Claremont Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremont, California.
- Location
- 590 S. Indian Hill Blvd., Claremont, California 91711
- CMS Provider Number
- 055344
- Inspections on file
- 41
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Claremont Heights Post Acute during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive deficit, and significant mobility impairment was care-planned for fall risk with interventions that included keeping the bed in a low position and using bilateral floor mats at the bedside. A fall risk evaluation identified the resident as high risk for falls, and the care plan directed that floor mats be applied next to the bed. During observation, the resident was found in bed with only one floor mat on the right side, while the other mat was placed against the wall instead of on the floor beside the bed. An LVN and the DON both confirmed that the care plan required floor mats on both sides of the bed, but this intervention was not implemented as written.
A resident with impaired cognition, muscle weakness, and dependence for transfers repeatedly called out from a wheelchair for help to use the bathroom. A CNA entered the room, looked around, and left without speaking to or assisting the resident, and another CNA later entered and left without providing toileting assistance or communication. An LVN remained at a nearby med cart and focused on medication preparation while the resident continued to call out. The facility’s policy on resident rights and quality of life requires staff to promptly respond to toileting requests and prohibits practices that compromise dignity, but this was not followed in this incident.
A resident with traumatic brain injury, muscle weakness, lack of coordination, moderately impaired cognition, and dependence for transfers was observed seated in a wheelchair repeatedly calling out for help to use the bathroom while the call light button, taped to the bed rail next to the resident, failed to activate any light or audible signal outside the room. A CNA confirmed the call light was not functioning, and maintenance staff later identified a non-working corridor light bulb and reported they had not previously been notified of the problem, despite facility policy requiring a maintained call system and immediate reporting of defective call alerts.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall. The LPN who responded did not notify the physician or family, nor document the incident, as no injury was observed at the time. Required notifications were only made days later after further changes in the resident's condition were identified, contrary to facility policy.
A resident with severe cognitive impairment was subjected to rough handling and verbal aggression by a CNA, including being placed forcefully into a wheelchair and having hair brushed roughly. Witnesses, including another resident and a CNA, observed and reported the mistreatment, which led to discomfort and distress for the resident. Facility staff and records confirmed the incident and noted that the actions violated the facility's abuse prevention policy.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
CNAs failed to maintain the dignity of two residents by leaving one uncovered during care and by not addressing the needs of another when responding to a call light in a shared room. Both residents, who were dependent on staff for daily care and had intact cognitive skills, reported feeling neglected and upset by these actions.
A resident admitted with a history of a sacral pressure injury was not accurately assessed for pressure ulcer risk, and the initial skin assessment missed additional wounds. Within a day, the resident developed new pressure injuries on the buttocks and both heels. The care plan did not include offloading interventions for the heels, and facility policies for skin assessment and individualized care planning were not fully followed.
A resident with a nephrostomy tube experienced two incidents of tube dislodgement, requiring hospital transfer for reinsertion, due to staff lacking proper training and competency assessment in nephrostomy tube care. Neither CNAs nor licensed nurses had received specific skills checks or education on managing nephrostomy tubes, despite the facility's policy requiring such evaluations when new procedures are introduced.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols for two residents with wounds and indwelling urinary catheters. In both cases, CNAs provided care without wearing required protective gowns, and in one instance, did not perform hand hygiene after care. Staff interviews confirmed knowledge of the requirements, but lapses occurred due to forgetting or not seeing signage, contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses refused ordered blood tests on two occasions, but the physician was not notified as required by facility policy. The DON confirmed that the refusals were not communicated to the physician, despite the need for regular CBC and valproic acid level monitoring due to psychotropic medication use.
A resident with severe cognitive impairment and multiple diagnoses was prescribed psychotropic medications requiring weekly blood tests, but the care plan did not include interventions for the required labs or address the resident's refusal of these tests. The DON confirmed these omissions during review.
Three residents with end stage renal disease and diabetes who required regular dialysis did not have complete pre- and post-dialysis assessments or documentation in their medical records as required by facility policy. Nursing staff failed to ensure that communication forms were fully completed by the dialysis center, resulting in missing or incomplete records of dialysis treatments and resident condition before and after dialysis.
A resident with severe cognitive impairment and on a scheduled morphine sulfate regimen had multiple doses documented as administered on the MAR, but the corresponding entries were missing from the Individual Narcotic Record. The ADON confirmed these discrepancies, which were not in accordance with facility policy requiring regular reconciliation of controlled substance inventories to the MAR.
Two residents' prescribed medications were left unsupervised on a nurse station desk by an LVN, rather than being properly disposed of according to facility policy. The medications included treatments for dementia, peripheral vascular disease, and hypertension. An RN confirmed that the medications should not have been left unattended and that the facility's policy requires proper documentation and destruction of discontinued medications.
The facility failed to implement its vaccination program for four residents. One resident refused the flu vaccine without documented education or a signed declination. Another received a flu vaccine without a documented lot number or informed consent. Two residents did not receive pneumococcal and flu vaccines despite signed consents. The facility did not adhere to its policies requiring education, consent, and documentation of vaccinations.
The facility failed to implement its COVID-19 immunization program for three residents and all staff. A resident was not offered the latest vaccine, another did not receive the vaccine despite consent, and a third had no documentation of education or consent for vaccination. Additionally, the facility lacked a system to track staff vaccination status, contrary to its policies.
The facility failed to designate a qualified Infection Preventionist (IP) during a COVID-19 outbreak, as the previous IP resigned and was reassigned to other duties. Interviews and staffing logs confirmed the absence of a designated IP, leaving the Infection Prevention and Control program unimplemented during a critical period.
During a COVID-19 outbreak, a facility failed to ensure proper infection control practices. An Activity Assistant removed their N95 mask in a resident care area, and a CNA wore their mask incorrectly. Another CNA did not perform hand hygiene after glove removal and before entering resident rooms. The DON acknowledged the need for staff education on proper mask usage and hand hygiene.
A resident with metabolic encephalopathy was discharged without a documented skin assessment, despite having a known wound on the right leg. The facility failed to document or communicate the resident's skin condition to the receiving facility, contrary to its discharge policy. Interviews confirmed the lack of required documentation and communication.
Two residents in an LTC facility experienced deficiencies in care and documentation. One resident with metabolic encephalopathy sustained a leg wound, but the treatment order was not properly documented or followed. Another resident with hemiplegia underwent a teeth extraction, but the procedure was not documented, and the family was not informed. Staff interviews revealed lapses in documentation and communication, contributing to these deficiencies.
The facility failed to maintain complete and accurate clinical records for three residents, leading to potential inappropriate care. A resident's leg wound treatment was not documented timely, another resident's tooth extraction location was unspecified, and a third resident's dental procedure was not recorded, with incorrect transcription of a physician's order. These documentation lapses could hinder care evaluation and communication among staff.
The facility failed to maintain resident dignity during meal assistance by not ensuring staff were at eye level with residents while feeding them. Observations showed that an LVN and a CNA fed residents from elevated positions, contrary to facility policies that emphasize promoting dignity and communication. This practice affected residents with conditions like dementia and dysphagia.
The facility failed to specify target behaviors for psychotropic medications for two residents, leading to potential overuse and inappropriate administration. A resident's Lorazepam order lacked specific behaviors and a duration limit, while another's Ziprasidone order used a broad term 'agitation' without clarification. This non-compliance with facility policy could result in adverse drug events.
A facility failed to maintain sanitary conditions in a resident's restroom, leaving a toilet uncleaned despite the resident's notification to staff. Additionally, two residents shared a restroom where an unlabeled peri cleanser was improperly stored, risking cross-contamination. These actions violated the facility's infection control policies, as confirmed by staff interviews and observations.
The facility failed to document and administer flu vaccinations for three residents during the flu season. Despite having signed consents, the immunization reports showed discrepancies: one resident's vaccine was marked as refused without a date, another's was pending consent, and the third was marked as not eligible without a date. The IPN planned to contact the health department for a vaccination clinic but lacked proof of communication.
The facility failed to educate and document COVID-19 vaccination information for 9 residents upon admission, who had various medical conditions. The IPN did not have access to the California Immunization Registry and failed to maintain a vaccination log, contrary to the facility's policy.
A resident left the facility Against Medical Advice (AMA) without the physician being informed, contrary to the facility's policy. The resident, who required supervision for certain activities, left without a discharge order. A registered nurse confirmed the lack of notification to the physician, which was necessary for ensuring appropriate post-care recommendations and medication adjustments.
A resident in an LTC facility felt uncomfortable and nauseated after witnessing another resident regurgitate and spit into a trashcan in the dining room without staff intervention. The incident involved residents with severe cognitive impairments and required assistance with daily living activities. Staff observed the incident but did not provide immediate assistance, failing to maintain a homelike environment as per facility policy.
A facility failed to develop a baseline care plan for a resident readmitted with a gastrostomy tube and on oxygen therapy. The resident's records did not reflect these needs, and no specific care plan was created to address them, contrary to the facility's policy requiring a care plan within 48 hours of admission. This oversight was confirmed by the RN Supervisor, highlighting a potential risk to the resident's health and safety due to inadequate communication among staff.
A facility failed to develop a care plan for a resident with impaired vision, despite the resident's history of worsening eye health and conditions such as diabetic retinopathy and cataracts. Interviews with nursing staff confirmed the absence of a care plan, which was contrary to the facility's policy on comprehensive person-centered care planning.
A resident with multiple health conditions, including diabetes and a foot ulcer, was found with soiled fingernails, indicating a failure in personal hygiene care. The facility's policy required referral to a podiatrist for nail care in such cases, but this was not done, increasing the risk of infection. The Infection Preventionist Nurse and a Registered Nurse confirmed the deficiency, highlighting the importance of proper nail hygiene in infection control.
A resident at risk for pressure ulcers was found to have their low air loss (LAL) mattress incorrectly set to static mode with a pressure setting of 350 pounds, despite weighing 137 pounds. This was confirmed by the Director of Staff Development and Treatment Nurse 1, who adjusted the pressure to 100 pounds. The resident's care plan required a LAL mattress for wound management due to their risk factors, and the facility's policy emphasized the importance of proper mattress settings to prevent pressure injuries.
A facility failed to ensure proper care for a resident receiving enteral feeding through a gastrostomy tube. The resident, with severe cognitive impairment and multiple diagnoses including chronic respiratory failure, was observed lying almost flat during tube feeding, contrary to the physician's order to elevate the head of the bed 30-45 degrees to prevent aspiration. Staff interviews confirmed the necessity of this intervention.
A resident with chronic respiratory failure and hypoxia did not receive proper oxygen therapy as per physician orders. The nasal cannula was found improperly placed, compromising the resident's respiratory care. The facility's policy required correct administration of oxygen, which was not followed.
A resident with multiple diagnoses, including diabetes and atrial fibrillation, did not receive recommended lab tests due to the facility's failure to communicate pharmacy recommendations to the attending physician. The oversight was identified during a review of the resident's medication regimen, which highlighted the need for specific lab tests to ensure medication safety and effectiveness.
A resident with impaired cognitive skills and visual function received TobraDex eye drops improperly during a medication pass. The LVN failed to compress the tear duct for the required time, leading to an additional dose being ordered by the physician. This error was identified through observation and interviews, highlighting a significant medication error in the facility.
A kitchen staff member failed to wear a beard net while preparing food, as observed during an inspection. The staff member acknowledged the mistake, and the Dietary Supervisor confirmed the requirement for beard nets to maintain hygiene and food safety standards. Facility policies emphasize personal cleanliness and the use of hair restraints to prevent contamination.
A resident was observed using a Low Air Loss (LAL) mattress without a physician's order in their medical record, despite facility policy requiring such an order for specialized medical devices. The resident, with diagnoses including metabolic encephalopathy and cognitive communication deficit, was dependent on assistance for daily activities. This deficiency was confirmed by a treatment nurse during a record review.
A facility failed to ensure coordinated care between its staff and a hospice agency for a resident under hospice care. The hospice calendars, essential for communication between hospice and facility staff, were incomplete or missing for several months, hindering the staff's ability to track hospice visits and care provided. The resident, who required total dependence on staff for daily activities, was admitted with encephalopathy and was receiving palliative care.
A facility failed to follow its Antibiotic Stewardship Program for a resident with Alzheimer's and dementia. Despite a urine culture showing resistance, the resident continued receiving Trimethoprim for UTI prophylaxis. The Infection Prevention Nurse noted the absence of a completed Surveillance Data Collection Form, a key step in the ASP process, leading to the deficiency.
The facility failed to provide a clean and homelike environment for two residents, leading to discomfort and potential safety issues. A resident with quadriplegia reported corroded and moldy showers, confirmed by the Maintenance Supervisor. Another resident with diabetes and hemiplegia felt dirty due to the moldy smell and missing tiles in the shower rooms. The Infection Preventionist noted missing grout, rust, and black discoloration, which could harbor bacteria, contradicting the facility's policy for a safe environment.
The facility failed to ensure cleanliness and repair in three of its four shower rooms, leading to potential bacterial growth. Observations revealed corroded, moldy conditions with missing grout and tiles, confirmed by the Maintenance Supervisor and Infection Preventionist. Two residents expressed discomfort with the state of the shower rooms, which contradicted the facility's infection control policy.
A resident with quadriplegia and chronic pain syndrome did not receive prescribed medications, baclofen and diazepam, upon returning from a hospital stay. The facility failed to administer these medications as per the transfer orders, leading to the resident experiencing withdrawal symptoms. The delay was due to the pharmacy requiring a signed authorization from the doctor, which was not promptly obtained.
A resident with multiple health issues, including moderate depression, did not receive a timely individualized care plan after a PHQ evaluation indicated depression. The facility delayed initiating a depression care plan, contrary to its policy, which was acknowledged by both the SSW and DON as necessary for effective intervention and care coordination.
Failure to Implement Care-Planned Bilateral Floor Mats for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention requiring bilateral floor mats at the bedside for a resident assessed as high risk for falls. The resident was admitted with dementia and lack of coordination, and a subsequent MDS assessment documented severe cognitive deficit and a need for maximal assistance with walking, transfers, and toileting. The resident’s care plans for risk of falls related to impaired mobility and weakness, initiated on 10/26/2025, specified that the bed may be in the lowest position with bilateral floor mats while in bed and that floor mats should be applied next to the bed as appropriate. A Fall Risk Evaluation dated 12/10/2025 showed a score of 16, indicating the resident was at high risk for falls. During observation on 1/23/2026, the resident was found lying in bed with the bed in a low position, a bed alarm in place, and only one fall mat located on the right side of the bed. In a concurrent interview and record review, an LVN confirmed that the resident’s fall risk care plan called for bilateral fall mats and stated the resident needed mats on both sides of the bed to prevent injuries in the event of a fall. The DON also stated that fall mats needed to be in place on both sides of the bed and, upon entering the room, found the left fall mat placed against the wall toward the right side of the bed rather than positioned on the floor beside the bed. The facility’s policy on Person Centered Care Planning required development and implementation of a comprehensive person-centered care plan, but the specified intervention of bilateral floor mats was not implemented as written.
Failure to Promptly Respond to Resident’s Repeated Toileting Requests
Penalty
Summary
The deficiency involves staff failing to promptly respond to a resident’s repeated requests for toileting assistance, resulting in unmet needs. The resident had been admitted with traumatic hemorrhage of the cerebrum, muscle weakness, lack of coordination, and had moderately impaired cognition. The resident’s MDS indicated dependence for rolling and chair/bed-to-chair transfers. During an observation period, the resident was seated in a wheelchair at the foot of the bed, facing away from the door, and repeatedly yelled, “Can I go to the bathroom,” a total of 16 times, and also stated, “I would make a mess and you going to be stuck with it.” During this time, CNA 1 entered the room while the resident was calling out but only looked around and left without communicating with or assisting the resident. CNA 2 later entered the room but also did not assist with toileting or communicate with the resident and then left. LVN 1 was observed standing by the medication cart near the resident’s room while the resident continued to call out, and then began preparing medications before entering the room to administer them. Staff interviews confirmed that LVN 1 was preoccupied with the medication pass and that CNA 1 was taking out meal trays and described the resident as very persistent. The facility’s “Resident Rights – Quality of Life” policy stated that demeaning practices and standards of care that compromise dignity are prohibited and that staff are to promote dignity by promptly responding to residents’ requests for toileting assistance.
Failure to Maintain Functional Call Light System for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a functioning call light system for a resident. The resident had been admitted with diagnoses including traumatic hemorrhage of the cerebrum, muscle weakness, and lack of coordination, and an MDS assessment documented moderately impaired cognition and dependence for rolling and chair/bed-to-chair transfers. During observation, the resident was seated in a wheelchair at the foot of the bed, facing away from the door, and repeatedly yelled, “Can I go to the bathroom,” 16 times. The call light button was taped on top of the bottom bed rail next to the resident. When the resident pressed the call light button, the call light bulb outside the room did not illuminate and there was no audible sound outside the door. A CNA confirmed that the call light did not activate any light or sound and stated they would call maintenance. Maintenance staff later entered the room and stated the light bulb outside the door was not working and that they had not previously received a report that the resident’s call light needed to be checked. The facility’s policy on the call system stated that the facility would maintain a communication system to allow residents to call for staff assistance from rooms and toileting/bathing areas, and that any defective call alert system would be reported to maintenance for immediate repair.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
Licensed Vocational Nurse 4 (LVN 4) failed to immediately notify the physician and family after a resident experienced an unwitnessed fall. The resident, who had diagnoses including osteoarthritis, dementia, and Alzheimer's disease, was severely cognitively impaired and dependent on staff for activities of daily living. On the evening of the incident, the resident was found on the floor mat by the bed and was assisted back to bed by LVN 4, LVN 3, and a CNA. LVN 4 did not document the fall or notify anyone, stating that there was no injury or distress observed at the time. Subsequent reviews of the resident's records showed that neither the physician nor the family were informed of the fall until several days later, after further changes in the resident's condition were noted, including swelling, discoloration, and eventually fractures requiring surgical intervention. The facility's policy required immediate notification of the physician and family in the event of an incident or accident involving a resident. The Director of Nursing confirmed that the policy applied to this situation and that the required notifications were not made at the time of the fall.
Failure to Protect Resident from Physical Abuse and Mistreatment by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide a safe environment and protect a resident with severe cognitive impairment from physical abuse and mistreatment. The resident, who had diagnoses of Alzheimer's disease and dementia and required moderate assistance with activities of daily living, was subjected to rough handling and verbal aggression by the CNA. Multiple witnesses, including the resident's roommate and another CNA, observed the CNA speaking loudly and firmly to the resident, grabbing the resident tightly by the arms, and placing the resident into a wheelchair in a fast and rough manner. The CNA was also seen brushing the resident's hair roughly, causing concern for the resident's comfort. The roommate, who was cognitively intact, reported that the CNA's actions were forceful enough to cause discomfort and that the CNA yelled at the resident not to get up. Another CNA corroborated these observations, stating that the resident appeared uncomfortable and that the CNA's tone of voice was inappropriate. The incident was reported to facility leadership, and interviews with staff and residents confirmed the rough treatment and verbal mistreatment by the CNA. The resident, when interviewed, did not recall the incident, but later described the CNA as rude and stated that the CNA had yelled and handled them harshly. The roommate refused further care from the CNA due to these actions. Facility records and interviews with the Director of Staff Development and Director of Nursing confirmed that concerns about the CNA's behavior were reported by both residents and staff, and that the facility's abuse prevention policy prohibits any form of resident abuse or mistreatment.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's condition at the time, are not provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision practices were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Resident Dignity and Address Needs During Care and Call Light Response
Penalty
Summary
Certified Nursing Assistants (CNAs) on the night shift failed to maintain the dignity of a resident with functional quadriplegia and multiple pressure ulcers by leaving the resident uncovered and with their gown up when they left to assist another resident. This occurred while the resident was dependent on staff for all activities of daily living, including bed mobility and transfers, and had intact cognitive skills. The resident reported feeling upset and neglected when left in this vulnerable state, as the CNAs did not focus on their care during these incidents. In a separate incident, staff failed to address the needs of a resident with diabetes, dysphagia, and an indwelling urinary catheter when responding to a call light in a shared room. Both a male staff member and a CNA only inquired about the needs of the roommate and did not check on the resident, despite the resident's repeated use of the call light. The resident expressed feeling bad about being overlooked, and the CNA later acknowledged that both residents in a shared room should be asked if they need assistance when a call light is activated.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to implement its policies and procedures for pressure injury prevention and skin and wound management for a resident who was admitted with a history of a sacral pressure injury. Upon admission, the resident's risk for developing pressure ulcers was not accurately assessed, as the Braden Scale completed indicated no impairment in sensory perception or mobility, despite the resident being dependent on staff for most activities and having decreased movement in both lower extremities. The initial skin assessment performed by the admitting nurse did not identify any pressure injuries other than the sacral wound, and it was later revealed that the assessment may have been incomplete, as the nurse admitted to possibly not removing the resident's socks during the examination. Within approximately 22.5 hours of admission, the resident developed additional pressure injuries on the left buttocks/ischium and both heels, which were not present upon discharge from the hospital or noted during the initial skin check. A subsequent assessment by the treatment nurse identified a Stage 4 pressure injury on the left ischium, a Stage 3 pressure injury on the right gluteus, and deep tissue injuries on both heels. The discrepancies between the initial and follow-up assessments made it difficult to determine whether these injuries were acquired prior to or after admission, but the facility's own staff acknowledged that a lapse in turning and repositioning could result in the development of pressure injuries within a single shift. The resident's care plan did not include specific interventions to offload pressure from the heels, despite the presence of deep tissue injuries in those areas. The facility's policies required a comprehensive skin assessment upon admission, accurate risk assessment, and individualized care planning to prevent pressure injuries, including offloading and use of pressure-redistributing devices. These steps were not fully implemented, resulting in the resident developing additional pressure injuries and being at risk for further skin breakdown.
Failure to Ensure Staff Competency in Nephrostomy Tube Care
Penalty
Summary
Licensed nurses and CNAs failed to demonstrate appropriate competencies in caring for a resident with a nephrostomy tube, resulting in two separate incidents where the tube became dislodged. The resident, who had a history of urinary tract infection and hydronephrosis, required substantial assistance with mobility and hygiene. On both occasions, the nephrostomy tube was found dislodged, with urine leaking from the insertion site and the resident's back wet, necessitating transfer to an acute care hospital for evaluation and reinsertion of the tube. Interviews and record reviews revealed that neither the CNAs nor the licensed nurses had received specific training or skills checks related to nephrostomy tube care prior to the incidents. Several CNAs confirmed they had not been trained on how to care for residents with nephrostomy tubes, and the Director of Staff Development acknowledged that skills evaluations for nephrostomy tube care were not conducted at the time of the resident's admission. The facility's own policy required competency evaluations when new procedures or equipment were introduced, but this was not followed in the case of nephrostomy tube care. Observations and interviews with the resident and family member indicated that the nephrostomy tube had not previously become dislodged at home, and the resident expressed concerns about staff awareness and handling of the tube during care activities such as turning and repositioning. The lack of staff competency assessment and training directly contributed to the improper handling of the nephrostomy tube, leading to its repeated dislodgement and the need for hospital intervention.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program for two of five sampled residents by not ensuring staff followed Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. Certified Nursing Assistant 1 (CNA 1) removed splints from a resident with multiple pressure ulcers and an indwelling urinary catheter without wearing a protective gown, despite being aware of the requirement due to the resident's wounds and catheter. CNA 1 acknowledged forgetting to don the gown during the care activity. In a separate incident, two other CNAs (CNA 2 and CNA 3) provided dressing care to another resident who had surgical wounds and an indwelling urinary catheter, also without wearing protective gowns. After completing care, both CNAs removed their gloves and exited the resident's room without performing hand hygiene. CNA 2 later stated that they were aware of the EBP requirements but did not see the EBP sign by the resident's room and therefore did not wear the gown. CNA 2 also confirmed the importance of hand hygiene and PPE use for residents with wounds or indwelling devices. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that EBP and hand hygiene are required for residents with wounds or indwelling medical devices, and that staff must don PPE and perform hand hygiene before and after resident care. Facility policies reviewed also indicated that EBP applies to all residents with wounds and/or indwelling medical devices, and that hand hygiene must be performed before donning and after doffing PPE, as well as upon entering and exiting resident rooms.
Failure to Notify Physician of Resident's Refusal of Blood Tests
Penalty
Summary
The facility failed to notify a resident's physician when the resident refused ordered blood tests on two separate occasions. The resident, who had diagnoses including metabolic encephalopathy, schizoaffective disorder, and Alzheimer's disease, was severely cognitively impaired and required significant assistance with daily activities. Physician orders were in place for weekly complete blood counts due to Clozapine use and for regular valproic acid level monitoring. Documentation showed that the resident refused blood draws on two dates, but there was no evidence in the medical record that the physician was informed of these refusals. During interviews and record reviews, the Director of Nursing confirmed that the physician was not notified each time the resident refused the blood draws, despite the facility's policy requiring timely notification of changes in a resident's condition to physicians, family, or legal representatives. The facility's policy also required updating the care plan to reflect the resident's current status, but this was not documented in relation to the refusals.
Failure to Develop and Implement Comprehensive Care Plan for Blood Test Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident by not including interventions to address the resident's refusal of ordered weekly blood tests. The care plan also did not document the required weekly blood tests, despite physician orders for a complete blood count every Monday due to Clozapine use and a valproic acid level every Wednesday. These omissions were identified during a review of the resident's care plan and order summary report, which showed that the care plan did not reflect the necessary interventions for the resident's specific needs. The resident involved had a history of metabolic encephalopathy, schizoaffective disorder, and Alzheimer's disease, and was severely impaired in cognitive skills, requiring varying levels of staff assistance for daily activities. The resident was prescribed psychotropic medications, including Clozapine and Depakote (valproic acid), which necessitated regular blood monitoring. The Director of Nursing confirmed that the care plan should have included interventions for both the required blood draws and the resident's behavior of refusing these tests.
Failure to Ensure Complete Dialysis Assessment and Documentation
Penalty
Summary
The facility failed to ensure that three residents who required dialysis services were properly assessed before, during, and after their dialysis treatments, and that all required documentation was maintained in their medical records according to facility policy. Specifically, the care plans for these residents indicated that nurses were to document the time, date, and general condition of the residents before transport to dialysis, as well as upon their return. However, reviews of the residents' medical records revealed missing or incomplete documentation, including absent pre- and post-dialysis evaluations and missing treatment records from the dialysis center. Resident 10, who had diagnoses including type 2 diabetes mellitus, respiratory failure, and dependence on renal dialysis, was admitted and readmitted to the facility and was scheduled for dialysis three times a week. The care plan required documentation of the resident's condition before and after dialysis, but the pre-dialysis evaluation form was found incomplete, with the section to be filled by the dialysis unit left blank. Similarly, Resident 11, with diagnoses of type 2 diabetes mellitus and end stage renal disease, was also scheduled for regular dialysis, but their medical record was missing post-dialysis evaluations for several dates, and the dialysis unit's section on the pre-dialysis evaluation forms was not completed. Resident 12, who had type 2 diabetes mellitus, end stage renal disease, and muscle weakness, was also scheduled for dialysis three times a week. The medical record for this resident did not include any documentation from the dialysis center for two treatment dates. Interviews with facility staff confirmed that the required documentation was either incomplete or missing, and that the dialysis center's nurse had not completed the necessary sections of the forms as required by facility policy. The facility's policy and procedure on dialysis management specified that all documentation concerning dialysis services and care should be maintained in the resident's medical record, and that communication forms should be sent to and completed by the dialysis center for each treatment.
Failure to Accurately Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to accurately inventory and reconcile a resident's controlled medication, morphine sulfate, with the Medication Administration Record (MAR). The resident, who was admitted with diagnoses including type 2 diabetes mellitus, dementia, and was receiving palliative care, was severely cognitively impaired and dependent on staff for daily activities. The resident had a physician's order for scheduled morphine sulfate for pain management. Record reviews and interviews revealed that while the resident's MAR indicated morphine sulfate was administered daily at 6:00 p.m. on several dates, the Individual Narcotic Record (INR) was missing corresponding entries for those administrations. The Assistant Director of Nursing confirmed these omissions. Facility policy required that controlled substance inventory be regularly reconciled to the MAR, but this was not done, resulting in incomplete documentation of the use and removal of the resident's morphine sulfate.
Unsecured Medications Left Unattended at Nurse Station
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services for two residents by not properly securing physician-ordered medications. For one resident with diagnoses including peripheral vascular disease, dementia, and Parkinsonism, medications Cilostazol and Memantine HCI were found unsupervised on the desk at the nurse station. This resident was severely cognitively impaired and dependent on staff for most activities of daily living. For another resident with type 2 diabetes, hypertension, and anemia, Metoprolol was also found unsupervised on the same desk. Both residents' medication orders were confirmed through record review. During an observation and interview, an LVN admitted to placing the medications on the desk while changing them out from the medication cart, acknowledging that they should have been disposed of in the medication room according to facility policy. The LVN further stated that the medications were not disposed of properly and that other residents could have accessed them. An RN confirmed that the medications should not have been left on the desk and reiterated the facility's policy for medication destruction, which requires documentation and proper disposal in the incineration container. Review of the facility's policy supported these procedures for medication destruction.
Failure to Implement Vaccination Program
Penalty
Summary
The facility failed to implement its influenza and pneumococcal immunization program for four of seven sampled residents. For one resident who refused the flu vaccination, the facility did not document that education was provided regarding the risks and benefits of the vaccination, nor was there a signed declination in the medical record. Another resident received a flu vaccination, but the facility failed to document the lot number of the vaccine and did not have a signed informed consent in the medical record. Additionally, the facility did not administer a pneumococcal vaccine to a resident despite having a signed informed consent from the resident's representative. Similarly, another resident who had signed informed consents for both the pneumococcal and flu vaccinations did not receive either vaccine. These failures indicate a lack of adherence to the facility's policies and procedures regarding vaccination documentation and administration. The facility's policies require that residents or their representatives be educated on the risks and benefits of vaccinations, and that informed consent be obtained and documented. The policies also mandate that the vaccine type, dose, route, and lot number be recorded. The deficiencies observed in the facility's vaccination program highlight a failure to follow these established protocols, potentially impacting resident safety and care.
Failure to Implement COVID-19 Immunization Program
Penalty
Summary
The facility failed to implement its COVID-19 immunization program effectively for three residents and all facility staff. Resident 2 was not offered the latest COVID-19 vaccination, as confirmed by the Director of Nursing (DON) during a review of the resident's medical records. Resident 4, who had signed an informed consent to receive the COVID-19 vaccination, did not receive the vaccine. The DON confirmed that the facility staff did not administer the vaccination to Resident 4. For Resident 5, the facility administered a COVID-19 vaccination but failed to document whether education regarding the benefits and potential risks associated with the vaccination was provided. Additionally, there was no signed consent in Resident 5's medical record for the vaccination administered. The DON acknowledged the lack of documentation regarding the education and consent for Resident 5. The facility also failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for the facility's staff. The newly hired Infection Preventionist (IP) stated that there was no system or documentation in place to track the COVID-19 vaccination status of the staff. The facility's policies and procedures required offering vaccinations to all residents and staff, along with maintaining records of consent or declination, but these were not followed as per the findings.
Failure to Designate Infection Preventionist During COVID-19 Outbreak
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for overseeing the Infection Prevention and Control program during a COVID-19 outbreak. The previous IP, a Licensed Vocational Nurse (LVN), had resigned from the position on 2/21/2025, and the facility did not appoint a replacement. Instead, the LVN was reassigned to pass medications and work as a charge nurse on 2/24/2025 and 2/25/2025, leaving the IP role unfilled during a critical time. Interviews with the Public Health Nurse (PHN) and the Director of Staff Development (DSD) confirmed that the facility was experiencing a COVID-19 outbreak, with at least three positive cases within a seven-day period. The PHN was unaware of who would assume the IP responsibilities, and the facility's staffing logs indicated that the LVN was not performing IP duties on the specified dates. The facility's job description for the IP role emphasized the importance of having a designated individual to oversee infection prevention and control, highlighting the deficiency in maintaining this critical position during an outbreak.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the spread of infections during a COVID-19 outbreak. An Activity Assistant was observed pulling down their N95 mask to drink from a bottle while standing in a hallway near the COVID-19 isolation zone, despite being trained to go to the break room for such activities. Additionally, a Certified Nursing Assistant was seen wearing their N95 mask incorrectly, with the bottom strap hanging loosely under their chin, and admitted to discomfort from the mask straps. This improper use of personal protective equipment could contribute to the spread of infections. Furthermore, another Certified Nursing Assistant failed to perform proper hand hygiene after removing gloves and before entering and exiting resident rooms. This CNA was observed discarding gloves and then interacting with a Licensed Vocational Nurse and entering a resident room without sanitizing or washing their hands. The Director of Nursing acknowledged the need for staff education on proper N95 mask usage and hand hygiene to control the COVID-19 outbreak. The facility's policies on respiratory protection and hand hygiene were reviewed, indicating the necessity for staff to adhere to these protocols to prevent infection spread.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident by not conducting and documenting a skin assessment upon discharge. The resident, who was admitted with metabolic encephalopathy and had significant cognitive and physical impairments, was discharged without a documented assessment of their skin condition. This oversight occurred despite the resident having a known wound on the right lower leg, which was not properly documented or treated as per the physician's orders prior to discharge. Additionally, there was no evidence that the resident's skin condition was communicated to the receiving facility. The facility's policy required a skin assessment to be conducted and documented before discharge to ensure appropriate treatment orders could be obtained and communicated. Interviews with facility staff, including the Director of Nursing, confirmed the absence of the required documentation and communication, highlighting a failure to adhere to the facility's discharge and transfer policy.
Deficiencies in Documentation and Care for Two Residents
Penalty
Summary
The facility failed to provide necessary care and services to two residents, leading to deficiencies in their treatment and documentation. Resident 2, who was admitted with metabolic encephalopathy and had limited capacity to understand and make decisions, sustained a wound on the right leg. The clinical record did not document how the wound occurred, and the treatment order for the wound was not transcribed in the resident's clinical record or Treatment Administration Record (TAR) until the following day. There was no evidence that the wound treatment was provided according to the physician's order. Resident 4, who had hemiplegia and hemiparesis following a cerebral infarction, underwent a teeth extraction procedure at the bedside. However, there was no documentation in the clinical record to indicate the procedure took place, nor was there evidence of monitoring for 72 hours post-extraction or that the family was informed. Additionally, the physician's order was incorrectly documented as a treatment for an excoriation instead of a teeth extraction, and there was no clarification of this order with the physician or the registered nurse who took it down. Interviews with staff revealed a lack of proper documentation and communication regarding the residents' care. Licensed nurses failed to transcribe physician's orders into the clinical records and TAR, and there was a misunderstanding about the process for documenting treatment orders. The Director of Nursing acknowledged the importance of documenting incidents and treatments to inform care plans and interventions, but the facility's policies and procedures were not followed, leading to these deficiencies.
Incomplete and Inaccurate Clinical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, leading to potential inappropriate care and evaluation issues. Resident 2's clinical record lacked documentation on how a right leg wound was sustained and the treatment order for the wound was not transcribed in the clinical record or the Treatment Administration Record (TAR) in a timely manner. This oversight was compounded by the fact that the treatment order was not documented in the Medication Administration Record (MAR) from the date it was ordered until the end of the month. Resident 3's clinical record was incomplete as it did not specify the location where a tooth extraction was performed. The Dental Progress Notes and Change in Condition Evaluation failed to provide this critical information, which is necessary for ensuring proper follow-up care and communication among care providers. This lack of documentation could hinder the evaluation of the care provided and the need for staff education. Resident 4's clinical record was missing documentation of a teeth extraction procedure, monitoring post-procedure, and family notification. Additionally, a physician's order was incorrectly transcribed, indicating treatment for an excoriation instead of the dental procedure. These documentation failures could lead to inadequate care and communication, as well as hinder the development of appropriate care plans and interventions.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff promoted dignity while assisting three residents during meals. Observations revealed that staff members were not maintaining eye level with the residents while feeding them, which is a practice that could affect the residents' self-worth and dignity. Specifically, Licensed Vocational Nurse 1 (LVN 1) was observed feeding Resident 55 while seated on a chair with her face about one foot higher than the resident's face. LVN 1 acknowledged that residents should be fed at eye level to observe how they tolerate the feeding. Resident 19, who has a diagnosis of contracture, dementia, and dysphagia, was observed being fed by LVN 1 while sitting in a wheelchair. LVN 1 was seated on an elevated chair, looking down on the resident, which was not at eye level. LVN 1 admitted that she was not at eye level with Resident 19, which was necessary to respect the resident's dignity. Similarly, Resident 52, diagnosed with Parkinson's disease, dementia, and dysphagia, was fed by CNA 1, who was seated on an elevated stool, not at eye level with the resident. CNA 1 acknowledged the importance of sitting at eye level to observe the resident chewing. The facility's policy and procedure on Resident Rights - Accommodation of Needs, last revised in 2012, and Resident Rights - Quality of Life, revised in 2017, emphasize the importance of maintaining residents' dignity and well-being. The policies indicate that staff should interact with residents in a manner that accommodates their physical or sensory limitations and promotes communication. The failure to adhere to these policies during meal assistance was identified as a deficiency in promoting resident dignity.
Failure to Specify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, Resident 54 and Resident 286, were free from unnecessary drugs by not specifying targeted behaviors for the administration of antipsychotic medications. For Resident 54, the facility did not include specific target behaviors for the use of Lorazepam, a medication prescribed for anxiety/agitation. The Licensed Vocational Nurse (LVN) and Registered Nurse (RN) both indicated that the absence of specific target behaviors in the medication order could lead to inappropriate administration and potential harm. Similarly, Resident 286's order for Ziprasidone lacked specific behavioral manifestations, with the term 'agitation' being too broad, which could result in overuse or inappropriate use of the medication. Additionally, the facility did not ensure that Resident 54's physician order for Lorazepam included a duration for the use of the medication. The LVN noted that there should be a 14-day limit on PRN psychoactive medication orders to promote responsible medication use and ensure regular reassessment of the resident's condition. The RN reiterated the importance of a 14-day window to prevent potential misuse or overuse of the medication, emphasizing that PRN orders should not exceed this period without a physician's reassessment. The facility's policy and procedure on Behavior/Psychoactive Medication Management required that any order for psychoactive medications include a specific behavior manifestation and that PRN orders not exceed 14 days unless justified by the physician. The failure to adhere to these guidelines resulted in the potential for overuse of antipsychotic medications without proper monitoring for effectiveness or ineffectiveness, which could lead to adverse drug events for the residents involved.
Infection Control Deficiencies in Resident Restrooms
Penalty
Summary
The facility failed to maintain sanitary conditions in the restroom of Resident 72, leading to an unsanitary environment. Resident 72's toilet was observed to have fecal-like matter around the rim and inside the bowl, with a strong odor present. Despite the resident notifying the night-shift staff, the toilet remained uncleaned, causing discomfort and embarrassment for the resident. Interviews with the Infection Preventionist Nurse and Housekeeper revealed that immediate cleaning should have been conducted by available staff to maintain sanitary conditions, but this was not done. In another instance, the facility did not ensure proper labeling and storage of personal toiletry items in the shared restroom of two residents, Resident 4 and Resident 58. An unlabeled peri cleanser was found stored on top of the toilet paper holder, which should have been labeled with the resident's name and date and kept at the resident's bedside. This oversight was confirmed by a Certified Nursing Assistant and the Infection Preventionist, who acknowledged the risk of cross-contamination due to the improper handling of personal care items. The facility's policies and procedures for infection control and prevention of cross-contamination were not adhered to, as evidenced by the unsanitary restroom conditions and the improper storage of personal care items. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to maintain a safe, sanitary, and comfortable environment for the residents.
Failure to Document and Administer Flu Vaccinations
Penalty
Summary
The facility failed to provide and document influenza vaccinations for three residents during the flu season, as required by their policy. Resident 22, admitted with hemiplegia, hemiparesis, and colon cancer, had a signed consent for the influenza vaccine, but the immunization report indicated the vaccine was refused without a documented date. Resident 23, with heart failure and diabetes mellitus type 2, had a signed consent, but the immunization report showed the vaccine was pending consent. Resident 32, with diabetes mellitus type 2 and chronic kidney disease, had a signed consent, but the immunization report stated the resident was not eligible, with no date provided. The Infection Prevention Nurse (IPN) mentioned plans to contact the local health department to arrange a vaccination clinic but did not provide evidence of such communication. The facility's policy on influenza prevention and control mandates offering immunizations annually during flu season unless contraindicated or already administered, with consent required. The lack of proper documentation and follow-through on vaccination plans led to the deficiency, potentially putting the residents at risk for influenza infection.
Failure to Educate and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide and document pertinent information regarding COVID-19 immunizations for 9 out of 21 residents upon admission. These residents were not educated about the benefits and potential side effects of the COVID-19 vaccine, nor were they given the opportunity to agree to or decline the vaccination. The residents involved had various medical conditions, including end-stage renal disease, chronic respiratory failure, HIV, acute pulmonary edema, and type 2 diabetes mellitus, which could potentially increase their risk of complications from COVID-19. The Infection Prevention Nurse (IPN) admitted to not having access to the California Immunization Registry, which hindered the collection of immunization data. The IPN was responsible for providing education on COVID-19 vaccines to residents and their representatives but failed to maintain a log for COVID-19 vaccinations for both staff and residents. The facility's policy indicated that they would offer COVID-19 vaccinations to all residents and maintain separate logs for tracking vaccination status, but this was not adhered to, as evidenced by the lack of documentation and education provided to the residents.
Failure to Notify Physician of Resident's AMA Discharge
Penalty
Summary
The facility failed to inform the physician of a resident's decision to leave the facility Against Medical Advice (AMA), as required by the facility's policy and procedure. The resident, who was admitted with diagnoses including hypertension, difficulty walking, and lack of coordination, was cognitively intact and required supervision for certain activities of daily living. Despite these needs, the resident left the facility without a discharge order, and the physician was not notified of this action, which was contrary to the facility's policy. During an interview and record review, a registered nurse confirmed that there were no discharge orders for the resident and acknowledged that the physician should have been informed of the resident's departure to ensure appropriate post-care recommendations and medication adjustments. The facility's policy on Discharge Against Medical Advice mandates that a licensed nurse notify the attending physician or medical director when a resident decides to leave AMA, and document all pertinent information in the progress notes. This failure to follow protocol had the potential to impact the resident's transition back home.
Failure to Maintain Homelike Environment During Dining
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for Resident 67 during lunch in the dining room area. On January 6, 2025, Resident 72 repeatedly regurgitated and spit into a trashcan located inside the dining room without staff intervention. This incident was witnessed by Resident 67, who felt uncomfortable, nauseated, and lost her appetite as a result. Resident 67 had been admitted to the facility with diagnoses including hemiplegia, hemiparesis, and anxiety disorder, and her cognition was severely impaired, requiring substantial assistance with activities of daily living and mobility. Resident 72, who was admitted with diagnoses including syncope, esophageal obstruction, and gastro-esophageal reflux disease, also had severely impaired cognition and required moderate assistance with activities of daily living and mobility. During the incident, staff, including a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), observed Resident 72's actions but did not provide immediate assistance to maintain privacy or address the situation. The facility's policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment, emphasizing comfort, independence, and personal needs, which was not upheld in this instance.
Failure to Develop Baseline Care Plan for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented for a resident who was readmitted with a gastrostomy tube and on oxygen therapy. This deficiency was identified during a review of the resident's records, which revealed that the resident was readmitted with multiple diagnoses, including chronic respiratory failure and dependence on supplemental oxygen. Despite these conditions, the resident's Minimum Data Set did not reflect the presence of a feeding tube or oxygen therapy, and there was no specific care plan addressing the resident's needs for gastrostomy tube management and oxygen administration. During an interview with the Registered Nurse Supervisor, it was confirmed that a care plan should have been created upon the resident's readmission to address the new needs related to the gastrostomy tube and oxygen therapy. The facility's policy and procedure on Comprehensive Person-Centered Care Planning, revised in November 2018, mandates that a baseline care plan be developed and implemented within 48 hours of a resident's admission. The absence of such a care plan for the resident had the potential to compromise the resident's health and safety due to a lack of communication among staff on how to manage the resident's care effectively.
Failure to Implement Care Plan for Resident's Impaired Vision
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with impaired vision. The resident, who was admitted with diagnoses including amputation, End Stage Renal Disease, and Diabetes Mellitus with diabetic neuropathy, was observed to have intact cognition and normally used a wheelchair. Despite having a history of worsening eye health, including conditions such as nystagmus, diabetic retinopathy, cataracts, and being legally blind, there was no documented evidence of a care plan addressing the resident's visual impairment. Interviews with nursing staff revealed that the resident received regular eye injections and had a rescheduled eye appointment, yet no care plan was in place to monitor and address the resident's impaired vision. The facility's policy on comprehensive person-centered care planning emphasized the need for care plans to reflect best practice standards and be updated based on assessed needs. However, the lack of a care plan for the resident's visual impairment indicated a failure to adhere to this policy, potentially affecting the resident's physical and psychosocial well-being.
Failure to Provide Adequate Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene care for Resident 285, who was dependent on assistance for activities of daily living. The resident, who had been admitted with conditions including rhabdomyolysis, diabetes mellitus with a foot ulcer, and pneumonia, was observed to have black residue under the fingernails on both hands. This observation was made during a visit by the Infection Preventionist Nurse, who confirmed that the resident's nails were soiled and should have been kept well-groomed as part of basic personal care and infection control. The facility's policy on grooming care indicated that Certified Nursing Assistants are responsible for trimming fingernails, except for residents with diabetes or circulatory impairments, who should be referred to a podiatrist. Despite this policy, the resident's nails were not properly maintained, and a referral to podiatry services was not made as required. The Registered Nurse acknowledged that dirty nails could harbor bacteria and other pathogens, posing an infection risk, especially for a diabetic resident like Resident 285, whose condition could impair the body's ability to fight infections. This oversight in nail care had the potential to negatively impact the resident's health by increasing the risk of infection and complications due to their existing medical conditions.
Incorrect LAL Mattress Settings for At-Risk Resident
Penalty
Summary
The facility failed to ensure the low air loss (LAL) mattress was set correctly for a resident at risk for developing pressure ulcers. The resident, who was readmitted with conditions including dysphagia, muscle weakness, and quadriplegia, required a pressure-reducing device for their bed as part of their care plan. However, during an observation, it was found that the LAL mattress was set to static mode and the pressure-adjust knob was incorrectly set at 350 pounds, which was too firm for the resident who weighed 137 pounds. This setting was confirmed by the Director of Staff Development and Treatment Nurse 1, who acknowledged the incorrect settings and adjusted the pressure to 100 pounds. The resident's care plan indicated the need for a LAL mattress for wound management due to their risk factors, including diabetes, incontinence, and impaired mobility and cognition. The facility's policy and procedure for pressure injury prevention and mattress use emphasized the importance of using pressure redistributing devices and ensuring they are properly working. The incorrect settings on the LAL mattress had the potential to result in the development of a pressure injury for the resident, as confirmed by Registered Nurse 1, who stated that incorrect settings could cause pressure injuries rather than prevent them.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving enteral feeding through a gastrostomy tube, as per the physician's order. The resident, who was admitted with multiple diagnoses including chronic respiratory failure and pneumonitis due to inhalation of food and vomit, was observed to be positioned almost flat in bed while the tube feeding was infusing. This was contrary to the active order which required the head of the bed to be elevated 30-45 degrees during feedings to prevent aspiration. The resident's cognitive skills were severely impaired, and they did not have the capacity to understand and make decisions. During an interview, a Licensed Vocational Nurse acknowledged that the resident's head of bed should be elevated to at least 30 degrees to prevent aspiration. The Registered Nurse Supervisor also confirmed that elevating the head of the bed is an intervention for aspiration precautions for residents on tube feeding.
Improper Administration of Oxygen Therapy
Penalty
Summary
The facility failed to provide proper respiratory care for Resident 185, who was diagnosed with chronic respiratory failure and hypoxia, and was dependent on supplemental oxygen. The resident's Minimum Data Set indicated severely impaired cognitive skills, and the History and Physical report confirmed the resident's inability to make decisions. According to the Order Summary Report, the resident was to receive oxygen therapy at 2-4 liters per minute via nasal cannula to maintain oxygen saturation at or above 92%. However, during an observation, the resident was found with the nasal cannula improperly placed on the side of the head instead of in the nostrils, while the oxygen tank was set at 2 liters per minute. Licensed Vocational Nurse 4 acknowledged that the nasal cannula should have been correctly placed in the resident's nostrils to prevent shortness of breath and hypoxia. The facility's policy and procedure on oxygen therapy, revised in November 2017, required staff to administer oxygen per physician orders, and the lesson plan emphasized the correct placement of the nasal cannula. The failure to adhere to these guidelines and physician orders compromised the resident's respiratory care, as the oxygen therapy was not administered properly.
Failure to Act on Pharmacy Recommendations for Resident
Penalty
Summary
The facility failed to communicate and act upon pharmacy recommendations for a resident, identified as Resident 68, which led to a deficiency. Resident 68 was admitted with diagnoses including depression, atrial fibrillation, and diabetes, and had moderately impaired cognition requiring maximal assistance with daily activities. The facility's consultant pharmacist conducted a Medication Regimen Review and recommended obtaining several laboratory tests, including a Complete Metabolic Panel, Complete Blood Count, Lipid Panel, A1C, and Thyroid-stimulating hormone levels, to ensure the resident's medication regimen was effective and safe. However, during an interview and record review, it was found that these recommendations were not communicated to the attending physician, and no physician orders for the recommended labs were obtained. This oversight was confirmed by a registered nurse, who acknowledged the importance of following pharmacist recommendations to prevent medication interactions and ensure proper monitoring. The facility's policy required that all findings and recommendations from the pharmacist be reported to the director of nursing, attending physician, medical director, and administrator, and that these recommendations be acted upon and documented, which did not occur in this case.
Improper Administration of Eye Drops Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a medication pass. The Licensed Vocational Nurse (LVN) administered TobraDex eye drops to the resident but did not follow the facility's policy and procedure for eye drop administration. Specifically, the LVN did not compress the tear duct in the inner corner of the eye for the required 1-2 minutes after instilling the drops, as per the facility's guidelines. This improper administration led to the resident's physician ordering an additional dose of the medication. The resident involved had multiple diagnoses, including unspecified age-related cataract and legal blindness, and was dependent on assistance for daily activities. The resident's cognitive skills were severely impaired, and they lacked the capacity to make decisions. The failure to administer the eye drops correctly had the potential to result in ineffective medication and enhance systemic side effects, potentially causing harm to the resident's eyes. The deficiency was identified through observation, interviews, and record reviews conducted by the surveyors.
Failure to Ensure Proper Beard Net Use by Kitchen Staff
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices by not ensuring that a kitchen staff member, Cook 1, wore a beard net during food preparation. This was observed during a kitchen inspection where Cook 1 was seen preparing lunch rolls without a beard net, although wearing a surgical mask that did not fully cover the sides of the face, leaving the beard exposed. Cook 1 acknowledged the oversight, stating that a beard net should have been worn to prevent contamination and protect against foodborne illnesses. The Dietary Supervisor confirmed that cooks with facial hair are required to wear beard nets to comply with hygiene and food safety standards, especially in environments serving vulnerable populations. The facility's policy and procedure documents, including the Dietary Department-Infection Control for Dietary Employees and Dietary Department-General, emphasize the importance of personal cleanliness and the use of effective hair restraints, including beard/mustache coverings when applicable, to maintain sanitation and safety standards. The deficiency was identified through observation, interview, and record review, highlighting a lapse in following established infection control policies.
Lack of Physician's Order for LAL Mattress
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident by not having a physician's order for the use of a Low Air Loss (LAL) mattress, which is a specialized medical device used to prevent or treat pressure injuries. The resident, who was admitted with diagnoses including metabolic encephalopathy, adult failure to thrive, and cognitive communication deficit, was observed using a LAL mattress without a corresponding physician's order in their medical record. This oversight was identified during a review of the resident's medical records and confirmed by Treatment Nurse 1, who acknowledged the absence of the necessary physician's order. The facility's policy and procedure require that air mattresses be used under the direction of a physician's order or when the resident's clinical condition warrants pressure-reducing devices. Additionally, the facility's policy on medical records emphasizes the importance of complete and accurate documentation. The failure to have a physician's order for the LAL mattress in the resident's medical record had the potential to result in inconsistent or inaccurate treatments for the resident, who was dependent on assistance for activities of daily living and required partial/moderate assistance with mobility.
Lack of Coordinated Hospice Care for Resident
Penalty
Summary
The facility failed to ensure coordinated care between the facility and the hospice agency for a resident, identified as Resident 24, who was under hospice care. The deficiency was identified through interviews and record reviews, which revealed that the hospice calendars, a critical communication tool between hospice staff and facility staff, were incomplete or missing for several months. Specifically, the hospice calendar for November 2024 was incomplete, the December 2024 calendar was left blank, and the January 2024 calendar was missing entirely. This lack of documentation hindered the ability of the facility staff to be informed about the hospice visits and the type of care provided to Resident 24. Resident 24 was admitted to the facility with diagnoses including encephalopathy and was receiving palliative care. The resident required total dependence on staff for daily activities such as dressing, toileting, and bathing. The facility's policy and procedure on hospice care required regular collaboration between facility and hospice staff, with all hospice-related documentation to be maintained in the resident's medical record. However, the failure to maintain complete hospice calendars compromised the coordination of care necessary to meet the resident's spiritual, emotional, intellectual, physical, and social needs.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program (ASP) policy and procedure for a resident, identified as Resident 40, who was admitted with Alzheimer's disease and dementia. The resident's Minimum Data Set indicated occasional understanding and expression of ideas. An active order for Trimethoprim was noted for urinary tract infection prophylaxis. However, a urine culture result showed resistance to Trimethoprim/Sulfamethoxazole, yet the facility continued administering Trimethoprim, potentially increasing the resident's antibiotic resistance. The Infection Prevention Nurse (IPN) revealed that no Surveillance Data Collection Form (SDCF) was completed for Resident 40, which is a critical step in the facility's ASP process. The IPN explained that the process should begin with a physician's antibiotic order, followed by communication to the facility's system, and the initiation of the SDCF by the licensed nurse. The facility's policy requires tracking antibiotic stewardship processes, including meeting McGeer's criteria when antibiotics are ordered. The failure to complete the SDCF and adhere to the ASP policy contributed to the deficiency identified in the report.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two residents, resulting in discomfort and potential safety concerns. Resident 1, who was admitted with quadriplegia, chronic pain syndrome, and muscle spasms, was dependent on staff for daily activities. During an interview, Resident 1 reported that the showers were corroded and moldy, with grout falling out, which was confirmed by the Maintenance Supervisor. The supervisor observed missing floor tiles and rusty door frames in the shower rooms. Resident 3, admitted with type 2 diabetes mellitus and hemiplegia following a cerebral infarction, required partial assistance for personal hygiene. Resident 3 expressed feeling dirty and uncomfortable due to the moldy smell and missing tiles in the shower rooms. The Infection Preventionist confirmed the presence of missing grout, black discoloration, and rusted door frames, which could harbor bacteria and germs, making it difficult for staff to clean effectively. The facility's policy and procedure on maintaining a safe and homelike environment emphasized cleanliness, order, and pleasant scents. However, the observations and interviews revealed that the facility did not adhere to these standards, compromising the residents' comfort and safety. The missing grout, rust, and moldy conditions in the shower rooms were not addressed, leading to the deficiency noted in the report.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain cleanliness and repair in three of its four shower rooms, which had the potential to harbor bacteria and cause infections among residents. Observations and interviews revealed that the shower rooms were corroded, moldy, and had missing grout and tiles. The Maintenance Supervisor confirmed the presence of missing floor tiles and rusty door frames in the shower rooms, which were pulling away from the walls. The Infection Preventionist noted that the missing grout and rusted door frames created areas that could harbor germs and were difficult to clean effectively. Resident 1, who was admitted with quadriplegia and other conditions, and Resident 3, who had type 2 diabetes and hemiplegia, both expressed discomfort with the state of the shower rooms, describing them as dirty and moldy. The facility's policy on infection control, which aims to maintain a safe and sanitary environment, was not adhered to, as evidenced by the observations of missing grout, rust, and mold in the shower rooms. These deficiencies were directly observed and confirmed by the facility's staff during the survey.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by their physician, leading to discomfort and potential health decline. The resident, who was admitted with diagnoses including quadriplegia, chronic pain syndrome, and muscle spasms, was dependent on staff for daily activities. Upon returning from a hospital stay, the resident did not receive the prescribed medications, baclofen and diazepam, as per the transfer orders from the hospital. The resident reported not receiving these medications upon readmission to the facility, despite having been on them prior to and during the hospital stay. The Director of Nursing confirmed that a telephone order was received for the medications, but the resident did not receive baclofen until the following day and did not receive diazepam for an extended period. The delay in receiving diazepam was due to the pharmacy requiring a signed authorization from the resident's doctor. The resident experienced withdrawal symptoms due to the lack of diazepam, which was confirmed by both the resident and the doctor. The doctor was unaware of the medication lapse and stated that the resident should have received the medications as per the transfer orders, highlighting the potential for withdrawal symptoms and associated health risks.
Failure to Timely Implement Depression Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan (CP) in a timely manner for a resident who was identified with moderate depression. The resident was admitted with multiple diagnoses, including heart failure, chronic kidney disease, diabetes mellitus with a foot ulcer, and homelessness. A Patient Health Questionnaire (PHQ) evaluation conducted shortly after admission indicated the resident was feeling down, depressed, or hopeless. Despite this, the facility did not initiate a depression care plan until several days later, which was not in accordance with the facility's policy and procedure for comprehensive person-centered care planning. Interviews with the Social Services Worker (SSW) and the Director of Nursing (DON) revealed that the care plan should have been initiated immediately after the PHQ evaluation to address the resident's mental health needs. The SSW acknowledged the delay in initiating the care plan and emphasized the importance of timely care planning for targeted interventions and coordinated care. The DON also highlighted the necessity of timely interventions to promote positive clinical outcomes and prevent potential negative consequences for residents with depression.
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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