmed that an assessment should have been completed to evaluate the resident's ability to self-administer medication safely. The lack of this assessment and the improper storage of the medication at the bedside posed a risk of medication errors, overdose, or theft, as the resident might not use the medication properly or another resident could access it.
Inappropriate Pain Management for a Resident
Penalty
Summary
The facility failed to ensure effective pain management for a resident by not administering the correct dosage of pain medication as per the physician's orders. Resident 100, who was admitted with a history of falling, difficulty in walking, and hypertension, had intact cognition and the capacity to understand and make decisions. The resident's Medication Administration Record (MAR) indicated that acetaminophen 500 mg was administered for a pain level of 5/10, which was inappropriate as the physician's orders specified this dosage for pain levels of 1-3/10. Instead, the resident should have received a different dosage for moderate pain severity of 4-6/10. During a review of the incident, the Director of Nursing confirmed that the administration of acetaminophen 500 mg for a pain level of 5 was not in accordance with the physician's orders. The facility's policy on pain recognition and management, as well as medication administration, requires adherence to prescribed dosages based on the pain scale. This oversight in following the prescribed pain management protocol could lead to confusion in care delivery and inadequate pain management for residents.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-hemodialysis assessment for a resident, identified as Resident 38, who required dialysis care. The resident was admitted with diagnoses including dysphagia and end-stage renal disease, and had a physician's order for dialysis three times a week. However, a review of the resident's Nurse's Dialysis Communication Record Book revealed that the post-dialysis assessment was left blank, indicating that the necessary monitoring and documentation were not performed. This included the assessment of the dialysis access site and the resident's vital signs after the dialysis treatment. During an interview and record review, a registered nurse confirmed that the post-dialysis assessment was not completed, as evidenced by the blank form. The facility's policy on dialysis care requires documentation of pre- and post-dialysis care, including assessments of the renal dialysis access site. The failure to conduct and document the post-dialysis assessment placed the resident at risk for complications associated with dialysis, such as bleeding at the access site and changes in vital signs.
Failure to Implement Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation for a resident's medication regimen review (MRR). Specifically, the recommendation to administer prednisone with food was not followed for a resident who was admitted with gastroesophageal reflux disease (GERD). The resident's physician's orders included prednisone for cough and congestion, but the order did not specify to take it with food, as recommended by the consultant pharmacist. This oversight placed the resident at an increased risk of experiencing adverse side effects, such as stomach irritation. During interviews and record reviews, the Assistant Director of Nursing (ADON) acknowledged that the licensed nurses did not follow the consultant pharmacist's recommendation. The facility's policy requires that recommendations from the MRR be reviewed, and if agreed upon by the doctor, the order should be changed accordingly. The policy also states that this process should be completed within 30 days. However, in this case, the recommendation was not acted upon, and the necessary change to the medication order was not made, leaving the resident vulnerable to potential medication-related issues.
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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