Country Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cajon, California.
- Location
- 1580 Broadway, El Cajon, California 92021
- CMS Provider Number
- 555431
- Inspections on file
- 46
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Country Hills Post Acute during CMS and state inspections, most recent first.
A resident went four days without a documented bowel movement, despite having a standing order for magnesium hydroxide to be given if no bowel movement occurred for three days. Nursing staff did not administer the ordered medication, and there were no progress notes addressing the resident’s bowel status or constipation management during this period. The resident was later admitted to a hospital with altered mental status, UTI, and fecal impaction. In an interview, the DON confirmed that the laxative should have been started after three days without a bowel movement and that the facility lacked a constipation management policy.
Surveyors found significant medication errors involving fentanyl patches and resident identification. An LVN applied a fentanyl transdermal patch ordered for one resident to another opioid‑naïve resident who had no fentanyl order, and the intended resident did not receive the ordered patch, resulting in a medication omission. In a separate observation, an LVN applied a new fentanyl patch to a resident without performing a full skin check to verify removal of the previous patch, despite EMAR documentation that a prior patch should have been present. Additionally, an LVN administered multiple medications, including oral drugs, eye drops, and lidocaine patches, to a cognitively intact resident without verifying identity, even though the resident lacked an ID band and facility policy required positive identification before medication administration. These failures led to an Immediate Jeopardy determination for noncompliance with safe medication administration practices.
A resident with dementia, severe cognitive impairment, and total dependence for ADLs, who was on 1:1 monitoring, struck a CNA during toileting and was transferred to the hospital for aggressive behavior. Facility staff reported this was the first known physical assault, though the resident had prior impulsive and verbally disruptive behaviors. After the transfer, the DON refused the resident’s return based on perceived unstable behavior and provided a cell number to the hospital, but there were no subsequent attempts by facility staff to contact the hospital for updates or to reassess the resident’s current condition. The ADMIN confirmed the transfer was for stabilization, not a discharge, and acknowledged the facility did not permit the resident to return and had no documented efforts to determine readiness for return, contrary to the facility’s bed-hold and return policy.
A resident had an order for a fentanyl transdermal patch for pain, but the medication was not delivered on the date it was first ordered. The MAR entry for that date was coded to indicate an exception, and a nurse's note documented that the facility was awaiting delivery. However, a nurse later documented on the MAR that a fentanyl patch was removed from the resident, even though, according to the DON and the controlled drug record, no patch had ever been applied. This resulted in inaccurate documentation that did not comply with the facility's policy requiring objective, complete, and accurate charting.
A non-verbal resident with Alzheimer's disease and severe cognitive deficits was found with an unwitnessed bruise of unknown origin on the left eye. Nursing staff identified the discoloration as a change in skin condition and considered it an injury of unknown origin, possibly related to contact with a padded bed rail, but there was no documentation that the incident was reported to CDPH, the Ombudsman, or law enforcement within required timeframes. The DON and Administrator acknowledged that the facility did not make the required reports, relying instead on a police officer’s conclusion that there was no evidence of abuse, despite facility policy and staff statements that such injuries must be reported immediately to appropriate authorities.
A resident with severe cognitive impairment and dementia allegedly grabbed and squeezed a cognitively intact roommate’s arms while reaching for a wheelchair between their beds, leading to the resident’s transfer to another floor. However, the CNA and LPN assigned to the transferred resident on the new unit were not informed of the prior altercation or the resident’s aggressive behavior, despite other staff acknowledging that assigned CNAs should know about such incidents to monitor behaviors and prevent further altercations. This lack of communication occurred despite a facility abuse-prevention policy stating residents have the right to be free from abuse, including from other residents.
A resident with multiple medical conditions authorized a family member to access his medical records. The family member requested to review the records in person after declining to pay for copies, but the facility insisted on charging a fee for both copies and in-person review. As a result, the family member was not able to review the records, and the resident's right to access his medical records was violated.
During a call light system outage, the facility did not ensure that residents had access to an alert system, with many not receiving manual call bells or having them placed out of reach. This affected numerous residents, including those with cognitive impairment, limited mobility, and a history of falls, leaving them unable to reliably summon staff for assistance.
A nurse prepared a set of medications for one resident and handed them to a new graduate nurse, who, due to miscommunication, administered the medications to the wrong resident. The error resulted in a resident receiving 17 medications not prescribed for her, including blood pressure, seizure, and pain medications. Staff interviews confirmed that the process used did not follow facility policy or standard medication administration protocols.
A resident with a history of cerebral infarction and hypertension was mistakenly given her roommate's medications, totaling 17 drugs, after a miscommunication between two nurses during a medication pass. The error occurred when one nurse prepared medications and another, who was new and in training, administered them to the wrong resident, contrary to facility policy and standard medication administration protocols.
A resident with a history of cerebral infarction and hypertension was mistakenly given 17 medications intended for her roommate after a nurse prepared the medications and handed them to another nurse in training, who misunderstood instructions and failed to verify the resident's identity. Both nurses did not follow the facility's medication administration policy, resulting in a significant medication error.
Kitchen staff did not maintain sanitary food practices, as evidenced by dirty drying racks and carts, dust-covered sprinkler heads above the stove, improper use of beard nets by a dishwasher, and a dishwasher aide failing to wash hands after handling trash. These lapses were acknowledged by staff and were not in accordance with facility policies on sanitation and hygiene.
Several dependent residents with cognitive and physical impairments were fed by staff who stood over them rather than sitting at eye level, contrary to facility policy and best practices for promoting dignity and respect. Staff and leadership interviews confirmed that feeding should occur at eye level, but lack of available chairs and inconsistent adherence to policy led to this deficiency.
Multiple residents were inaccurately assessed and reported in the MDS, including errors in documenting serious mental illness, tobacco use, anxiety diagnosis, urinary catheter presence, and dialysis treatment. These inaccuracies were confirmed by the MDSC and DON, who acknowledged that the assessments did not reflect the residents' true clinical status as required by facility policy and CMS guidelines.
Three residents were not notified or invited to participate in their care conferences with the IDT, and there was no documentation of notification or declination. Residents reported not being asked to join care conferences, and staff confirmed that residents should have been given the opportunity to participate and provide input on their care plans.
The facility did not properly set low-air loss mattresses for five residents at risk for pressure ulcers, either failing to adjust the settings to match actual resident weight or to accommodate comfort for those able to express preferences. Observations showed mattresses set at incorrect or maximum settings, with no documentation of individualized assessment or care plan updates, placing residents at risk for skin breakdown and injury.
Staff failed to properly label and discard perishable food items in resident refrigerators, with multiple items found without dates or use-by information. Licensed nurses, the dietary manager, and the registered dietician demonstrated inconsistent understanding of their responsibilities, and the facility's policy requiring labeling and timely disposal was not followed.
Four residents were not properly informed about the binding arbitration agreement, with staff failing to explain its meaning, provide copies, or inform them of their right to decline within 30 days. Some residents signed under pressure or while cognitively impaired, and documentation of explanation or acknowledgment was lacking, contrary to facility policy.
The QAA committee did not identify or include several trends found by surveyors—such as delayed call light response, smoker management, RD recommendations, kitchen hygiene, RD kitchen audits, resident care conferences, and low air loss mattress settings—in the facility's QAPI plan. The ADM and DON confirmed these issues were not part of the current QAPI focus areas and were not previously recognized.
A resident with functional quadriplegia and contracted hands was unable to use the standard call button provided, as it required gripping and pressing with the thumb. Despite being care planned to use the call light for assistance, the resident had to yell for staff due to the lack of an appropriate adaptive device. Nursing staff and leadership acknowledged the need for a tap call button, but the necessary accommodation was not made.
A hospice resident and their family reported that the shared bathroom was persistently dirty, with feces on the floor, walls, toilet seat, and faucet cover, as well as a strong feces-like odor. Staff placed stained draw sheets and shower blankets on the floor for convenience in cleaning up after a roommate's incontinence, which both staff and the DON acknowledged created unsanitary and potentially hazardous conditions. These practices did not meet the facility's policy for a clean, sanitary, and homelike environment.
A resident's MDS assessment data was not submitted to the federal database within the required 14-day period after completion and signature by the RN Assessment Coordinator. The delay was confirmed through record review and interviews, with staff acknowledging the importance of timely MDS submission for accurate federal reporting.
A resident with ESRD was not provided with a comprehensive care plan that included the requirement for staff to accompany them to dialysis, despite this instruction being present in the medical record and facility policy. The resident was observed returning from dialysis unaccompanied on multiple occasions, and both the IP and DON confirmed the omission in the care plan.
A resident with significant physical and cognitive impairments was found with long, unclean fingernails due to staff failing to provide routine nail care as required. Staff interviews revealed confusion about responsibilities and procedures for nail care, and the facility's policy for daily cleaning and regular trimming was not followed.
Two residents were placed at risk when staff placed linens on a bathroom floor, creating a slip hazard for a resident with a history of falls, and failed to complete a timely smoking assessment for another resident with nicotine dependence and cognitive deficits. Staff acknowledged the hazards, and facility policies for fall prevention and resident assessment were not followed.
A resident with dysphagia and pressure ulcers experienced significant, progressive weight loss, but staff failed to consistently obtain weekly weights as recommended by the RD. Despite facility policy requiring ongoing monitoring, there were gaps in weight documentation and no clear guidance on following RD recommendations, resulting in inadequate tracking of the resident's nutritional status.
Two residents with ESRD did not receive dialysis care according to physician orders and special instructions. One resident's post-dialysis dressing was not removed within the required timeframe, and there was no RN assessment or care plan addressing this need. Another resident, who required staff accompaniment to dialysis, was sent unaccompanied, and this requirement was not included in the care plan. Facility staff confirmed these lapses and acknowledged that care plans and orders were not followed.
A resident's Ipratropium-Albuterol solution vials were found unlabeled, undated, and unpackaged in a bedside drawer, with the resident self-administering the medication in the evenings. Staff confirmed that medications were not stored according to manufacturer guidelines or facility policy, and there was no physician order for self-administration. The vials were not kept in protective foil pouches and were not dated, making it unclear how long they had been stored.
Staff did not sanitize a blood pressure cuff between use on different residents, instead cleaning it only after all vital signs were taken. The facility's policy lacked clear guidance on the frequency of sanitizing non-critical items. Additionally, the Infection Prevention and Control Program policy was not updated annually as required, with the most recent update occurring over a year prior.
Two residents were found without functional call buttons, one due to physical limitations that made the standard button unusable and another due to a broken device that was not reported or repaired. Staff and management confirmed that facility policy required functional call systems or alternatives for residents unable to use standard devices, but these procedures were not followed, resulting in the residents being unable to communicate their needs.
A resident room was found to have both live and dead cockroaches, with a resident reporting widespread pest activity and food stored around dressers. Staff interviews confirmed the expectation for pest-free rooms and outlined a process for reporting pests, but no record of the issue was found in the maintenance log. The facility's pest control service had previously noted pest activity in the same room, yet the deficiency persisted.
A resident with dementia sustained a skin tear while being assisted by a CNA, leading to an uninvestigated allegation of staff-to-resident abuse. Despite documentation and communication among staff, the incident was not reported to authorities or investigated, contrary to facility policy. The lack of action left all residents at risk for potential harm.
A resident with Parkinson's disease was inaccurately assessed for language preference in the MDS, leading to incorrect information being sent to CMS. The resident, who preferred Spanish, was listed as preferring English, and a Spanish communication board was missing from their room. The MDSN acknowledged the error, and the DON expected accurate MDS information.
The facility failed to ensure kitchen staff competently carried out food and nutrition services, leading to improper dish machine sanitizing and incorrect cool down processes for cooked meats. These lapses had the potential to expose residents to foodborne illnesses.
The facility failed to maintain safe and sanitary conditions in the kitchen and resident nourishment areas, leading to potential food contamination. Observations revealed dirty floor sink drains, a broken refrigerator thermometer, unclean kitchen tools, worn cutting boards, and expired food items in resident refrigerators. Staff acknowledged the need for proper cleaning and disposal of expired items.
The facility failed to follow infection control protocols, including improper hand hygiene and PPE use by staff, handling meal trays without sanitizing hands, and not providing a resident with appropriate hand hygiene options due to a non-functioning sink.
The facility failed to ensure the kitchen and resident areas were free of pests, including flies, gnats, and roaches. Observations revealed a dirty kitchen with flies, fruit flies near a resident refrigerator, and a dead roach in another resident's refrigerator. Interviews confirmed ongoing pest control issues despite efforts to address them.
A resident with moderately impaired cognition was observed using a bedpan washer to rinse his hands in the toilet reservoir tank due to a nonfunctioning sink in his room. The issue, which persisted for at least three weeks, was not reported or followed up on by staff, leading to an unhomelike environment and potential infection control problems.
A facility failed to develop a comprehensive care plan for a resident's AV fistula used for dialysis. The care plan only addressed infection signs and symptoms but did not include assessments for thrill or bruit to ensure functionality or specify when to remove the post-dialysis dressing. This oversight could delay the identification of issues with the AV fistula.
The facility failed to develop patient-centered care plans for two residents, one with a left hand contracture and bilateral foot drop, and another with PTSD. The lack of comprehensive care plans had the potential to result in unmet care and service needs.
A resident experienced a severe weight loss of 18.4% over six months due to the facility's failure to ensure appropriate nutritional parameters. Despite the resident's low intake of the renal diet, timely adjustments were not made, and the Director of Nursing was unaware of the severe weight loss. The facility's policies for weight assessment and intervention were not adequately followed, leading to potential risks for further nutritional decline.
The facility failed to provide Trauma Informed Care for a resident with PTSD, resulting in an inability to identify triggers that could lead to re-traumatization. Staff were unaware of the resident's specific triggers and had not received instructions on managing the resident's behaviors. The facility's policy on trauma-informed care was not followed, highlighting a significant gap in care.
The facility failed to meet the minimum PPD and CNA PPD requirements on multiple days, with staffing postings not updated to reflect actual numbers, potentially resulting in residents not receiving adequate care.
The facility failed to ensure a nurse was assessed for competency in medication administration, resulting in the incorrect administration of medications to a resident. The DON confirmed that neither the staffing agency nor the facility had assessed the nurse's competency.
The facility failed to post actual daily staffing, only displaying projected staffing, which was not updated to reflect changes throughout the day. This resulted in residents and visitors being unaware of the actual staff present.
The facility failed to follow medication orders for two residents. One resident did not receive prescribed insulin on multiple occasions without notifying the physician, and another resident was given oxycodone for pain levels below the prescribed threshold. Both the DON and ADON confirmed the importance of following physician orders and notifying the physician if orders are not followed.
The facility failed to ensure that two residents were not prescribed Trazodone for a non-FDA approved indication. Both residents were given Trazodone to treat insomnia, not depression, and there was no evidence that other causes for their inability to sleep were ruled out or that non-drug therapies were attempted. The prescribed dosages also did not align with the manufacturer's guidelines for treating major depressive disorder.
A facility failed to maintain a medication error rate below five percent, resulting in a 12.5 percent error rate. A resident did not receive scheduled pain medications due to a nurse's incorrect assumption that the medications were to be given on an as-needed basis. The resident did not refuse the medications and was unaware they were not administered.
The facility failed to follow the Pureed diet menu as printed, serving mashed potatoes and regular diet stuffing instead of pureed dressing to residents on a pureed diet. This discrepancy was observed during meal service, and the Registered Dietitian confirmed that the kitchen staff is expected to follow approved menus and recipes.
The facility did not ensure that food was palatable and served according to policy, potentially affecting residents' nutritional intake. Observations revealed that pureed meals had incorrect textures and flavors, and the kitchen staff did not follow approved recipes.
Failure to Administer Ordered Constipation Treatment Leading to Fecal Impaction
Penalty
Summary
The facility failed to provide treatment and care according to physician orders when staff did not respond to a resident’s lack of bowel movements for four consecutive days. The resident was admitted with diagnoses including muscle weakness, and documentation showed the last recorded bowel movement occurred on 2/22/26, with no bowel movements recorded on 2/23, 2/24, 2/25, or 2/26. The resident had a standing order dated 11/10/25 for magnesium hydroxide to be administered if no bowel movement occurred for three days, but the Medication Administration Record showed the medication was not given on those four days. The facility’s progress notes contained no documentation between 2/22/26 and 2/26/26 regarding the resident’s bowel status or any offer or administration of magnesium hydroxide. On 2/27/26, a nurse’s note recorded that the resident had been admitted to a general acute care hospital with diagnoses including altered mental status, urinary tract infection, and fecal impaction. In a subsequent interview, the DON stated that nursing staff should have started magnesium hydroxide on 2/25/26 and acknowledged the facility did not have a policy on managing constipation.
Significant Medication Errors Involving Fentanyl Patches and Resident Identification
Penalty
Summary
The deficiency involves multiple significant medication errors related to fentanyl transdermal patch administration and resident identification. One resident with COPD, dependence on renal dialysis, Alzheimer’s disease, memory problems, and severely impaired cognitive skills was found by a hospital to have a fentanyl patch on admission, despite having no physician order for fentanyl and only being prescribed acetaminophen at the facility. The DON reported that an internal investigation determined that on 3/3/26 an LVN assigned as the medication nurse for this resident and another resident applied the other resident’s ordered fentanyl patch to this resident’s chest while providing care. On 3/4/26, the resident experienced a change in condition with increased work of breathing, low oxygen saturation, tachypnea, tachycardia, crackles in bilateral lung fields, and weak cough, leading to emergency transfer to an acute care hospital, where the fentanyl patch without an order was discovered and reported back to the facility. A second resident, admitted with traumatic subarachnoid hemorrhage, a history of falls, a diagnosis of pain, and severe cognitive impairment, was on hospice services and had a physician’s order for a fentanyl transdermal patch every 72 hours for pain and comfort. The DON stated that on 3/3/26 this resident was scheduled to receive a fentanyl patch, but the patch intended for this resident was instead applied to the first resident. The LVN later acknowledged that he had Resident 2’s fentanyl patch with him while changing the first resident’s gastrostomy tube dressing and did not administer the ordered fentanyl patch to the correct resident, resulting in a medication omission. Another LVN reported that on 3/4/26 she was informed the second resident had not received the fentanyl patch on 3/3/26, and a skin check revealed no fentanyl patch on the resident, confirming the omission. A further deficiency occurred during a medication administration observation for the second resident when an LVN prepared a fentanyl transdermal patch and, according to the EMAR, expected to find a previously applied patch on the resident’s right arm that needed removal before applying a new patch. During administration, the LVN applied a new fentanyl patch to the right side of the resident’s chest after failing to locate a patch on the right or left arm and did not perform a full body or skin check to verify whether a prior patch remained in place, despite acknowledging that the purpose of removal was to prevent the resident from receiving too much fentanyl. Additionally, during a separate medication pass for a third resident with chronic pain, type 2 diabetes, and intact cognition, the same LVN administered multiple oral medications, eye drops, and lidocaine patches without verifying the resident’s identity. The resident was not wearing an identification band, and the LVN did not use alternative identification methods such as checking the photograph in the EHR or confirming identity with other staff, contrary to facility policy requiring verification of resident identity before medication administration. Surveyors determined that these failures to correctly identify residents before administering medications, to ensure medications were given only as ordered, to avoid administering one resident’s fentanyl patch to another resident without an order, to ensure an ordered fentanyl patch was not omitted, and to verify removal of a previously applied fentanyl patch before applying a new one constituted significant medication errors. The facility’s own fentanyl drug reference materials described fentanyl as a very strong opioid narcotic with a high potential for fatal overdose due to respiratory depression, and the pharmacy consultant noted that the first resident was opioid naïve and at higher risk for respiratory depression, sedation, and confusion when given fentanyl. The survey team notified the facility of Immediate Jeopardy related to the failure to identify the correct resident prior to administering a fentanyl patch and the failure to verify the location of a previously administered fentanyl patch before applying a new one, which placed the involved residents at risk for serious injury, harm, impairment, or death.
Removal Plan
- Medical Records conducted a sweep of all residents who were receiving narcotic pain patches.
- The Assistant Director of Nursing conducted a visual check to ensure narcotic pain patches were applied as ordered.
- The Medical Records Department conducted a facility-wide sweep for residents' identification bands.
- Residents who did not have an identification band were provided with one containing: name, date of birth, doctor's name, facility address, and facility phone number.
- Licensed nurses are required to check for the location of narcotic pain patches every shift so missing patches are identified prior to the next administration date.
- All licensed nurses were required to attend an in-service prior to administering any medications.
Failure to Allow Hospitalized Resident to Return Under Bed-Hold and Return Policy
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a hospitalization, contrary to the facility’s bed-hold and return policy and the resident’s right to return. The resident had psychotic disorder with hallucinations due to a physiological condition and dementia, with a BIMS score of 6 indicating severe cognitive impairment, and was dependent on staff for all ADLs and bed mobility. She had been on 1:1 monitoring and required two staff for all ADLs. During toileting assistance, the resident swung her fist and struck a CNA in the face, then continued to come toward staff while yelling for them to get out of the room. Staff did not leave because of the 1:1 monitoring requirement. Facility staff, including the DON and SSD, reported this was the resident’s first known incident of physical assault, although she had a history of confusion, impulsive behavior, yelling at staff, and attempting to stand unassisted. Following this incident, the resident was sent to the hospital for physically aggressive behavior. The DON stated that on the day after transfer, the facility refused to accept the resident back because they believed her behaviors had not been stabilized, and the DON provided her cell phone number to the hospital with the statement that once the resident was stable, the facility would take her back. The DON also stated that after that date, she did not know of any attempts by facility staff to contact the hospital for updates on the resident’s status. The Administrator confirmed that the transfer was for stabilization and not considered a discharge, acknowledged the facility did not allow the resident to return because of the assaultive behavior, and stated there were no documented attempts to contact the hospital to determine if the resident had been stabilized or was ready to return. The facility’s “Bed-Holds and Returns” policy indicated that following hospitalization, residents whose return is in question due to clinical or behavioral concerns are to be evaluated based on their current condition, not their condition at the time of transfer, which was not followed in this case.
Inaccurate MAR Documentation of Fentanyl Patch Removal
Penalty
Summary
The deficiency involves inaccurate medical record documentation related to a fentanyl transdermal patch order for Resident 2. The resident had an order initiated on 2/25/26 for a 12 mcg/hr fentanyl patch to be applied every 72 hours for pain/comfort and removed per schedule. On the February 2026 MAR, the administration entry for 2/25/26 at 12:24 P.M. was coded with "9," which the MAR legend defined as "Other/ See Nurses Notes." A progress note entered at 12:25 P.M. by LN 4 documented that the facility was awaiting delivery of the fentanyl patch, and the DON later confirmed that Resident 2 did not receive a fentanyl patch on 2/25/26 because the medication was not delivered until 2/28/26. Despite the absence of an applied patch, Resident 2's February 2026 MAR showed an entry on 2/28/26 at 11:56 A.M. indicating that a fentanyl patch was removed. During interviews, the DON stated that, based on the controlled drug record, the fentanyl patch had not been applied on 2/25/26 and therefore there was no patch to remove on 2/28/26. The DON confirmed that LN 1 documented removal of the fentanyl patch on the MAR and acknowledged that this documentation was not accurate. The facility's Charting and Documentation policy, revised July 2017, requires that documentation in the medical record be objective, complete, and accurate, which was not followed in this instance.
Failure to Report Injury of Unknown Origin to Required Authorities
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for one resident to the California Department of Public Health (CDPH), the Ombudsman, and law enforcement, as required by its abuse reporting policy. The resident had a history of Alzheimer's disease and was documented on the MDS as rarely or unable to understand others or make herself understood, with severe cognitive deficits affecting decision-making. Nursing staff identified a change in skin condition with discoloration to the resident's left eye, described as a bruise of unknown origin, and the injury was unwitnessed. Despite this, there was no documentation that the incident was reported to the required external entities within the mandated timeframe. Interviews with facility staff confirmed that the DON, Administrator, and Social Services Director were aware of the injury and considered it an injury of unknown origin, with staff speculating it may have occurred when the resident leaned her head against a padded bed rail. The DON and Administrator stated the facility did not report the incident because they relied on an El Cajon Police Department officer’s conclusion that there was no evidence of abuse, even though the officer had been notified of the injury through an external report and not by the facility. The Social Services Director and a licensed nurse both acknowledged that injuries of unknown origin should be reported to CDPH, law enforcement, and the Ombudsman within required timeframes, and the facility’s written policy stated that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the administrator and other officials according to state law. Nonetheless, the required reports were not made by the facility.
Failure to Inform Staff of Resident-to-Resident Altercation and Abuse Allegation
Penalty
Summary
The facility failed to ensure thorough investigation and appropriate corrective action of an abuse allegation following a resident-to-resident altercation involving Resident 1 and Resident 6. Resident 1, who had severe cognitive impairment with a BIMS score of 5 and diagnoses including unspecified dementia, was alleged in the psychosocial care plan dated 1/5/26 to have grabbed her roommate’s wrists and hands and squeezed them hard after attempting to use the roommate’s wheelchair. Resident 6, who had intact cognition with a BIMS score of 14 and diagnoses including abnormality of gait and mobility, reported to the Social Service Assistant that her roommate grabbed her arm while reaching for a wheelchair positioned between their beds. The Assistant Director of Nursing stated Resident 1 was transferred from the fourth floor to the third floor due to this altercation. Despite this, key direct-care staff on the receiving unit were not informed of the incident or the behavior. The CNA assigned to Resident 1 on the third floor stated she did not know why Resident 1 was transferred and only reported that Resident 1 had episodes of anger and grabbing staff. The licensed nurse assigned to Resident 1 on the third floor similarly stated she did not know the reason for the transfer. Another CNA stated that the CNA assigned to a resident involved in an altercation should know about the incident in order to monitor the resident with the behavior and prevent another altercation. The Social Service Assistant and the ADON both stated that staff should be aware of such incidents and resident behaviors for safety reasons. The facility’s abuse, neglect, exploitation, and misappropriation prevention policy indicated residents have the right to be free from abuse and that the program is intended to protect residents from abuse, including from other residents, but staff on the new unit were not made aware of the prior altercation or behavior.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident's family member, despite having proper authorization. The resident, who had diagnoses including heart failure, deafness, and parkinsonism, authorized his family member to access his medical records on two separate occasions. The family member initially requested copies of the records but declined to pay the associated fees. When the family member then requested to review the records in person without obtaining copies, the facility informed him that he would still be required to pay a fee to review the records. As a result, the family member was not able to review the resident's medical records at the facility. Interviews and record reviews confirmed that the facility's policy allowed residents to request access to their records, but the policy did not specify the required timeframe for making records available. Despite the family member's written request to inspect the records in person, the facility maintained that a fee would be charged for both copies and in-person review, and did not provide access within 24 hours as required. This resulted in the resident and his family member being unaware of the details of his medical record, constituting a violation of the resident's right to access his medical records.
Failure to Provide Accessible Call System During Outage
Penalty
Summary
The facility failed to provide an alert call system for 20 out of 44 residents after the electronic call system on Station 3 North stopped working. This deficiency was identified during an unannounced visit following a complaint about non-functioning call lights. Observations revealed that multiple residents, including those with significant cognitive and physical impairments, did not have access to either the electronic call system or manual call bells at their bedsides. In several cases, manual call bells were not present or were placed out of reach, preventing residents from being able to summon staff for assistance. Interviews with facility staff, including the DON, Administrator, and Director of Maintenance, confirmed that the electronic call light system had been out of service for several days. While efforts were made to procure and distribute manual call bells, documentation and staff interviews indicated that not all residents received them, and some bells that were distributed were subsequently missing or inaccessible. The Director of Staff Development stated that staff were instructed to check on residents every 30 minutes, but there was no documentation of these checks, and staff were unaware of the whereabouts of missing call bells. Residents affected by the deficiency included individuals with a range of medical conditions such as stroke, Parkinson's disease, COPD, dementia, and sepsis. Many of these residents had impaired cognition, limited mobility, or were dependent on staff for daily activities. Some had a history of falls within the facility. The lack of a functioning call system or accessible manual call bells left these residents without a reliable means to request assistance, as observed during the surveyor's room rounds.
Medication Administration Error Due to Staff Miscommunication and Policy Deviation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in medication administration, resulting in a medication error involving one resident. On the date of the incident, a nurse (LN 3) prepared medications intended for one resident but handed them to another nurse (LN 4), who was a new graduate and in orientation. Due to miscommunication, LN 4 administered the medications to the wrong resident, giving a full set of 17 medications prescribed for a different resident to the affected individual. The medications included blood pressure medications, blood thinners, seizure medications, pain medications, and other treatments not prescribed for the recipient. The error occurred in a shared room where the two residents had similar medical histories, including conditions such as cerebral infarction, hypertension, hemiplegia, and hemiparesis. LN 3 labeled the medication cup with the intended resident's name but did not personally administer the medications, instead instructing LN 4 to do so. LN 4 misunderstood the instructions and gave the medications to the wrong resident. The error was discovered when the intended recipient noticed discrepancies in her medication cup and reported it to the staff. Interviews with staff revealed that the process of one nurse preparing medications for another to administer was not in accordance with facility policy or standard medication administration protocols, which require verification of the five rights (right resident, right drug, right dose, right route, right time). The facility's policy explicitly states that medications ordered for a particular resident may not be administered to another resident, and that the individual administering medications must verify the resident's identity and check the medication label three times.
Medication Administration Error Due to Failure to Follow Protocols
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error involving one resident. A resident with a history of cerebral infarction and hypertension was incorrectly given her roommate's medications, which included a total of 17 different drugs not prescribed for her. This error was discovered during a review of the resident's progress notes and care plan, which documented the administration of medications intended for another resident who had hemiplegia and hemiparesis following a cerebral infarction. The incident occurred when a nurse (LN 3) prepared medications for one resident and labeled the medication cup accordingly, then handed the cup to another nurse (LN 4), who was new and in training. Due to a miscommunication, LN 4 administered the medications to the wrong resident. LN 4 believed she was giving the medications to the correct person based on instructions, but later realized the error after the intended recipient questioned the contents of her medication cup. Interviews with staff revealed that the process of one nurse preparing medications for another to administer was not standard practice and contributed to the error. Further interviews with facility staff and the consultant pharmacist confirmed that proper medication administration protocols were not followed, specifically the verification of the five rights (right resident, right drug, right dose, right route, right time). The facility's pharmacy policy also required that medications be administered directly to the intended resident by the person who prepared them, which was not adhered to in this case.
Medication Error Due to Improper Administration and Communication
Penalty
Summary
A significant medication error occurred when a resident with a history of cerebral infarction and hypertension was administered medications intended for her roommate, who had diagnoses of hemiplegia and hemiparesis following cerebral infarction. The error took place during a medication pass when a nurse (LN 3) prepared medications for one resident and handed them to another nurse (LN 4), who was in training. Due to miscommunication, LN 4 administered the medications to the wrong resident, resulting in the resident receiving 17 medications not prescribed for her, including blood pressure medications, blood thinners, seizure medications, pain medications, and others. Interviews with nursing staff revealed that the standard procedure for medication administration was not followed. LN 3 admitted to preparing medications and giving them to another nurse to administer, a practice she had observed but was not consistent with facility policy. LN 4, a new graduate nurse, misunderstood instructions and administered the medications to the wrong resident. Both nurses failed to verify the resident's identity and did not adhere to the five rights of medication administration (right resident, right drug, right dose, right route, right time). The facility's policy clearly states that medications must be administered by the individual who prepares them and that resident identity must be verified before administration. The incident was confirmed through interviews, record reviews, and observation, with the resident who received the wrong medications reporting no awareness of the error and no change in condition at the time of the survey. The error was reported to facility leadership and the consultant pharmacist, who confirmed the risk associated with the medications administered.
Failure to Maintain Sanitary Food Practices in Kitchen
Penalty
Summary
Kitchen staff failed to maintain sanitary food practices in several areas. Observations revealed that drying racks and a drying cart used for air-drying pots and pans were visibly dirty, with debris and grit that could be removed by a finger swipe. The Dietary Manager acknowledged the unclean conditions and was unable to provide a checklist documenting deep cleaning tasks. Additionally, the sprinkler heads above the stove were covered in dust, which the Dietary Manager confirmed could fall onto food during preparation, leading to cross contamination. These findings were inconsistent with the facility's sanitation policy, which requires all equipment, food contact surfaces, and utensils to be kept clean and sanitized. Further deficiencies included a dishwasher not wearing a beard net properly, with the net hanging around his neck instead of covering his beard, and a dishwasher aide failing to wash hands after removing trash and reentering the kitchen before handling dishes. Both staff members admitted to forgetting these required hygiene practices, which are outlined in the facility's policies. The Registered Dietician and Director of Nursing both stated expectations for cleanliness, proper use of hair and beard nets, and handwashing upon entering the kitchen. However, a review of kitchen staff training and a recent kitchen audit indicated incomplete documentation and oversight of these practices.
Failure to Promote Dignity During Feeding Assistance
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity and respect for five out of thirteen residents reviewed for dignity. Multiple residents with diagnoses such as dysphagia, dementia, Parkinson's disease, and end stage renal disease, all of whom required assistance with activities of daily living and feeding, were observed being fed by staff who were standing rather than seated at eye level. This practice was observed both in the dining room and in residents' rooms, with staff standing over residents while feeding them, contrary to the facility's own policies and procedures. Certified Nurse Assistants (CNAs) and Licensed Nurses (LNs) involved in feeding these residents acknowledged during interviews that staff should be seated at eye level with residents during feeding to promote communication, dignity, and respect. Staff reported that there were no chairs available in the dining room for use during feeding, and both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that staff should not have been standing while feeding residents. The DON emphasized that this expectation applied regardless of the resident's cognitive status. Facility policy and procedure documents reviewed indicated that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, specifically stating that staff should not stand over residents while assisting them with meals. Despite this, observations and staff interviews confirmed that the practice of standing while feeding dependent residents was occurring, resulting in a failure to honor residents' rights to dignity and respect during mealtimes.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately assess and transmit Minimum Data Set (MDS) assessments for five residents, resulting in incorrect information being reported to the Centers for Medicare and Medicaid Services (CMS). For one resident with diagnoses of paranoid schizophrenia and bipolar disorder, the MDS was coded as not having a serious mental illness, despite documentation and staff acknowledgment of these conditions. Facility policy required all staff completing any portion of the MDS to attest to its accuracy, but this was not followed in this case. Another resident, identified as a tobacco user requiring supervision while smoking, was incorrectly coded as a non-smoker on the MDS, despite care plans and direct observation confirming tobacco use. The Minimum Data Set Coordinator (MDSC) and Director of Nursing (DON) both acknowledged the error, noting that the resident's tobacco use was not captured as required by assessment protocols. Similarly, a resident with a diagnosis of anxiety and prescribed anti-anxiety medication was not coded as having an active anxiety diagnosis on the MDS, even though care plans and physician orders supported the diagnosis. Additional deficiencies included a resident with an indwelling urinary catheter not being coded as such on the MDS, despite medical records and staff interviews confirming the presence of the catheter. Another resident with chronic kidney disease and a history of dialysis was inaccurately coded on quarterly MDS assessments as not receiving dialysis, even though physician notes and prior MDS assessments indicated otherwise. In each case, the MDSC and DON confirmed the inaccuracies and referenced facility policy and CMS requirements for accurate assessment and reporting.
Failure to Notify and Involve Residents in Care Conferences
Penalty
Summary
The facility failed to notify or invite residents and/or their responsible parties to participate in care conferences, as required for the development and review of comprehensive, person-centered care plans. During interviews with three residents, each stated they were not informed, invited, or asked to join care conferences with the interdisciplinary team (IDT) to provide input on their preferences or receive updates about their care plans. Instead, residents reported that IDT members would speak to them individually, but not as a group in a formal care conference setting. Record reviews confirmed that there was no documentation showing these residents were notified or declined to attend their scheduled care conferences. The Social Service Director (SSD) and Director of Nursing (DON) both acknowledged that residents and/or their responsible parties should have been given the opportunity to participate in care conferences to ensure their preferences and concerns were included in their care plans. Facility policy also required residents to be informed of their right to participate in care planning and to receive advance notice of care conferences. The lack of notification and participation documentation for the residents reviewed demonstrated a failure to promote person-centered care planning and to update care plans according to resident input.
Failure to Individualize Low-Air Loss Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to properly set low-air loss mattresses (LALM) according to manufacturer weight recommendations and/or resident comfort for five residents at risk for pressure ulcers. Observations and interviews revealed that LALM settings were not consistently aligned with either the residents' actual weights or their expressed comfort preferences, as appropriate for their cognitive status. For example, one cognitively intact resident repeatedly reported discomfort and the need to use extra pillows and blankets, while her LALM was set at weights significantly higher than her actual weight, and there was no documentation of comfort testing or care plan updates to reflect her preferences. Other residents with cognitive deficits or who were unable to express their comfort had LALM settings that did not correspond to their actual weights. In several cases, the mattresses were set to the maximum weight setting, far exceeding the residents' actual weights, without any documented rationale or adjustment. Licensed nurses and the DON confirmed during interviews that the LALM should be set according to weight for residents unable to express comfort, and according to comfort for those who are cognitively intact, but this was not consistently practiced or documented. Facility policy and manufacturer guidelines both indicated that LALM settings should be adjusted to minimize tissue damage, promote comfort, and prevent skin breakdown. However, record reviews showed a lack of documentation regarding individualized comfort assessments or care plan updates for LALM settings. The deficient practice placed the affected residents at risk for skin breakdown and injuries, as the support surfaces were not properly individualized based on either weight or comfort as required.
Failure to Label and Discard Perishable Food in Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of perishable food items stored in resident refrigerators, as observed during multiple interviews and inspections. In three out of six resident refrigerators, food items such as sushi, spinach/artichoke dip, strudel, fudge cookies, a meat and vegetable meal, raspberries, and Mexican food were found without appropriate labeling of the date they were placed in the refrigerator or a use-by date. Licensed nurses acknowledged that these items should have been dated and discarded according to policy, but this was not done. Some food items appeared old or dehydrated, and receipts or labels did not consistently include all required information. Interviews with staff, including licensed nurses, the dietary manager, the registered dietician, and the director of nursing, revealed a lack of clarity and consistency regarding responsibility for monitoring and discarding perishable food. The dietary manager and registered dietician stated they did not inspect resident refrigerators, while the director of nursing indicated that licensed nurses were responsible for checking and discarding food every shift, with a maximum storage time of 72 hours. The facility's policy required perishable food to be labeled with the resident's name, item, and use-by date, and to be discarded on or before the use-by date, but these procedures were not followed.
Failure to Properly Explain and Document Arbitration Agreements
Penalty
Summary
The facility failed to properly inform and explain the binding arbitration agreement to four out of five reviewed residents, resulting in these residents being unaware that signing the agreement meant waiving their rights to pursue legal action in court. During a resident council meeting, four residents reported not understanding the arbitration agreement, not knowing they had 30 days to decline it, and not receiving a copy of the agreement. One resident described being pressured to sign the agreement during a hospital transport, with staff insisting it was required for re-admission. Another resident stated they were unaware of the agreement's purpose and would have declined it if they had understood their options. Two other residents reported not receiving an explanation or a copy, with one noting they were likely confused due to medication at the time of signing. Record reviews confirmed that there was no documented evidence that the arbitration agreement was explained or that copies were provided to the residents. The agreements were only available in English, and translation services were not consistently used. The Minimum Data Set (MDS) assessments indicated that three of the four residents had moderate cognitive impairment at the time of signing, while one had no cognitive problems. Despite this, there was no documentation that the agreements were explained or that the residents acknowledged understanding them. Interviews with the Admissions Coordinator and the Director of Nursing confirmed that the facility's policy required staff to ensure residents verbally acknowledged understanding the arbitration agreement and to document this in the medical record. Both staff members acknowledged the importance of providing copies and explanations of the agreement, but admitted that this was not done for the affected residents. The facility's policy also stated that a signature alone was not sufficient to demonstrate understanding, yet this was not followed in practice.
QAA Committee Failed to Address Surveyor-Identified Trends in QAPI Plan
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to identify and include several trends identified by surveyors during the recertification survey in their Quality Assurance Performance Improvement (QAPI) plan. Specifically, the QAA did not address issues related to delays in call light response, management of smokers, following Registered Dietician (RD) recommendations, kitchen hygiene, RD kitchen audits, resident care conferences, and low air loss mattress settings. During an interview and review of the QAPI/QAA program with the Administrator (ADM) and Director of Nursing (DON), it was revealed that the current QAPI focus areas did not cover these deficiencies, and the ADM was unaware of the issues identified during the survey.
Failure to Provide Suitable Call Button for Resident with Physical Limitations
Penalty
Summary
A deficiency occurred when the facility failed to provide a suitable call button for one resident with significant physical limitations. The resident was admitted with diagnoses including cognitive communication deficit, functional quadriplegia, and metabolic encephalopathy, and was assessed as having intact cognition but being dependent or requiring substantial assistance for all self-care needs. The care plan directed the resident to use the call light for assistance. However, observations revealed that the call button provided required gripping and pressing with the thumb, which the resident was unable to do due to contracted hands. The resident reported being unable to use the call button and instead had to yell for staff assistance. Interviews with nursing staff, the Assistant Director of Nursing, and the Director of Nursing confirmed that the resident's physical condition prevented use of the standard call button and that an alternative, such as a tap call button, was needed. The facility's policy required evaluation and ongoing review of adaptive devices to accommodate individual needs, but this was not implemented for the resident in question, resulting in the resident being unable to communicate needs to staff through the call system.
Failure to Maintain Sanitary and Homelike Environment in Resident Bathroom
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a hospice resident who shared a bathroom with a roommate. Multiple observations over several days revealed that the shared bathroom contained feces on various surfaces, including the floor, walls, toilet seat, and faucet cover. The bathroom also had a persistent strong feces-like odor. White shower blankets and draw sheets, stained with brown and yellow marks, were found spread on the bathroom floor, and a used incontinence pad with brown stains was left in an unlined trash bin. These unsanitary conditions were directly observed by surveyors, family members, and staff. The resident, who had a history of malignant neoplasm of the prostate and was receiving hospice care, and their family members reported that the bathroom was dirty and had a strong odor. Family members stated they avoided using the bathroom due to its unsanitary state and expressed concern about the lack of a comfortable, home-like environment. Staff interviews confirmed the presence of feces-like stains and acknowledged that the draw sheets were placed on the floor for convenience when cleaning up after the roommate's incontinence episodes. Both a CNA and a licensed nurse noted that the draw sheets could pose a fall hazard in addition to contributing to the unsanitary conditions. The Director of Nursing confirmed that staff should not have placed draw sheets or shower blankets on the bathroom floor, as this created a potential fall hazard and did not promote a sanitary, orderly, or home-like environment. The facility's own policy required a clean, sanitary, and orderly environment, which was not upheld in this instance. The deficiency was substantiated by direct observation, staff and family interviews, and a review of facility policy.
Late Submission of MDS Assessment Data
Penalty
Summary
The facility failed to submit the Minimum Data Set (MDS) assessment data to the federal database within the required timeframe for one resident. Specifically, a review of the resident's records showed that the quarterly MDS was completed and signed by the RN Assessment Coordinator on 1/27/25, but the data was not transmitted to the federal database until 2/16/25, which exceeded the 14-day submission requirement. The MDS Final Validation Report confirmed that the submission was late, as it was more than 14 days after the completion date indicated by Z0500. Interviews with the MDS Coordinator revealed that the delay occurred because the MDS was not submitted within the mandated period after completion. The MDS Coordinator acknowledged the importance of timely submission to ensure the federal database has up-to-date information on resident status and quality measures. The Director of Nursing also stated that the expectation is for MDS assessments to be completed and submitted accurately and on time, in accordance with the Resident Assessment Instrument (RAI) manual.
Failure to Include Staff Escort Requirement in Dialysis Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically omitting special instructions for staff accompaniment during dialysis for a resident diagnosed with End Stage Renal Disease (ESRD). Observations showed that the resident was returned to the facility from dialysis via medical transport on two occasions without being accompanied by facility staff, despite the electronic medical record's Special Instructions section stating that staff must accompany the resident to dialysis and remain with them at the dialysis center. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the care plan did not include the requirement for staff to escort the resident to dialysis, even though this instruction was present in the Special Instructions section and recognized as necessary for the resident's safety. The facility's policy on ESRD care also required that the comprehensive care plan reflect the resident's needs related to dialysis care, which was not done in this case.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide routine nail care for a resident who was dependent on staff for activities of daily living. The resident, who had hemiplegia and hemiparesis following a stroke, dysphagia, and epilepsy, was unable to perform self-care and did not have the capacity to make decisions. During observations, the resident was found with long fingernails on the left hand and dark material under the nails. Multiple staff interviews revealed uncertainty among CNAs regarding their authority to trim nails, especially for residents without diabetes or fungal infections. Staff acknowledged that nail care should have been performed during showers and documented, but this was not consistently done. The facility's policy required daily cleaning and regular trimming of nails to prevent infection, but this was not followed for the resident in question. The DON and ADON confirmed that it was the responsibility of all staff to check and maintain residents' nails, and that nail trimming was scheduled weekly. Despite these guidelines, the resident's nails were not properly maintained, resulting in poor hygiene and a risk for infection.
Failure to Maintain Hazard-Free Environment and Inadequate Smoking Safety Assessment
Penalty
Summary
The facility failed to maintain a safe, hazard-free environment for two residents, resulting in deficiencies related to accident prevention and supervision. For one resident with a history of unsteadiness and multiple recent unwitnessed falls, staff placed shower blankets and draw sheets on the bathroom floor for convenience in cleaning up incontinence. Observations over several days revealed these items spread across the bathroom floor, along with visible stains and a strong fecal odor. Both a CNA and a licensed nurse acknowledged that the use of these linens on the floor created a slipping hazard, and the Director of Nursing confirmed that this practice was not appropriate for managing incontinence due to the potential for falls. Additionally, another resident with a history of COPD and nicotine dependence, and moderate cognitive deficits, was not properly assessed for current smoking status or safety planning. The last documented smoking assessment for this resident was completed several months prior, despite facility policy and staff statements indicating that quarterly assessments were necessary to evaluate ongoing smoking behavior and update care plans for safety. Interviews with the MDS Coordinator and DON confirmed that the lack of a recent assessment meant the resident's smoking safety and care plan were not current. Facility policies reviewed included guidelines for managing fall risks and resident assessments, but the observed practices and documentation did not align with these policies. The deficiencies were identified through direct observation, staff interviews, and record reviews, which demonstrated lapses in both environmental safety and resident-specific risk assessment.
Failure to Monitor Nutritional Status After Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor the nutritional status of a resident with a history of dysphagia and pressure ulcers, who experienced progressive and significant weight loss since admission. Despite documented weight loss of 17.8% (22.9 lbs) over a three-month period, weekly weights were not consistently obtained as required after the significant decline. The resident's weight records showed gaps in weekly monitoring, particularly from early January to late January, and again in February, even after the Registered Dietician (RD) recommended weekly weights due to the resident's condition. Interviews with staff revealed that the process for obtaining and reporting weights involved CNAs notifying licensed nurses of any changes, but the RD and Director of Nursing (DON) both acknowledged that weekly weights were not performed as recommended. The facility's policy required ongoing monitoring and documentation of weight and dietary intake, but did not provide specific guidance regarding RD assessment and recommendations. The lack of consistent weight monitoring following significant weight loss constituted a failure to ensure the resident's nutritional status was properly tracked.
Failure to Follow Dialysis Care Orders and Special Instructions
Penalty
Summary
The facility failed to follow physician's orders and established protocols for dialysis care for two residents with End Stage Renal Disease (ESRD). For one resident, who had severe cognitive deficits and was unable to make decisions or communicate effectively, the physician's order required removal of the pressure dressing from the right AV fistula 4-6 hours post dialysis if no bleeding was noted. Observations and interviews revealed that the dressing was not removed within the specified timeframe, and there was no documentation of a post-dialysis assessment by a Registered Nurse (RN) as required by facility policy. The care plan for this resident also did not include instructions for post-dialysis dressing care, and the facility's policy indicated that the care plan should reflect the resident's needs related to dialysis care. For the second resident, who also had a diagnosis of ESRD, the facility failed to follow special instructions documented in the medical record that required a staff member to accompany the resident to dialysis and remain with them during treatment. Observations showed that the resident was returned from dialysis appointments without being accompanied by facility staff. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the instruction for staff accompaniment was present in the medical record but was not being followed, and this requirement was not included in the resident's care plan. Both deficiencies were confirmed through interviews, record reviews, and direct observation. Facility staff acknowledged the lapses in following physician orders and care plan requirements, and the facility's own policies indicated that comprehensive care plans should address the specific needs of residents receiving dialysis care.
Improper Storage and Labeling of Resident's Breathing Treatment Medications
Penalty
Summary
Facility staff failed to properly store and label a resident's breathing treatment medications, specifically Ipratropium-Albuterol solution vials. The resident was observed keeping unlabeled, undated, and unpackaged vials in a bedside drawer, and self-administering the medication in the evenings. Staff, including a respiratory therapist (RT), confirmed that medications were found at the bedside without proper labeling or packaging, and there was no physician order for self-administration. The RT stated she had repeatedly informed the charge nurse that medications should not be left at the bedside, but the issue persisted. Manufacturer guidelines for the medication require that vials be stored in protective foil pouches and used within one week of removal, but the vials at the resident's bedside were outside the pouch and not dated, making it impossible to determine how long they had been stored. Facility policy also requires all medications to be stored in locked compartments and in their original packaging. Interviews with nursing staff and facility leadership confirmed that the observed storage and labeling practices did not comply with facility policy or manufacturer guidelines.
Failure to Sanitize Equipment and Update Infection Control Policies
Penalty
Summary
Facility staff failed to implement infection control standards of practice in two key areas. First, a Certified Nurse Assistant (CNA) was observed using a portable wrist blood pressure cuff on multiple residents without sanitizing the device between uses. The CNA acknowledged that she sanitized the cuff only after completing all residents' vital signs, rather than between each resident. Another CNA and the Director of Nursing (DON) both confirmed that equipment such as blood pressure cuffs should be sanitized after each resident to prevent infection. Review of the facility's policy and procedure (P&P) on cleaning and disinfection indicated that non-critical items like blood pressure cuffs require cleaning and disinfection, but did not specify the frequency for sanitizing these items between residents. Additionally, the facility failed to update its Infection Prevention and Control Program (IPCP) policy and procedure in accordance with federal regulations. The Infection Preventionist (IP) stated that the IPCP P&P was last updated in December 2023 and had not been reviewed or updated annually as required. The DON confirmed that the IPCP should be updated annually to ensure accuracy and compliance with regulatory updates. The current P&P stated that the program is to be reviewed annually and updated as necessary, but this process was not followed.
Failure to Provide Functional Call Systems for Dependent Residents
Penalty
Summary
The facility failed to provide two residents with functional call buttons, preventing them from making their needs known and having those needs met. One resident, who had cognitive communication deficits, functional quadriplegia, and pressure ulcers, was found to have a call button that required gripping and pressing with the thumb. Due to contracted hands, the resident was unable to use the provided call button and instead had to yell for assistance. Multiple staff, including a licensed nurse, the assistant director of nursing, and the director of nursing, confirmed that the call button was not appropriate for the resident's physical limitations and that an alternative, such as a tap-activated call button, was needed. The facility's policy required that residents with disabilities preventing use of the standard call system be provided with an alternative means of communication, documented in the care plan, but this was not done. Another resident, dependent on staff for self-care, was found to have a non-functional call button missing its red centerpiece. There was no maintenance request logged for the broken call button, and staff interviews revealed that the required process of reporting and documenting broken equipment in the maintenance log was not followed. The facility manager, CNA, and licensed nurse all acknowledged that the expectation was for staff to report and log such issues so that repairs could be made and residents would have a functioning means to communicate with staff. The assistant director of nursing and director of nursing reiterated that all residents should have functional call buttons and that the facility's policy required this. Observations, interviews, and record reviews confirmed that the facility did not ensure that each resident had a working call system in their bathroom and bathing area, as required by policy. The lack of functional call buttons for these two residents, and the failure to provide alternative communication methods or promptly repair broken equipment, directly led to the deficiency cited in the report.
Failure to Maintain Resident Room Free of Cockroaches
Penalty
Summary
The facility failed to maintain a resident room free from cockroaches, as observed in one specific room housing three residents. During an initial tour, a cockroach was seen outside the room on a glove dispenser, and further inspection revealed dead cockroaches in the frame holding the daily menu and in the light behind a resident's bed. One resident reported that cockroaches were present throughout the room and that the housekeeper had seen cockroaches behind the dresser earlier that day. The resident also noted that both roommates stored food in and around their dressers, which may have contributed to the pest issue. Dead cockroaches were observed in the areas mentioned by the resident. Interviews with staff, including a CNA, Licensed Nurse, Assistant Director of Nursing, Director of Nursing, Facility Manager, and Administrator, confirmed that the expectation was for resident rooms to be pest free and that the process for reporting pests involved notifying maintenance and logging the issue. However, a review of the maintenance log showed no record of cockroach sightings in the affected room, despite multiple staff and resident reports. The facility's pest control service summary also indicated prior activity in the room and recommended clearing items to allow for better inspection, but the ongoing presence of cockroaches demonstrated that the room was not kept free of pests as required by facility policy.
Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident abuse involving a resident with dementia and moderate cognitive impairment. The incident occurred when a certified nursing assistant (CNA) was assisting the resident back to his room, resulting in a skin tear on the resident's heel. Despite the incident being documented and communicated among staff, it was not reported to the appropriate authorities or thoroughly investigated as required by the facility's policy. Interviews with various staff members revealed a lack of communication and follow-through regarding the incident. The Director of Staff Development (DSD) was informed of the incident but did not perceive it as an abuse allegation and assumed others were handling it. The Director of Nursing (DON) acknowledged that the incident should have been reported and investigated, but it was not elevated to the department heads. The Assistant Director of Nursing and the Social Services Director were also unaware of any abuse allegations. The facility's policy mandates immediate reporting of suspected abuse to the administrator and state authorities, but this protocol was not followed. The incident was not reported to the facility's Abuse Coordinator, and no investigation was conducted. The failure to address the incident left all residents at risk for potential harm and abuse, as the necessary steps to ensure their safety were not taken.
Inaccurate Language Assessment in MDS
Penalty
Summary
The facility failed to accurately assess and document the preferred language of a resident, leading to incorrect information being transmitted to the Centers for Medicare and Medicaid Services (CMS). The resident, who was readmitted with a diagnosis of Parkinson's disease, was observed expressing discomfort in Spanish, indicating a language preference that was not reflected in the facility's records. The Minimum Data Set (MDS) assessment inaccurately listed English as the resident's preferred language, despite the care plan indicating Spanish as the primary language. During an interview, the Minimum Data Set Nurse (MDSN) acknowledged the error in the quarterly MDS assessment and noted the absence of a Spanish communication board in the resident's room. The Director of Nursing (DON) expressed an expectation for all MDS information to be accurate. The incorrect assessment resulted in CMS not having accurate information about the resident's language preference at the time.
Deficiencies in Food and Nutrition Services Department
Penalty
Summary
The facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department. A Dietary Aide (DA 1) was unable to determine the correct wash, rinse, and sanitizing temperatures and process for the dish machine. DA 1 admitted to writing down incorrect values for the dish machine log and using an improper method to test the sanitizer solution. The Certified Dietary Manager (CDM) and a dish machine vendor confirmed that DA 1's method was incorrect and that the proper process involves testing a dish after it comes out of the machine. The Registered Dietitian (RD) also emphasized the importance of accurate dish machine temperatures and proper sanitizing procedures according to the FDA Food Code and facility policy. Additionally, a Cook (CK 1) did not correctly follow the cool down process for a beef roast. CK 1 initially stated the incorrect cool down process and later failed to achieve the required temperatures within the specified timeframes. Despite reheating the beef roast and attempting the cool down process again, the meat still did not reach the correct temperature. The CDM and RD both agreed that the beef roast should not be served to residents due to the failure to meet food safety standards. The RD reiterated the importance of following the correct cool down process as outlined in the FDA Food Code. These deficiencies in the food and nutrition services department had the potential to expose dishes to unsanitary practices and contaminate food, which could result in foodborne illness among residents. The facility's policies and procedures, as well as federal guidelines, were not adhered to, leading to these significant lapses in food safety and sanitation practices.
Failure to Maintain Safe and Sanitary Conditions in Kitchen and Resident Nourishment Areas
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen and resident nourishment areas, leading to potential food contamination. During an initial kitchen tour, three floor sink drains were found full of dirt, food debris, trash, and black grime, with one floor sink drain uncovered, allowing insects to enter. Additionally, a reach-in refrigerator was found with a broken thermometer and contained multiple cases of milkshakes and a quart of milk. Several kitchen tools, including measurement scoops, dome lids, and a metal egg slicer, were found with brown and black grime and food debris after being washed and stored as clean. Seven cutting boards were visibly worn with multiple tears and discolorations, making them difficult to clean and sanitize effectively. Further observations revealed that four resident nourishment refrigerators on nursing units contained expired food items and visible dirt and sticky grime on the inside of the doors. Specific instances included a refrigerator with brown liquid sticky stains, black crumbs, and debris inside the door, and another with a half-eaten store-bought cake showing signs of contamination. Staff acknowledged that these items should have been discarded and that the refrigerators should have been cleaned by housekeeping. The facility's policies and procedures were reviewed and found to be inadequate in ensuring proper maintenance and cleanliness. The policies indicated that the maintenance department was responsible for keeping the buildings, grounds, and equipment in a safe and operable manner, and that all utensils, counters, shelves, and equipment should be kept clean and in good repair. However, the observed conditions in the kitchen and resident nourishment areas did not align with these policies, leading to potential exposure of residents to food contamination and foodborne illness.
Infection Control Protocol Failures
Penalty
Summary
The facility failed to ensure infection control protocols were followed in several instances. Staff 11 did not perform hand hygiene or don/doff personal protective equipment (PPE) when entering and exiting a resident's room that was on contact isolation precautions. Staff 11 also admitted to not having received training on the use of PPE and contact isolation. This was confirmed by the infection prevention nurse (IPN) and the director of nursing (DON), who acknowledged that Staff 11 should have completed infection control training before performing work duties in a contact isolation room. A Licensed Nurse (LN 22) was observed handling and serving resident meal trays without sanitizing her hands or using gloves during the lunch meal service. LN 22 admitted to forgetting to wash her hands or use hand sanitizer while handling the food trays, acknowledging that this could be an infection control concern. The Registered Dietitian (RD) confirmed that all kitchen and nursing staff are expected to follow appropriate hand hygiene protocols to prevent cross-contamination. Resident 548 was not provided with appropriate hand hygiene options due to a non-functioning sink in his room. The resident had been using a bedpan washer to rinse his hands in the toilet reservoir tank. Both the Certified Nursing Assistant (CNA 56) and Licensed Nurse (LN 57) were unaware of this practice, which was identified as an infection control issue. The Administrator (ADM) and the IPN confirmed that the resident should have been given alternative hand hygiene options and educated about appropriate hand hygiene practices. The DON also acknowledged that the non-functioning sink could contribute to the spread of infection.
Pest Control Deficiency in Kitchen and Resident Areas
Penalty
Summary
The facility did not ensure the kitchen and resident areas were free of pests, including flies, gnats, and roaches. During an initial kitchen tour, flies were observed flying around a dirty kitchen with food debris and grimy substances on the equipment. On a subsequent day, fruit flies were seen near the resident refrigerator area on the second floor, and a dead black roach was found inside the freezer door of a resident's refrigerator on the third floor. These observations were confirmed by licensed nurses present at the time. Interviews with the Maintenance Director and the Administrator revealed that the facility had been working on pest control for a few years but still struggled with pest issues. The Pest Control Vendor invoices from January to February 2024 indicated that the kitchen floor drains were dirty and full of debris. The facility's policy and procedure on pest control, dated 2001, stated that the facility should maintain an effective pest control program, which was not being effectively implemented as evidenced by the ongoing pest issues.
Nonfunctioning Sink Leads to Unhomelike Environment and Infection Control Issue
Penalty
Summary
The facility failed to ensure a homelike environment for a resident when the resident's bathroom sink was left nonfunctioning for at least one week. The resident, who had moderately impaired cognition and required supervision for personal hygiene, was observed using a bedpan washer to rinse his hands in the toilet reservoir tank due to the nonfunctioning sink. This issue was not reported or followed up on by the staff, including a CNA and LN, who were unaware of the resident's alternative handwashing method. The facility manager and administrator acknowledged that the nonfunctioning sink was unacceptable and posed an infection control problem. The resident's admission record indicated that the sink had been nonfunctional since the resident's admission, approximately three weeks prior. Despite the facility's policy to provide a safe, clean, and homelike environment, the broken sink was not repaired in a timely manner, and no alternative hand hygiene options were provided to the resident. The deficiency was confirmed through multiple observations and interviews with the resident, CNA, LN, facility manager, and administrator, all of whom recognized the importance of maintaining functional equipment to prevent infection and ensure a homelike environment.
Failure to Develop Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to ensure that a care plan was developed for a resident's dialysis access of an AV fistula. The resident, who was admitted with diagnoses including diabetes and renal failure requiring dialysis, had a care plan that only addressed the assessment of signs and symptoms of infection. The care plan did not include approaches for assessing the thrill or bruit to ensure the AV fistula was functional, nor did it specify when the post-dialysis AV fistula dressing should be removed. This omission could result in issues with the AV fistula not being identified in a timely manner to receive immediate care.
Failure to Develop Patient-Centered Care Plans
Penalty
Summary
The facility failed to develop patient-centered care plans for two residents, Resident 32 and Resident 154, which had the potential to result in unmet care and service needs. Resident 32 was admitted with a left hand contracture and bilateral foot drop, but no care plans were in place to address these conditions. During an observation, Resident 32 was found in bed with a splint on her left hand and both feet exhibiting foot drop. Licensed Nurse 42 confirmed that there were no care plans addressing these specific needs for Resident 32. Resident 154, who was readmitted with a diagnosis of PTSD, also lacked a comprehensive care plan. The resident exhibited aggressive behavior, medication refusal, and a preference to be left alone. Licensed Nurse 44 and the Social Service Director confirmed that the care plans did not include information about the traumatic event that triggered Resident 154's PTSD, which is crucial for managing the resident's condition. The Director of Nursing acknowledged the necessity of care plans to address residents' problems, and the facility's policies emphasized the importance of individualized, trauma-informed care plans.
Failure to Maintain Nutritional Parameters for Resident
Penalty
Summary
The facility failed to ensure appropriate nutritional parameters were maintained for a resident, resulting in a severe weight loss of 18.4% over six months. The resident, who had end-stage renal disease, dysphagia, type 2 diabetes mellitus, and a Vitamin D deficiency, experienced significant weight loss from 125.4 pounds to 102.3 pounds between October 2023 and March 2024. Despite the resident's low intake of the renal diet, the Registered Dietitian (RD) did not adjust the diet until February 2024, when it was changed to a fortified diet with mechanical soft texture and thin liquids consistency. The Director of Nursing (DON) was unaware of the severe weight loss, and the facility's weight committee did not take timely action based on the RD's recommendations. The facility's records indicated that the resident's meal intake was between 25%-50%, and the recommended energy needs were not being met. The resident's care plan, which was revised in March 2024, noted the potential for altered nutrition and fluctuating weights but did not effectively address the severe weight loss. The facility's policies and procedures for weight assessment and intervention were not adequately followed, as the significant weight loss was not promptly identified and addressed by the treatment team. Interviews with the RD and DON revealed a lack of communication and timely intervention regarding the resident's nutritional needs. The RD acknowledged the resident's low intake of the renal diet and discussed diet liberalization with the Nurse Practitioner (NP), but there was no follow-up or documentation of the NP's response. The facility's failure to monitor and address the resident's severe weight loss in a timely manner resulted in a potential risk for further nutritional decline and associated health complications.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that Resident 154 received Trauma Informed Care (TIC), which is essential for individuals with a history of trauma such as post-traumatic stress disorder (PTSD). Resident 154 was readmitted to the facility with a diagnosis of PTSD. Observations and interviews revealed that the resident exhibited behaviors such as moodiness, refusal of care, aggression, and a preference to stay in bed. Staff members, including CNAs and LNs, were unaware of the specific triggers related to the resident's PTSD and had not received instructions on how to manage these behaviors effectively. The social service director admitted that she had not inquired about the traumatic events experienced by Resident 154, which is crucial for identifying triggers and providing appropriate care. The director of nursing also acknowledged the importance of identifying traumatic events to support the resident and develop a care plan. The facility's policy on Trauma-Informed and Culturally Competent Care, dated August 2022, outlines the need for an in-depth assessment to evaluate symptoms, their relationship to trauma, and the identification of triggers. However, this policy was not followed, resulting in the facility's inability to identify possible triggers that could lead to re-traumatization for Resident 154. This deficiency highlights a significant gap in the facility's approach to providing trauma-informed care, which is essential for the well-being of residents with PTSD or similar conditions.
Failure to Meet Minimum Staffing Requirements
Penalty
Summary
The facility failed to ensure they provided the minimum number of sufficient staff or PPD (Per Patient Day) required to meet the needs of every resident. The review of actual staffing from 3/12/24 to 3/28/24 revealed that the facility did not meet the minimum PPD of 3.5 and the CNA PPD minimum of 2.4 hours on multiple days. Specifically, on 3/12/24, the CNA PPD was 2.37 hours; on 3/13/24, the PPD was 3.24 and the CNA PPD was 2.16 hours; on 3/14/24, the CNA PPD was 2.3 hours; on 3/15/24, the PPD was 3.4 and the CNA PPD was 2.22 hours; on 3/16/24, the PPD was 2.89 and the CNA PPD was 1.97 hours; on 3/17/24, the PPD was 3.11 and the CNA PPD was 2.19 hours; on 3/21/24, the PPD was 3.44 and the CNA PPD was 2.23 hours; on 3/22/24, the CNA PPD was 2.33 hours; on 3/23/24, the PPD was 3.27 and the CNA PPD was 2.22 hours; and on 3/24/24, the PPD was 3.41 and the CNA PPD was 2.33 hours. The facility's staffing postings were not updated throughout the day to reflect actual staffing numbers, which contributed to the failure to meet the required PPD and CNA PPD minimums. The DSD (Director of Staff Development) indicated that the projected staffing was calculated daily and posted, but the postings were not modified if staffing numbers changed during the day. This lack of accurate and updated staffing information may have resulted in residents not receiving the care they deserved on the specified days.
Failure to Assess Nurse Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that one of three licensed nurses (LN 12) was assessed for competency in medication administration. During an observation of medication administration, LN 12 failed to administer three physician-ordered medications and administered an incorrect amount of medication to a resident (Resident 122). The Director of Nursing (DON) confirmed that it was expected for residents to receive their medications correctly and as ordered by the physician. However, LN 12's medication administration was not performed competently. Further investigation revealed that LN 12 was from a staffing agency, and the DON initially believed that the agency had assessed LN 12's competency. However, it was later confirmed that neither the staffing agency nor the facility had assessed LN 12's competency in medication administration. The facility's policy on staffing and competent nursing, revised in August 2022, indicated that staff must demonstrate the necessary skills and techniques for medication management, which was not adhered to in this case.
Failure to Post Actual Daily Staffing
Penalty
Summary
The facility failed to ensure they posted the actual daily staffing, instead only posting the projected staffing. This deficiency was identified through interview and record review, revealing that from 3/12/24 to 3/28/24, the facility posted a single staffing projection for the entire building at the first-floor reception desk. According to the Director of Staff Development (DSD), the projected staffing was calculated daily and posted, but it was not updated to reflect any changes in staffing throughout the day. Consequently, residents and visitors were not informed of the actual staff working at any given time.
Failure to Follow Medication Orders
Penalty
Summary
The facility failed to ensure medication orders for two residents were carried out as ordered. Resident 60, who was admitted with end-stage renal disease and diabetes mellitus, had a physician's order to receive Lantus insulin 20 units every morning. However, the medication administration record (MAR) indicated that the insulin was not given on four occasions in March 2024 because the resident was out to dialysis. The nursing progress notes did not show that the resident's physician was notified of the missed doses. Licensed Nurse 1 confirmed that the physician was not informed, which was against the facility's policy and the Director of Nursing's (DON) expectations that physician orders should be followed and the physician notified if they are not followed. Resident 64, admitted with chronic pain syndrome and opioid dependence, had an order to receive oxycodone 10 mg for severe to excruciating pain (pain level 8-10). The MAR showed that the resident was given oxycodone for pain levels below 8 on multiple occasions in March 2024. Both Licensed Nurse 2 and the Assistant Director of Nursing (ADON) acknowledged that the medication was administered incorrectly and that the physician should have been contacted to adjust the pain medication order. The DON reiterated that physician orders must be followed to ensure proper treatment and that the physician should be notified if orders are not followed.
Unnecessary Prescription of Trazodone for Non-FDA Approved Indication
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 181 and Resident 215, were not prescribed Trazodone for a non-FDA approved indication. Resident 181 was admitted with a diagnosis of cognitive impairment and was prescribed Trazodone 50mg at bedtime for depression as exhibited by an inability to sleep. However, the medication was used to treat insomnia, which is not an FDA-approved indication for Trazodone. The clinical record did not show any evidence that other causes for the resident's inability to sleep were ruled out or that non-drug therapies were attempted. Additionally, the prescribed dosage did not align with the manufacturer's guidelines, which recommend divided daily doses for treating major depressive disorder (MDD), the FDA-approved use for Trazodone. Similarly, Resident 215, who was admitted with a diagnosis of insomnia, was prescribed Trazodone 100mg at bedtime for depression as exhibited by an inability to sleep. The medication was again used to treat insomnia, not depression, and there was no evidence in the clinical record that other causes for the resident's inability to sleep were ruled out or that non-drug therapies were attempted. The prescribed dosage also did not follow the manufacturer's guidelines for treating MDD. Both cases highlight the facility's failure to ensure that the residents' drug regimens were free from unnecessary drugs, as Trazodone was prescribed without an adequate FDA-approved indication.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 12.5 percent. During the medication administration process for one of seven randomly observed residents, four medication errors were observed out of 32 opportunities. Specifically, Resident 122, who was admitted with diagnoses including dorsalgia, did not receive her scheduled doses of acetaminophen, baclofen, and gabapentin at 9 A.M. despite not refusing the medications. Instead, she was administered other medications that were not part of her 9 A.M. routine, including an incorrect dose of vitamin D3. Licensed Nurse (LN) 12, who administered the medications, incorrectly assumed that the pain medications were to be given on an as-needed basis (prn) and did not administer them because the resident reported no pain or muscle spasms at the time. However, the resident later confirmed that she did not refuse the medications and was unaware they were not given. The Director of Nursing (DON) confirmed that it was the facility's expectation for medications to be administered as ordered by the physician and acknowledged that the resident's pain management medications should not have been withheld unless explicitly refused by the resident.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to ensure the Pureed diet menu was followed as printed, which had the potential to alter the nutritional value of the pureed meals for 30 residents on a pureed diet. During a review of the facility's Therapeutic Menu Spreadsheet, it was noted that the pureed diet should include specific items such as pureed roast turkey, pureed bread dressing, and pureed three bean salad. However, during an observation in the 4th floor dining room, a Dietary Aide (DA 2) served mashed potatoes instead of pureed dressing and later served regular diet stuffing with small pieces of celery and other vegetables to residents on a pureed diet. At least ten residents on pureed diets were served dressing at lunch, which was not in accordance with the printed menu. Further observations revealed that a feeding assistant (FA 1) confirmed serving mashed potatoes with pureed turkey and pureed peas to a resident on a pureed diet. The facility's recipe for pureed bread products indicated that the texture should be smooth and moist, similar to applesauce. The Registered Dietitian (RD) stated that the kitchen staff is expected to follow the facility-approved menus and recipes to ensure appropriate nutrition. The facility's policy and procedure for menu planning indicated that any changes to the daily menu should be noted and approved by the Facility Registered Dietitian, FNS Director, or Cook. However, these procedures were not followed, leading to the deficiency in the meal service for residents on a pureed diet.
Facility Failed to Ensure Palatable and Properly Prepared Food
Penalty
Summary
The facility did not ensure that food was palatable and served according to the facility policy, which had the potential to affect meal and food intake, thereby impairing the nutrition status of the residents. During the initial resident survey screening, comments were made about the lack of flavor in the facility's food. A review of the facility's Therapeutic Menu Spreadsheet revealed that the pureed diet meals included items such as a baked hamburger patty, which was found to have a semi-thin texture and a gritty aftertaste during a test tray observation. Additionally, the sweet potatoes in the pureed diet had a few chunks, which is inconsistent with the expected smooth, pudding-like texture. The Certified Dietary Manager (CDM) and Registered Dietitian (RD) both confirmed that pureed foods should not have chunks and that the pureed meat should not have a thin liquid texture. Further interviews with the RD indicated that the kitchen staff was expected to follow the facility-approved menus and recipes to ensure appropriate nutrition for the residents. A review of the facility's undated recipe for pureed meats specified that the puree should reach a consistency slightly softer than whipped topping, which was not achieved in the observed meals. The failure to adhere to these guidelines and recipes resulted in food that was not palatable or properly prepared, potentially impacting the residents' nutritional intake.
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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