Cottonwood Canyon Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cajon, California.
- Location
- 1391 Madison Avenue, El Cajon, California 92021
- CMS Provider Number
- 055064
- Inspections on file
- 48
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cottonwood Canyon Healthcare Center during CMS and state inspections, most recent first.
A resident with IDD, severe cognitive deficits, dysphagia, and a documented high fall risk was care-planned for 1:1 feeding assistance and identified as needing close supervision, yet staff left the resident alone with a meal tray and unsupervised in a wheelchair in the hallway. Multiple CNAs observed the resident as confused, unable to reliably use the call light, and engaging in unsafe behaviors such as sitting at the edge of the bed and attempting to stand or ambulate without assistance, but several staff reported they were never informed the resident was a fall risk. The fall care plan contained generic interventions like reminding the resident to use the call light, which leadership later acknowledged were not individualized to the resident’s cognitive and safety needs and did not include 1:1 supervision. The resident was later found face down on the floor in the room with a bleeding head wound and agonal or irregular respirations, and hospital evaluation revealed an L4 compression fracture, need for intubation and ICU care, and new-onset seizure activity, with no prior history of seizures or feeding tube dependence before this event.
A resident with IDD and severe cognitive deficits experienced a fall resulting in a head laceration, bleeding, abrasions to both UEs, agonal and slowed respirations, and unresponsiveness. Nursing notes documented these findings, including a closed head injury with altered consciousness and the need for cervical precautions. However, the MDS for that assessment period was not coded to reflect a major injury under Section J1900C, despite CMS RAI Manual criteria and facility policy requiring that MDS data match clinical documentation and resident observations.
A resident with IDD, severe cognitive deficits, and a known fall history was admitted with documented fall risk and severe swallowing impairment requiring 1:1 supervision and 1:1 feeding assistance. The care plan for fall risk contained only generic interventions such as reminding the resident to use the call light and keeping the call light within reach, despite the resident’s inability to reliably understand or use it. Staff interviews showed inconsistent communication of the resident’s fall-risk status and supervision needs: some CNAs and an LN were unaware the resident was a fall risk, while others knew but did not have the resident care-planned for 1:1 supervision or clearly assigned monitoring responsibilities. On the day of the incident, the resident was left unsupervised in a wheelchair in the hallway and later found on the floor with a bleeding head wound. Additionally, although the nutritional care plan and speech evaluation specified 1:1 feeding assistance due to severe swallowing deficits and aspiration risk, the assigned CNA provided a meal tray and allowed the resident to eat independently, indicating the feeding assistance plan was not implemented.
A resident with intellectual developmental disability and severe cognitive deficits was allowed to remain unsupervised in a wheelchair in a hallway, despite some staff being aware the resident was a fall risk and observing attempts to stand. After the resident was found on the floor with a bleeding head wound, minimally or non-responsive and exhibiting agonal or irregular breathing but with a pulse, nursing staff applied oxygen via a non-rebreather mask but did not assess chest rise, did not provide rescue breaths, and inaccurately documented chest compressions as performed. Leadership later confirmed that staff were expected to follow AHA BLS guidelines, which require rescue breathing for an unresponsive person with a pulse and abnormal or ineffective breathing, and that passive oxygen alone does not ensure ventilation.
A resident with intellectual developmental disability, severe cognitive impairment, high fall risk, and severe swallowing deficits required close supervision, 1:1 feeding assistance, and adherence to AHA BLS guidelines during emergencies. Staff left the resident unsupervised in a wheelchair despite known impulsive and unsafe behaviors, and the resident was later found on the floor in the room with a bleeding head wound, unresponsive or minimally responsive, and with irregular breathing. The responding nurse confirmed the resident had a pulse but did not assess chest rise, did not provide rescue breaths, and only applied oxygen via a non‑rebreather mask, while documentation inaccurately indicated chest compressions were performed. The resident’s care plan and feeder list identified 1:1 feeding assistance due to aspiration risk, yet the assigned CNA, who reported not being informed of the resident’s fall risk or feeding needs, placed a meal tray for the resident to eat independently in the hallway. Multiple CNAs and nurses stated they were not clearly informed of the resident’s high fall‑risk status or supervision requirements, demonstrating a failure to ensure staff were competent, informed, and trained to meet this resident’s safety and care needs.
A resident with severe cognitive deficits and a history of IDD was observed independently wheeling in the hallway and later found face down on the floor in his room with a bleeding head wound, unresponsive and with irregular or agonal respirations. Multiple CNAs and an LN reported that the resident had a pulse, that oxygen via non-rebreather was applied, and that no CPR or chest compressions were performed, only stimulation such as chest rubs. However, late-entry nursing notes by two LNs and an IDT fall note documented that chest compressions were initiated along with oxygen administration. One LN acknowledged that the documentation of chest compressions was inaccurate and should have reflected chest rubs only. The DSD and DON stated that documentation must be timely, accurate, complete, objective, and reflect only the care actually provided, and identified the notes documenting chest compressions as inaccurate.
A resident with severe dementia and no family or surrogate decision-maker was discharged to an assisted living facility without documented IDT meetings, conservatorship planning, or evidence that the discharge decision was appropriately authorized or that the new setting could meet the resident's care needs. The facility did not follow its policy requiring interdisciplinary involvement in discharge planning.
A resident with a pelvic fracture did not receive a shower for 11 days due to the facility's failure to reschedule or find a suitable shower time according to the resident's preferences. Staff did not document any attempts to notify the physician or family or offer alternatives after multiple refusals, resulting in compromised hygiene and a lack of adherence to facility policy.
A resident with heart failure was discharged without a required discharge care plan in place. Record review and staff interviews confirmed that the Social Service Director and DON did not develop or implement the individualized discharge plan as required by facility policy.
A resident with a diagnosis of malignant neoplasm in the digestive system did not receive prescribed medications for constipation management over a three-day period. Despite being at risk for bowel regimen complications, the facility failed to administer Magnesium Hydroxide, Bisacodyl Suppository, and Fleet enema as ordered. The DON confirmed the oversight, which had the potential to impact the resident's health and safety.
A resident admitted with a diagnosis of malignant neoplasm of the digestive system experienced a medication error when the facility failed to match the hospital's discharge medication list with the facility's admission list. The resident was prescribed Sennosides 17.2 mg by the hospital, but the facility's order indicated only 8.6 mg. The DON confirmed the error was due to incorrect transcription by a nurse, violating the facility's medication reconciliation policy.
A facility failed to maintain complete medical records and inventory documentation for a resident. An LN did not document a medication order change properly, omitting details such as the prescriber's name and method of communication. Additionally, the resident's inventory sheet was not signed upon discharge, leaving the facility unable to verify the belongings taken home. The DON acknowledged these documentation lapses, and the facility lacked a policy for residents' belongings accountability.
The facility failed to offer and document advance directives for several residents, resulting in incomplete POLST forms and a lack of clarity on residents' treatment preferences and legal healthcare agents. Despite having policies in place, the facility did not consistently follow procedures to ensure residents' wishes were documented and accessible.
The facility failed to label opened dressings with an open date and remove expired food from the walk-in refrigerator, as observed during an interview with the DDS. Undated gallons of mayonnaise and Asian artisan dressings, along with an expired tub of cottage cheese, were found. The DDS confirmed that staff should have labeled and used or discarded the food by the used-by date, as per facility policy. These failures risked residents acquiring foodborne illness.
The facility failed to maintain accurate medical records for four residents, including incomplete treatment records for dialysis monitoring and diabetic administration. A resident's post-dialysis note lacked reassessment documentation after a bleeding incident, while two residents had missing blood sugar results, hindering proper insulin management. The DON confirmed the importance of complete documentation to prevent care issues.
The facility failed to follow infection control practices by using expired disinfectant wipes during wound care and delaying the implementation of Enhanced Barrier Precautions (EBP) for a resident with a wound infection. The Treatment Nurse used wipes with expired or unreadable dates, and the resident was not placed on EBP until days after the wound was identified, risking the spread of infection.
The facility failed to respond to call lights in a timely manner, causing residents to experience frustration and a lack of dignity. Residents reported waiting up to an hour for assistance, including for medications, due to understaffing and simultaneous staff breaks. Interviews with staff confirmed ongoing issues despite efforts to address them, and facility policy requires immediate call light responses.
A facility failed to obtain proper informed consent for a resident's psychotropic medication. The resident, diagnosed with paranoid schizophrenia, was taking Buspirone and Olanzapine. While the resident consented to Buspirone, the consent for Olanzapine was given verbally by a sister-in-law, who was not an authorized representative. The facility's records were inconsistent regarding the resident's ability to make medical decisions, and no authorized representative was designated for health care decisions.
A resident was discharged from the facility without being offered an Advanced Beneficiary Notice (ABN), which is necessary to inform residents and their families of their options regarding discharge placement and care. The resident, who had primary hypertension and osteoarthritis, was discharged home with home health and durable medical equipment. Facility staff acknowledged the oversight, and the facility's policy lacked guidance on ABNs. The resident's daughter expressed concerns about managing care at home.
Two residents in an LTC facility did not receive appropriate care due to the lack of comprehensive care plans. One resident was not repositioned or provided with necessary nail care, while another resident's pressure ulcer was not addressed in a care plan. These deficiencies were confirmed through observations and staff interviews.
The facility failed to follow physician's orders for two residents, leading to potential medical risks. One resident did not receive the ordered elevation of feet, while another did not receive proper care for a jejunostomy tube site and had medications administered incorrectly. Staff interviews revealed communication and documentation lapses.
A resident in a facility did not receive an audiology appointment, resulting in a lack of access to hearing aids. Despite a physician's order for evaluation and treatment, the resident's appointments were canceled due to being bed-bound and the clinic's inability to accommodate a gurney. Staff interviews revealed a lack of follow-up and coordination, with the Social Service Director acknowledging the oversight and the ADON confirming the consult was not completed.
The facility failed to follow physician's orders for oxygen administration for two residents. One resident with COPD received more oxygen than prescribed, while another with chronic pulmonary edema used oxygen without a physician's order until it was documented later. Staff acknowledged the discrepancies, and the facility's policies on medication and treatment orders were not adhered to.
A facility failed to provide Trauma Informed Care for a resident with PTSD, as staff were unaware of the diagnosis and potential triggers. The resident had a history of traumatic events, and the facility lacked in-service training on trauma-informed care. The Kardex did not include the resident's PTSD information, and staff interviews revealed a lack of awareness and training, contrary to the facility's policy.
A facility failed to conduct a monthly Medication Regimen Review (MRR) for a resident with paranoid schizophrenia, as required by their policy. The absence of MRRs for two consecutive months was confirmed by both the Assistant Director of Nursing and the Pharmacy Consultant, leading to a potential for unnecessary medications and unattended medication irregularities.
A resident on Olanzapine for schizoaffective disorder was monitored for lack of motivation, despite not exhibiting this behavior. Staff interviews revealed the resident experienced hallucinations, which were not documented as target behaviors. The Pharmacy Consultant noted that behavior monitoring should reflect actual symptoms, such as hallucinations, per facility policy.
The facility failed to maintain adequate staffing levels based on payroll data for the fourth quarter of 2024, specifically from July to September. This deficiency was identified through a review of the facility's PBJ Staffing Data Report, which indicated excessively low weekend staffing. The issue was triggered by a single day of low staffing in July, acknowledged by the DON and HR/Payroll personnel, who noted heavy reliance on registry staff. The facility's corporate office submitted the quarterly staffing data, but it failed to meet CMS requirements.
A resident with severe cognitive impairment repeatedly refused essential medications for various conditions, including depression and seizures, without a comprehensive care plan in place. The facility's staff acknowledged the absence of a care plan, which hindered consistent care and potentially risked the resident's health. Despite frequent refusals, no interdisciplinary team meeting was conducted to address the issue.
Two residents experienced inadequate pain management due to delays in medication reordering and insufficient pain relief measures. One resident with diabetic polyneuropathy faced missed doses of morphine and dilaudid, while another with osteomyelitis reported severe pain and insufficient nighttime relief. Interviews with LNs highlighted issues in the medication ordering process, contributing to the deficiency.
A resident with Parkinson's disease was prescribed Lorazepam without documented changes in condition or behavioral symptoms. The medication was administered routinely due to incorrect transcription of the physician's order, and the involved LNs failed to document the necessary details as per facility policy.
Failure to Provide Required 1:1 Feeding Assistance and Fall Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and provide adequate supervision and assistance for a high fall-risk resident with severe cognitive impairment and dysphagia. The resident was admitted with difficulty walking, muscle weakness, a history of falls, an Intellectual Developmental Disability, and dysphagia, and was documented as having decreased safety judgment and severe cognitive deficits. The resident’s MDS identified them as a fall risk with prior falls, and the admission fall risk assessment scored the resident as high risk. The nutritional care plan and speech evaluation specified that the resident required 1:1 feeding assistance due to severe swallowing impairment and aspiration risk, and the resident’s name appeared on the facility’s feeding list. Despite these assessments and care plan directives, staff left the resident alone with a meal tray and did not provide the required feeding assistance or supervision. On the day of the incident, a CNA reported seeing the resident independently wheeling in the hallway and provided a meal tray, observing the resident eat independently while seated in a wheelchair in the hallway without supervision until approximately 8 p.m. The CNA stated she was not informed that the resident was a fall risk and did not request another staff member to supervise the resident when she left the area to use the restroom. Other CNAs on the unit also reported they were not informed that the resident was a fall risk, although they observed the resident as confused, not fully oriented, and unable to reliably use the call light. One CNA described the resident as requiring maximum assistance for sit-to-stand and transfers, being wobbly and unstable, and needing prompt staff response to prevent unsafe attempts to stand. Another CNA reported that from admission, the resident frequently sat on the edge of the bed, attempted to stand or ambulate without assistance, had difficulty understanding how to use the call light, and was known to be a fall risk, and that these concerns had been reported to licensed nurses. Licensed nursing staff and leadership interviews further showed that the resident’s fall risk and supervision needs were not adequately assessed, care-planned, or communicated. The supervising nurse on duty acknowledged that the resident was a high fall risk who required close supervision and should have been on 1:1 supervision for safety, but there were no orders or care plan for 1:1 supervision. The nurse documented that the medication nurse had instructed CNAs to perform visual inspections every 30 minutes and to keep the resident under continuous supervision, including remaining in the room if the resident was alone, but this level of supervision was not consistently implemented. Another nurse stated she was not aware the resident was a fall risk prior to the incident, although she recognized that the resident’s IDD, confusion, and communication deficits warranted considering the resident a safety and fall risk. The Director of Staff Development and DON both stated that the resident’s fall risk care plan, which included generic interventions such as educating the resident to call for assistance and keeping the call light within reach, was not individualized to the resident’s cognitive and safety needs and did not effectively reduce fall risk for a resident who could not comprehend or appropriately use the call light. The incident culminated when staff found the resident lying face down on the floor in the room with a bleeding forehead laceration, unresponsive, and with agonal or irregular respirations. Staff applied oxygen via a non-rebreather mask, stabilized the cervical spine, and called emergency services. Hospital records documented that the resident sustained an L4 compression fracture with 30% height loss, required intubation, was transferred to the ICU, and experienced seizure activity. The hospital discharge summary indicated diagnoses including seizure disorder and dysphagia and stated it was presumed the resident suffered arrest from acute respiratory failure in the setting of recurrent aspiration, with MRI findings consistent with recent seizure activity. The records also showed that the resident had no documented history of seizure activity or feeding tube dependence prior to this facility-to-hospital transfer. The facility’s own policies on comprehensive person-centered care plans and managing falls and fall risk required individualized interventions based on assessment, but the resident’s care plan and supervision practices did not reflect the resident’s identified high fall risk, cognitive impairment, and need for 1:1 feeding assistance and close supervision.
Inaccurate MDS Coding of Major Injury After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) to reflect a resident’s true injury status following a fall. The resident, who had a history of Intellectual Developmental Disability and was assessed on the MDS as rarely or never understood with severe cognitive deficits, experienced a fall on a specified date. Nursing progress notes documented that when staff entered the room, the resident was lying face down with agonal respirations, had a bleeding laceration on the top left of the forehead, slowed respirations, and was fully unconscious. A subsequent late entry nursing note further described bleeding on the left side of the head, abrasions to both upper extremities, and that the resident was unresponsive at that time. Despite these documented clinical findings, the MDS dated for that assessment period was not coded to indicate a major injury under Section J1900C, which includes closed head injury with altered consciousness. During interview and record review, the MDS Coordinator acknowledged that the resident’s condition, including the need for cervical precautions, slowed respirations, head bleeding, and full unconsciousness, met the criteria for a major injury and should have been coded as such. The DON also stated that accurate MDS coding is essential to correctly reflect a resident’s clinical status and to guide care planning and clinical decision making. The facility’s own Resident Assessments policy required that information in MDS assessments consistently reflect information in progress notes, plans of care, and resident observations/interviews, which did not occur in this case.
Failure to Individualize and Implement Care Plan for Fall Prevention and Feeding Assistance
Penalty
Summary
The deficiency involves the facility’s failure to develop, revise, and implement an individualized, person-centered care plan addressing supervision, fall prevention, and feeding assistance for a high fall-risk resident with intellectual developmental disability and severe cognitive deficits. The resident’s MDS documented that he was rarely or never understood and had severe cognitive impairment, and he had a known history of falls prior to admission. Despite this, the fall-risk care plan initiated on 12/22/25 contained only generic interventions such as educating/reminding the resident to call for assistance, keeping the call light within reach, and keeping the resident within supervised view “as much as possible,” without tailoring these interventions to the resident’s inability to understand or reliably use the call light or recognize danger. The DSD stated that this care plan was not individualized or specific to the resident’s cognitive and safety needs and that relying on the call light alone was insufficient given his decreased safety awareness and limited understanding. On the day of the fall, multiple staff interviews showed that the resident’s high fall-risk status and need for close supervision were not consistently communicated or incorporated into his care plan. CNA 1, who was assigned to the resident, reported that she was not informed the resident was a fall risk and therefore did not arrange for supervision when she left the area to use the restroom. She stated she had observed the resident independently wheeling himself in the hallway and had provided a meal tray, watching him eat independently, and that he remained seated in his wheelchair unsupervised in the hallway until approximately 8 p.m., when he was later found on the floor with a bleeding head wound. CNA 2, who worked on the same unit but was not assigned to the resident, also stated she was not informed the resident was a fall risk, observed him sitting alone in his wheelchair appearing confused, and did not recognize the need for close supervision. In contrast, CNA 3, a registry CNA, stated she had been informed by LNs at the start of the shift that the resident was a fall risk and had observed him attempting to stand from his wheelchair, but she reported that CNA 1 did not instruct her to monitor or supervise the resident before leaving for the restroom. Licensed nursing staff interviews further demonstrated that the resident’s supervision needs were not translated into an updated, individualized care plan or clear staff assignments. LN 1, the nursing supervisor on duty, stated he had verbally directed CNAs on the hallway to closely monitor the resident because he was a high fall-risk, had repeatedly attempted to get out of his wheelchair, and required close supervision at all times, including 1:1 supervision for safety. However, he acknowledged that there were no physician orders for 1:1 supervision and that the resident was not care-planned for 1:1 supervision, even though he believed this should have been done. LN 2 stated she was not aware the resident was identified as a fall risk prior to the incident, but given his IDD, confusion, and communication deficits, he should have been considered a safety and fall risk and the care plan should have been updated with interventions such as 1:1 supervision. The DON stated her expectation that staff complete a comprehensive safety assessment, personalize safety needs based on cognitive impairment and decreased safety awareness, and implement structured monitoring with clearly assigned staff responsibility, and acknowledged that failure to clearly communicate the fall risk and lack of supervision resulted in inadequate monitoring and hospitalization. The deficiency also includes failure to implement the resident’s nutritional care plan for feeding assistance. The resident’s nutritional care plan, initiated on 12/22/25, specified 1:1 feeding assistance, and a speech evaluation from the same date documented severe swallowing abilities, prior 1:1 feeder treatment, and aspiration risk. The facility’s feeding list included the resident’s name, and CNA 5 stated that although the resident could physically feed himself, he was on her feeder list due to difficulty swallowing and to prevent choking hazards. Despite these documented needs, CNA 1 reported that she provided the resident with a meal tray and watched him eat independently, indicating that 1:1 feeding assistance as outlined in the care plan was not followed. The DSD stated that staff were required to communicate resident-specific risks and care needs, including feeding assistance, through shift handoff reports and nurse-led huddles before providing care, and that failure to communicate these risks could result in preventable injuries such as choking. The DON stated that assigned staff were required to provide direct assistance during feeding due to choking risk and not leave the resident unattended, and that failure of staff to understand and follow the resident’s specific risks and care needs placed him at risk for injury, further health decline, and death.
Failure to Provide Rescue Breathing and Supervision After Resident Fall With Abnormal Breathing
Penalty
Summary
The deficiency involved the facility’s failure to provide appropriate emergency respiratory interventions, including rescue breaths or assisted ventilation, to a resident who was found on the floor after a fall. The resident had a history of intellectual developmental disability and severe cognitive deficits, was rarely or never understood, and was unable to make decisions. On the day of the incident, a CNA reported that the resident had been independently wheeling himself in the hallway, was provided a meal tray, and ate independently. The CNA stated she was not informed the resident was a fall risk and that the resident remained unsupervised in his wheelchair in the hallway until approximately 8 p.m., when she returned from a bathroom break and observed nursing staff with the resident lying face down on the floor with a bleeding head wound. Multiple CNAs and licensed nurses described the resident’s condition after the fall as minimally responsive, non-responsive, or having irregular or agonal breathing. One CNA reported that the resident had been seen earlier in the hallway sitting in his wheelchair, making random sounds, not fully verbal, and attempting to stand up from the wheelchair, and that she had been informed by licensed nurses that the resident was a fall risk. However, neither she nor another CNA were instructed to monitor or supervise the resident, including when the assigned CNA left the area to use the restroom. After the fall, staff observed the resident on the floor with a bleeding forehead, non-responsive, with irregular breathing and body twitching, and oxygen was applied via a non-rebreather mask. Licensed nursing staff interviews and record review confirmed that, following the fall, the resident had a pulse but was experiencing agonal or irregular breathing, and that staff did not assess chest rise and fall to determine effective breathing and did not provide rescue breaths. One nurse stated that the only intervention provided was oxygen via a non-rebreather mask and acknowledged that chest compressions were inaccurately documented as having been performed when they were not. Another nurse stated that the resident’s oxygen saturation was not registering on the pulse oximeter, that she did not check for chest rise, and that she did not provide rescue breaths despite uncertainty about the resident’s respiratory status. The Director of Staff Development and the DON stated that staff were expected to follow AHA BLS guidelines, which require rescue breathing at a rate of one breath every six seconds for an unresponsive person with a pulse and abnormal or ineffective breathing, and that supplemental oxygen alone does not provide ventilation or ensure air movement into the lungs. The facility’s policy indicated staff are trained to follow current AHA guidelines for recognition of cardiac arrest, initiation of resuscitation, and opening the airway.
Failure to Ensure Staff Competence in Emergency Response, Fall Prevention, and Feeding Assistance for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff caring for a high fall‑risk resident were competent, informed, and trained to meet the resident’s safety and care needs. The resident had a history of intellectual developmental disability, severe cognitive deficits, and was rarely or never understood, with documentation indicating the resident did not have capacity to understand and make decisions. The resident’s fall risk assessment showed a high fall‑risk score, and hospital physical therapy records documented decreased awareness of the need for safety and assistance. Despite this, the resident’s fall care plan contained only general interventions such as reminding the resident to call for assistance, keeping the call light within reach, and keeping the resident within supervised view as much as possible, which the Director of Staff Development later acknowledged were not individualized to the resident’s cognitive and safety needs. On the day of the incident, multiple CNAs and nurses described that the resident was confused, impulsive, and had poor safety awareness, with a history of sitting on the edge of the bed, attempting to stand or ambulate without assistance, and not reliably using the call light. One nurse supervisor stated he had verbally instructed CNAs to closely monitor the resident, perform visual checks every 30 minutes, and keep the resident under continuous supervision, including staying in the room if the resident was alone. However, the assigned CNA reported she was not informed that the resident was a fall risk and did not ask another staff member to supervise the resident when she left the area to use the restroom. A registry CNA also reported she was not instructed to monitor the resident. Other CNAs on the unit stated they were not told the resident was a fall risk or that close supervision was required. During this period, the resident remained seated in a wheelchair in the hallway, unsupervised, and later was found in his room lying face down on the floor with a bleeding head wound, unresponsive or minimally responsive, and with irregular breathing. After the fall, several staff members described the resident as unresponsive or non‑responsive, with irregular or agonal breathing, twitching, and oxygen saturation not registering on the pulse oximeter. The nurse who responded confirmed the resident had a pulse but did not assess chest rise and fall to determine effective breathing and did not initiate rescue breaths, instead applying oxygen via a non‑rebreather mask and performing chest rubs. Multiple CNAs confirmed that no rescue breaths or chest compressions were provided, and the nurse later acknowledged that documentation indicating chest compressions had been done was inaccurate. The Director of Staff Development and the DON both stated that staff were expected to follow AHA BLS guidelines, which require rescue breathing for an unresponsive person with a pulse and abnormal or ineffective breathing, and that supplemental oxygen alone does not provide ventilation. In addition, the resident had a nutritional care plan and speech evaluation indicating severe swallowing impairment, aspiration risk, and a requirement for 1:1 feeding assistance, and the resident’s name appeared on the facility’s feeder list. Nonetheless, the assigned CNA reported she was unaware the resident required 1:1 feeding assistance and had placed the meal tray on a bedside table for the resident to eat independently while seated in a wheelchair in the hallway. The DSD and DON stated that staff were required to communicate resident‑specific risks, including fall risk and feeding assistance needs, through shift reports and huddles, and that failure to communicate these needs left staff unaware of the resident’s required level of care.
Inaccurate Emergency Event Documentation for Fall and Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and reliable medical records that reflected the actual care provided to a resident during an emergency event. The resident had a history of intellectual developmental disability and an MDS indicating severe cognitive deficits, was rarely or never understood, and was unable to make decisions. On the evening of the incident, a CNA reported that she began her shift and observed the resident independently wheeling himself in the hallway, provided him a meal tray, and saw him eat independently. She stated she was not informed the resident was a fall risk and that he remained unsupervised in his wheelchair in the hallway until approximately 8 p.m., when she returned from a bathroom break and found nursing staff with the resident lying face down on the floor with a bleeding head wound. She reported that oxygen was applied and that the resident was minimally responsive, moving only his hand, and that CPR or chest compressions were not initiated because the resident had a pulse. Multiple staff interviews consistently indicated that chest compressions were not performed, while the medical record documented that they were. LN 1 stated that the resident’s baseline was alert but not oriented x3 and non-verbal, and that during the event the resident had agonal breathing but a pulse. LN 1 reported that the only intervention provided was oxygen via non-rebreather and explicitly stated that what was documented in the medical record about chest compressions was not true. CNA 2 stated she assisted in placing the resident in a safe position, observed irregular breathing, and saw LN 2 administer oxygen via non-rebreather, confirming that CPR or chest compressions were not initiated because the resident had a pulse. CNA 3, a registry CNA, stated she had been informed by LNs at the start of the shift that the resident was a fall risk and had observed the resident in the hallway attempting to stand from his wheelchair and being impulsive and resistant to redirection. She reported that after the fall, oxygen via mask was applied and that she observed no rescue breaths or chest compressions, and that the resident did not regain consciousness and his body was twitching on the floor. In contrast to these accounts, the resident’s EHR contained nursing notes and an IDT fall note documenting that chest compressions were initiated. A nurse’s note by LN 1 at 20:55, entered as a late entry, described the resident lying face down with agonal respirations and a bleeding laceration, oxygen via non-rebreather being applied, and stated that, as per the medication nurse, the carotid pulse was too faint to be identifiable and that compressions were briefly initiated and then stopped after breathing stabilized and a carotid pulse was noted. A separate nurse’s note by LN 2 at 21:00, also a late entry, documented that the resident was found on the floor unresponsive, with bleeding to the head and abrasions, and stated that “the chest compression initiated and oxygen with a non re-breather mask was given” and that 911 was called. The IDT fall note likewise stated that the resident was unresponsive and that chest compressions and oxygen with a non-rebreather mask were given. LN 2 later acknowledged that documentation indicating chest compressions were performed was inaccurate and that it should have reflected chest rubs only. The DSD and DON both stated that nursing documentation must be accurate, complete, objective, and reflect exactly what care was provided, and that documenting interventions that did not occur, such as chest compressions in this case, was not acceptable and could misrepresent the resident’s clinical status and negatively impact continuity of care during hospital transfer.
Failure to Ensure Proper Discharge Planning for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident with severe cognitive impairment due to dementia and no family or surrogate decision-maker. The resident was admitted with dementia and had a BIMS score of 2, indicating severe cognitive impairment. The medical record showed that the resident was under a bioethics interdisciplinary team (IDT) and could not make medical decisions. Although a public resident representative met with the Social Service Director (SSD) to discuss criteria for a public representative, there was no documented evidence of a plan for conservatorship or that IDT meetings were conducted to address the resident's discharge needs, goals, or the appropriateness of the assisted living facility selected for discharge. The SSD documented the resident's discharge to an assisted living facility without evidence of how the decision was made, who authorized it, or whether the facility could meet the resident's dementia care needs. Interviews with the DON and SSD confirmed that no IDT meeting or third-party agency decision occurred prior to discharge, and the resident had no family member to assist in decision-making. The facility's policy required the care planning/interdisciplinary team to develop the discharge plan with the assistance of the resident and representative, but this process was not followed in this case.
Failure to Provide Timely Bathing and Accommodate Resident Preferences
Penalty
Summary
A resident admitted with a left ilium fracture did not receive a shower for 11 days, despite having a scheduled shower every Wednesday and Saturday. The resident preferred morning showers, but the facility's schedule placed the shower during the PM shift. Documentation showed that staff did not assist the resident with showering from 6/23/25 until 7/4/25. The resident had refused showers three times, but there was no evidence that staff attempted to reschedule the shower to accommodate the resident's preferences or find a suitable alternative time. Additionally, there was no documented communication with the resident's physician or family regarding the prolonged period without a shower or the resident's refusals. The Assistant Director of Nursing acknowledged that not showering for 11 days was excessive and that staff should have offered alternatives and notified the physician and family. The facility's policy emphasized the importance of bathing for cleanliness, comfort, and skin observation, but these procedures were not followed in this instance.
Failure to Develop Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a discharge care plan for one resident who was admitted with heart failure, as evidenced by a review of the resident's medical record showing no discharge care plan was created prior to the resident's discharge. Interviews with the Social Service Director and the Director of Nursing confirmed that the responsibility for creating the discharge care plan was missed, despite facility policy requiring an individualized discharge plan to be initiated at admission and included in the comprehensive care plan. The absence of a discharge care plan was identified during a record review and staff interviews, with both the Social Service Director and Director of Nursing acknowledging the oversight.
Failure to Implement Resident-Centered Care Plan for Constipation Management
Penalty
Summary
The facility failed to implement a comprehensive resident-centered care plan for a resident who had no bowel movements for three days. The resident was admitted with a diagnosis of malignant neoplasm of ill-defined sites within the digestive system and was at risk for complications with bowel regimen due to decreased physical mobility, weakness, and medication use. The care plan included administering medications per physician order to manage constipation. However, the facility did not follow the physician's orders for administering Magnesium Hydroxide, Bisacodyl Suppository, and Fleet enema as needed. The Bowel Movement Report indicated that the resident had no bowel movements for three days, and the Medication and Treatment Administration Record showed no evidence that the medications were offered or given as ordered. During an interview, the Director of Nursing confirmed that the licensed nurse should have administered the medication to help with constipation but failed to do so. This oversight in following the care plan and physician's orders had the potential to affect the resident's health and safety.
Medication Reconciliation Error on Admission
Penalty
Summary
The facility failed to ensure that the discharge medication list from the hospital matched the facility's admission medication list for a resident, resulting in a significant medication error. The resident, who was admitted with a diagnosis of malignant neoplasm of ill-defined sites within the digestive system, was prescribed Sennosides 17.2 milligrams by the hospital. However, the facility's Order Summary indicated that the resident was to receive only 8.6 milligrams, one tablet orally at bedtime, instead of the two tablets required. There was no evidence of an order change from the physician, and the Licensed Nurse responsible for transcribing the order was unavailable for an interview. The Director of Nursing confirmed that the Licensed Nurse did not transcribe the order correctly, which was against the facility's policy and procedure for medication reconciliation on admission.
Incomplete Medical and Inventory Documentation
Penalty
Summary
The facility failed to maintain complete medical records for a resident, leading to an inability to verify a physician's order and incomplete documentation of the resident's belongings upon discharge. A licensed nurse (LN) did not document the details of a medication order change, including who authorized the change and how the order was received. This lack of documentation occurred after the resident expressed dissatisfaction with the medication regimen, which was initially prescribed as needed and later changed to routine. The nurse practitioner was contacted to change the order back to as needed, but the LN failed to record the prescriber's name, credentials, and the method of communication, as required by the facility's policy. Additionally, the facility did not ensure the completion of the resident's inventory sheet upon discharge. The inventory sheet, which should have been signed to confirm the resident's belongings were taken home, was left blank. The Director of Nursing acknowledged that the inventory should have been reviewed and signed before the resident's departure. The facility was unable to provide a policy and procedure for the accountability of residents' belongings, further highlighting the deficiency in maintaining accurate records.
Failure to Offer and Document Advance Directives
Penalty
Summary
The facility failed to offer and follow up on advance directives for seven out of twenty sampled residents, leading to a lack of documentation regarding residents' treatment preferences and legal healthcare agents. This deficiency was identified through observations, interviews, and record reviews. For instance, Resident 10, diagnosed with paranoid schizophrenia, had no evidence of being offered an advance directive, and the Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete. Similarly, Resident 29, with a cerebral infarction diagnosis, also lacked documentation of an advance directive, despite having designated agents to manage care. Further findings revealed that Resident 77, responsible for himself, had no advance directive information on his POLST form, and there was no evidence of the facility offering or following up on this matter. The Assistant Director of Nursing (ADON) confirmed the absence of advance directive documentation for Residents 10, 29, and 77, emphasizing the importance of having such directives to honor residents' wishes when they can no longer make decisions. The facility's policy required staff to offer assistance in establishing advance directives and document the offer in medical records. Additional residents, including Resident 36 with chronic osteomyelitis, Resident 237 with chronic pulmonary edema, Resident 62 with acute respiratory failure, and Resident 61 with hemiplegia following a cerebral infarction, also had incomplete POLST forms with no advance directive information. Interviews with the ADON and the Director of Nursing (DON) highlighted the expectation for nursing staff to verify advance directives upon admission and ensure they are uploaded into medical records. The facility's policy outlined the responsibility of social services to inquire about and provide information on advance directives, but this was not consistently followed, resulting in the deficiency.
Failure to Label and Discard Expired Food in Kitchen
Penalty
Summary
The facility failed to ensure that opened dressings were labeled with an open date and that expired food was removed from the walk-in refrigerator in the kitchen. During an observation and interview with the Director of Dietary Services (DDS), it was noted that there were opened, undated gallons of mayonnaise and Asian artisan dressings, as well as an opened tub of cottage cheese with a 'USED BY' date that had already passed. The DDS acknowledged that the kitchen staff should have labeled the food with the date it was opened and should have used or discarded the food before the used-by date. The facility's policy on food receiving and storage requires that refrigerated foods be labeled, dated, and monitored to ensure they are used by their use-by date, frozen, or discarded. These failures placed residents at risk of acquiring foodborne illness.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents, leading to potential risks in their care. Resident 66's treatment record was incomplete, as the monitoring of the dialysis site for bleeding and infection was not documented on several occasions. The Director of Nursing (DON) confirmed that the dialysis site should have been monitored per the physician's order, and the lack of documentation indicated that the monitoring was not performed. The facility was unable to provide a policy and procedure for Treatment Administration Records, further complicating the issue. Resident 23's post-dialysis note was incomplete, lacking documentation of reassessment after a bleeding incident at the dialysis site. The resident reported that after returning from dialysis, the AV shunt began to bleed, and the staff response was delayed. Although pressure was applied to stop the bleeding, the Licensed Nurse (LN) did not document all reassessments, which was confirmed by the DON and the Assistant Director of Nursing (ADON). The facility's policy required documentation of observations post-dialysis, which was not adhered to in this case. Residents 36 and 63 had incomplete Diabetic Administration Records (DAR), with missing blood sugar results on multiple occasions. This lack of documentation meant that staff and physicians could not accurately assess the residents' blood sugar levels or determine the need for insulin coverage. The DON acknowledged the importance of complete and accurate documentation to prevent glycemic reactions and to allow physicians to monitor and adjust medication as needed. The facility's policy required documentation of blood glucose levels and medication administration, which was not consistently followed.
Infection Control Deficiencies: Expired Disinfectant Wipes and Delayed EBP Implementation
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the use of expired disinfectant wipes by the Treatment Nurse (TN) during wound care procedures. The TN initially used wipes from a container with an expired date and then attempted to use another container with an unreadable expiration date. The Infection Preventionist (IP) confirmed that expired wipes should not be used to ensure efficacy and prevent the spread of germs, as per the facility's policy on cleaning and disinfection of environmental surfaces. Additionally, the facility did not timely implement Enhanced Barrier Precautions (EBP) for a resident with a wound infection. The resident, who was readmitted with diagnoses including muscle weakness and acute respiratory failure with hypoxia, was not placed on EBP until several days after the wound was identified. The IP and Assistant Director of Nursing (ADON) acknowledged the delay in implementing EBP and the failure to notify the resident's physician, which was crucial to prevent the spread of infection and protect the resident's health condition.
Delayed Call Light Response Leads to Resident Frustration
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, which resulted in residents experiencing a lack of dignity and expressing anger and frustration. During a confidential group meeting, three out of seven attendees reported complaints about the facility's call light response time, noting that it varied depending on the shift and staff availability. Residents reported waiting up to an hour for assistance, including for medications and pain relief, due to understaffing and staff taking breaks simultaneously. The Resident Council Minutes from September to November 2024 consistently documented ongoing concerns about call light response times. Interviews with facility staff, including the Activity Director (AD), Director of Staff Development (DSD), and Assistant Director of Nursing (ADON), confirmed the ongoing issues with call light response times. The AD stated that concerns were communicated to department leaders, but no improvements were observed. The DSD acknowledged receiving complaints and conducting in-services, but the issues persisted. The ADON emphasized the importance of timely responses, noting that delays could lead to resident agitation and increased risk of infection. The facility's policy on answering call lights mandates immediate responses to residents' requests and needs.
Failure to Obtain Proper Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident had an authorized responsible party to sign the informed consent for the use of psychotropic medication. Resident 10, who was admitted with a diagnosis of paranoid schizophrenia, was taking Buspirone Hydrochloride and Olanzapine. Although Resident 10 consented to the Buspirone, the consent for Olanzapine was given verbally by the resident's sister-in-law, who was not an authorized representative for health care decisions. The facility's records indicated that Resident 10 was responsible for herself, but conflicting information in the history and physical report suggested that she could not make medical decisions due to her schizophrenia. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that Resident 10 had five emergency contacts involved in her care, but none were designated as her representative for health care decisions. The facility's policy required informed consent to be obtained from the resident or an appropriate representative, which was not adhered to in this case. The DON acknowledged that informed consent should have been signed by the resident or a responsible party, highlighting a lapse in the facility's adherence to its own policies and procedures regarding psychotropic medication use.
Failure to Provide Advanced Beneficiary Notice for Discharge
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident, identified as Resident 39, who was discharged from the facility. Resident 39 was admitted with diagnoses including primary hypertension and osteoarthritis. The Physician's Order Summary indicated a discharge order for Resident 39 to return home with home health and durable medical equipment. However, the Business Office Manager and the Social Service Director both acknowledged that an ABN was not offered to Resident 39, which was necessary to inform the resident and her family of their options regarding discharge placement and care. Interviews with facility staff revealed that the responsibility for offering the ABN was not fulfilled, as the Social Service Director admitted to not providing the notice. The facility's policy on Admission, Transfer, and Discharge did not include guidance on ABNs. Additionally, the resident's daughter expressed concerns about the ability to care for Resident 39 at home, particularly regarding lifting and the use of durable medical equipment. The absence of an ABN potentially limited the resident's options for a safe discharge and care plan.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for two residents, leading to deficiencies in their care. Resident 29, who was at risk for skin breakdown due to impaired mobility and incontinence, was not assisted with repositioning while in bed, as observed multiple times throughout the day. Additionally, Resident 29's nail care was neglected, with long nails on the right hand causing discomfort. Despite the care plan indicating the need for regular repositioning and nail care, these interventions were not carried out, as confirmed by interviews with the CNA and nursing leadership. Resident 62, who had a pressure ulcer on the left foot, did not have a care plan addressing this wound, despite being on enhanced barrier precautions. The absence of a specific care plan for the wound was acknowledged by the ADON, who emphasized the importance of having such a plan for effective care. The DON also confirmed the expectation for individualized care plans to ensure proper care delivery. The facility's policies on care plans and repositioning were not adhered to, resulting in these deficiencies.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to potential risks for medical complications. For Resident 64, who was admitted with hemiplegia and hemiparesis following a stroke, the physician's order to elevate both feet with a pillow every shift was not followed. Observations over several days confirmed the absence of pillows under the resident's feet, despite the Medication Administration Record indicating compliance. Interviews with staff, including the Director of Staff Development and the Assistant Director of Nursing, revealed a lack of communication and responsibility in ensuring the physician's order was implemented. For Resident 286, who was admitted with morbid obesity and stomach cancer, the facility failed to follow the physician's order for the care of the jejunostomy tube site and the administration of medications. The resident reported that the treatment for the JT site was not performed, and medications were given orally instead of through the JT. Staff interviews confirmed the failure to transcribe and follow the physician's orders accurately. The facility's policy on administering medications through an enteral tube was not adhered to, as evidenced by the lack of proper documentation and execution of the treatment orders.
Failure to Arrange Audiology Appointment for Resident
Penalty
Summary
The facility failed to arrange an audiology appointment for a resident, resulting in the resident not having access to hearing aids. The resident, who was readmitted to the facility, had a moderately impaired mental cognition but was capable of understanding and making decisions. A physician's order for an audiology evaluation and treatment was issued, but there was no documentation indicating that the resident was seen by an audiologist. Scheduled audiology appointments were canceled due to the resident being bed-bound and the clinic's inability to accommodate a gurney. Interviews with facility staff revealed a lack of follow-up on the audiology consults. The Social Service Director acknowledged the oversight, and the Unit Clerk mentioned the clinic's limitations in accommodating the resident's needs. The Assistant Director of Nursing confirmed that the audiology consult was not completed and outlined the roles of staff in coordinating appointments and transportation. The facility's policy on referrals indicated that social services should coordinate resident referrals and document them in the medical record, which was not done in this case.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in providing respiratory care for two residents. Resident 16, who was admitted with chronic obstructive pulmonary disease (COPD), was observed receiving oxygen at five liters per minute, contrary to the physician's order of four liters per minute. This discrepancy was noted during an observation and confirmed by LN 21, who acknowledged that the physician's order was not followed. The Assistant Director of Nursing (ADON) also confirmed the physician's order and emphasized the importance of adhering to it, especially given Resident 16's COPD diagnosis. Resident 237, admitted with chronic pulmonary edema, was using oxygen without a physician's order until one was obtained on 12/10/24. The Treatment Nurse (TN) was unaware of any existing order during an observation, and the ADON confirmed that the order was only documented after the resident had already been using oxygen. The Director of Nursing (DON) highlighted the necessity of having physician's orders to ensure continuity of care and proper administration of oxygen. The facility's policies on medication and treatment orders, as well as oxygen administration, were not followed, leading to these deficiencies.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care (TIC) for a resident diagnosed with PTSD and suicidal ideations. The resident, identified as Resident 9, was admitted with a history of traumatic events, including molestation at a young age. Despite this, the facility did not ensure that staff were aware of the resident's PTSD diagnosis or potential triggers that could lead to re-traumatization. Observations and interviews revealed that the resident experienced difficulty sleeping due to noise, and staff members, including CNAs, were unaware of the resident's PTSD diagnosis and its implications. The facility's Director of Staff Development confirmed the absence of in-service training on trauma-informed care or PTSD for staff. The Kardex, which should have contained information about the resident's PTSD, did not include this critical information. Interviews with various staff members, including CNAs and the Director of Nursing, highlighted a lack of awareness and training regarding the resident's PTSD, which is essential for providing appropriate care and minimizing triggers. The facility's policy on Trauma Informed Care and Culturally Competent Care, which mandates staff training and identification of triggers, was not effectively implemented.
Failure to Conduct Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a Medication Regimen Review (MRR) was completed monthly for a resident, leading to a potential for unnecessary medications and unattended medication irregularities. The resident, who was admitted with a diagnosis of paranoid schizophrenia, did not have documented MRRs for October and November 2024. During a joint interview and record review, the Assistant Director of Nursing confirmed the absence of these reviews, acknowledging that they should have been conducted monthly. The Pharmacy Consultant also confirmed the lack of evidence for the MRRs during these months, despite the facility's policy requiring monthly reviews.
Inappropriate Behavior Monitoring for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure appropriate behavior monitoring for a resident prescribed antipsychotic medication, specifically Olanzapine, for schizoaffective disorder. The resident, who was admitted with diagnoses including paranoid schizophrenia, was monitored for lack of motivation as a target behavior for the medication. However, interviews with staff, including CNAs and the Assistant Director of Nursing, revealed that the resident did not exhibit issues with lack of motivation but rather experienced hallucinations, such as hearing voices and seeing people who were not there. The Pharmacy Consultant confirmed that the behavior monitoring should align with the resident's actual experiences, such as auditory or visual hallucinations, rather than lack of motivation. The facility's policy on psychoactive/psychotropic medication use requires that symptoms and therapeutic goals be clearly identified and documented, which was not adhered to in this case. This oversight had the potential to result in the unnecessary use of psychotropic medication for the resident.
Failure to Maintain Adequate Weekend Staffing Levels
Penalty
Summary
The facility failed to maintain adequate staffing levels based on payroll data for the fourth quarter of 2024, specifically from July 1 to September 30. This deficiency was identified through a review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, which indicated excessively low weekend staffing. The issue was triggered by a single day of low staffing in July 2024. During an interview, the Director of Nursing (DON) and HR/Payroll personnel acknowledged the deficiency, noting that the facility had relied heavily on registry staff during that period. The facility's corporate office submitted the quarterly staffing data, but it failed to meet the Centers for Medicare & Medicaid Services (CMS) requirements due to the low staffing incident. The CMS policy manual emphasizes the importance of staffing in ensuring quality care in nursing homes, and the deficiency was noted as a failure to meet these standards.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident who repeatedly refused to take prescribed medications. This deficiency was identified during a review of the resident's clinical records and interviews with facility staff. The resident, who had a severely impaired cognitive score, was prescribed several medications for conditions including depression, hypertension, chronic heart failure, chronic chest pain, and seizures. Despite the importance of these medications, the resident frequently refused them, and there was no documented care plan addressing these refusals. The Medication Administration Record revealed multiple instances where the resident refused medications, including Sertraline, Carvedilol, Sacubitril-Valsartan, Ranolazine, Depakote Sprinkles, and Levetiracetam. Additionally, the resident refused blood sugar checks on numerous occasions. Despite these refusals, there was no evidence of an interdisciplinary team meeting to address the issue, nor was there a care plan developed to manage the resident's refusal of medications. Interviews with facility staff, including a licensed nurse and the Director of Nursing, confirmed the absence of a care plan for the resident's medication refusals. The staff acknowledged that the lack of a care plan prevented them from consistently addressing the resident's needs and potentially put the resident at risk for worsening medical conditions. The facility's policies on care plans and refusal of care emphasize the importance of addressing underlying issues and reassessing care plans when significant changes in condition occur, which was not adhered to in this case.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide effective pain management services for two residents, resulting in psychological harm due to unrelieved pain. Resident 1, diagnosed with Type 2 diabetes and diabetic polyneuropathy, experienced delays in receiving pain medication due to issues with medication reordering and availability. The resident reported waiting up to three hours for pain medication and noted that nurses did not reorder medication in time, leading to missed doses of morphine and dilaudid. Additionally, the resident mentioned that warm showers helped alleviate pain, but they were not provided frequently enough. Resident 2, suffering from acute osteomyelitis and embolism, reported severe pain in her left arm, which was not adequately managed. Despite being prescribed Norco, the resident expressed a desire for additional pain relief at night to aid sleep, as the pain was rated at a 10 on a 1/10 scale. The resident also mentioned that over-the-counter Tylenol PM was taken away by staff, and no one inquired about managing her pain more effectively. Interviews with licensed nurses revealed inconsistencies in the medication reordering process, with delays attributed to the need for manual reordering and waiting for physician signatures. The Assistant Director of Nursing confirmed that missed doses of pain medication could lead to increased pain for residents and acknowledged the lack of documentation regarding physician notification or pain management referrals for Resident 1.
Failure to Document Change in Condition and Correctly Transcribe Medication Order
Penalty
Summary
The facility failed to document a change in a resident's condition before starting Lorazepam and ensure the correct transcription of the physician's order. Resident 1, diagnosed with Parkinson's disease, was prescribed Lorazepam 1 mg twice a day without any documented change in condition or behavioral symptoms. The medical record lacked documentation of the resident's behavior and the interventions attempted before the medication was ordered. The Lorazepam was administered routinely from 4/20/24 to 4/29/24 without proper documentation or monitoring of the resident's behavior. Licensed Nurse (LN) 1 and LN 2 were involved in the transcription and administration of the Lorazepam order. LN 1 transcribed the order based on a verbal communication from LN 2, who had received the order from the Nurse Practitioner (NP). However, LN 2 did not document the change in condition or the event leading to the medication order. The Assistant Director of Nursing (ADON) confirmed that the order was intended to be as needed, not routine, and that LN 1 had transcribed it incorrectly. The facility's policies on psychotropic medication use and documenting changes in resident condition were not followed, leading to the potential for unnecessary medication administration without proper monitoring.
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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