Country Oaks Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 215 W Pearl St, Pomona, California 91768
- CMS Provider Number
- 055247
- Inspections on file
- 59
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Country Oaks Care Center during CMS and state inspections, most recent first.
A resident with acute pulmonary edema, ESRD, and severe sepsis experienced altered mental status and respiratory compromise, but the CICE form was left incomplete, containing only earlier vital signs and lacking behavioral, respiratory, cardiovascular, GI, GU, and neuro assessments or physician notification. An LVN documented that the resident was pale with shallow breathing and low O2 sat and that 911 was called, but the recorded time of the 911 call conflicted with an RN’s account. The RN reported placing the resident on a non-rebreather mask, initiating continuous O2 and heart rate monitoring, and remaining at the bedside until paramedics arrived, yet none of these assessments or interventions were documented in the medical record, resulting in incomplete and inaccurate documentation.
Six licensed nurses responsible for Pleurx catheter care did not have documented competency assessments, despite receiving in-service training. The Director of Staff Development confirmed the absence of competency validation, and facility policies require such assessments for specialized care. This failure meant there was no verification that staff could properly manage Pleurx catheters.
A resident admitted with a Pleurx catheter and multiple complex diagnoses did not have a care plan developed upon admission to address the presence and management of the catheter. Staff interviews and record reviews confirmed that no care plan specific to the device was created, despite facility policy and the resident's clinical needs.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
A resident with a G-tube and complex medical needs experienced redness and leaking at the G-tube stoma, which was noted in a change in condition evaluation but not documented in the required nursing progress notes over several shifts. Multiple LVNs and the DON confirmed that such findings should have been recorded in the skin assessment section of the medical record, in accordance with facility policy.
Staff failed to follow hand hygiene and Enhanced Barrier Precautions when caring for a resident with a gastrostomy tube and tracheostomy. Two sitters provided care without wearing gloves and did not perform hand hygiene before donning gloves, despite facility policy and posted instructions. The sitters were unable to explain the importance of these precautions or the purpose of EBP, and the DON confirmed that these actions were required to prevent the spread of MDROs.
A staff member transferred a resident using a mechanical lift without the required assistance of a second staff member, contrary to facility policy. The resident, who required total assistance for transfers due to multiple medical conditions and impaired balance, was observed being lifted by only one staff member. Both the staff member and the DSD confirmed that two staff are required for such transfers to ensure safety.
A facility failed to maintain a safe and sanitary bathroom for four residents, with issues such as mold, cracked tiles, and exposed screws. The maintenance logs did not show any repairs or checks for the bathroom, and the Maintenance Supervisor acknowledged the need for repairs. The residents had respiratory conditions, making them vulnerable to the unsanitary conditions.
The facility failed to ensure proper medication administration and accountability, leading to two deficiencies. Narcotic medications in a medication cart were not accurately accounted for during shift changes, as the off-going nurse's signature was missing from the Controlled Substances Shift Count Log. Additionally, a resident with severe cognitive impairment did not receive the correct dose of Polyvinyl Alcohol Ophthalmic Solution as prescribed, with only one drop administered per eye instead of the ordered two drops.
Facility staff failed to adhere to infection control protocols in two instances. A Respiratory Therapist did not properly secure an isolation gown during tracheostomy care for a resident under enhanced barrier precautions, risking contamination. Additionally, a Certified Occupational Therapy Assistant did not wear required PPE while assisting a resident on contact isolation for potential C. diff infection. These actions violated facility policies designed to prevent infection spread.
The facility failed to maintain a clean and safe environment, with issues in the kitchen, resident rooms, and a shared bathroom. Observations included cracked plaster, worn and chipped tiles, and unpainted walls. Staff were unaware if these issues had been reported, and maintenance logs did not reflect necessary repairs. The Maintenance Supervisor acknowledged the need for repairs, recognizing the potential health hazards posed by the unsanitary conditions.
The facility failed to provide adequate gastrostomy tube (GT) care for two residents. One resident's GT was disconnected, causing feeding to spill on the floor, while another resident's GT tip touched the floor, violating infection control protocols. Additionally, a CNA improperly handled the GT feeding pump, contrary to facility policy. Both residents had severe cognitive impairments and required staff assistance for daily activities.
Two residents with impaired cognition and respiratory conditions had unlabeled IV sites, contrary to facility policy, risking potential complications and infections. Observations confirmed the absence of date and time labels on the IV dressings, which were required to track changes and prevent infections.
A resident with chronic respiratory failure and severe cognitive impairment did not have their nasal cannula properly placed, as it was found on their forehead instead of inside the nostrils. This oversight was confirmed by the facility's Infection Prevention Nurse and Director of Nursing, who both stated that proper placement is necessary to maintain the resident's oxygen saturation levels as per the physician's order.
A CNA was observed disconnecting and operating a gastrostomy tube (GT) machine for a resident, actions outside their scope of practice. The resident, with severe cognitive impairment, required GT feeding as per a physician's order. Facility policy indicated that CNAs were not trained or authorized to perform these tasks, as confirmed by interviews with nursing staff.
A resident received Aripiprazole for schizophrenia without a documented diagnosis, leading to an inaccurate MDS assessment. The resident's Admission Record did not list schizophrenia, and the MDS did not reflect it as an active diagnosis, despite hospital notes indicating it. The facility's policy requires accurate assessment coding, which was not followed.
A facility failed to develop a care plan for a resident's IV therapy, despite the resident's severe cognitive impairment and dependency on staff for daily activities. The resident was admitted with chronic respiratory failure and pneumonia, and a physician's order was in place for IV therapy. Interviews with staff confirmed the absence of a care plan, which was required by the facility's policy.
A resident with Alzheimer's and rheumatoid arthritis, identified as high risk for falls, experienced an unwitnessed fall due to inadequate supervision. Despite a history of falls and a policy requiring a sitter, the facility failed to ensure continuous supervision, leading to the incident. Staff interviews confirmed the absence of a sitter at the time of the fall, contrary to the facility's Fall Prevention Program.
A resident with complex medical conditions had their indwelling urinary catheter bag lying on the floor, contrary to infection control guidelines. Staff acknowledged the risk of infection due to this oversight, as the facility's policy emphasized proper catheter positioning to prevent complications.
A facility failed to ensure a specific indication for Ativan use for a resident, as required by their policy on psychotropic medications. The resident, admitted with chronic respiratory failure and hypoxia, was prescribed Ativan for agitation, which was not considered a specific diagnosis. The Director of Nurses confirmed that the indication was insufficient, as the facility's policy requires a specific diagnosed condition for administering psychotropic drugs.
A cook in an LTC facility was observed using the same gloves to handle ready-to-eat food after touching potentially contaminated surfaces, risking cross-contamination. The Dietary Supervisor confirmed the need for glove changes to prevent foodborne illness, aligning with facility policies and FDA guidelines.
A resident with impaired cognition and at risk for falls was found without access to a call light, contrary to the facility's policy. The call light was observed hanging out of reach, and both a nurse and the DON confirmed the necessity for it to be accessible for safety and assistance.
A facility failed to provide information about an Advance Directive (AD) to the responsible party of a resident with severe cognitive impairment. The resident's medical record incorrectly indicated an AD was executed, but the social worker admitted the form was filled out incorrectly. The Director of Nursing confirmed the need for discussion of AD forms upon admission, and the responsible party stated they were unaware of what an AD was, as it was not discussed with them.
The facility failed to provide adequate space in 11 resident rooms, each with three beds and only 190 square feet, falling short of the required 80 square feet per resident. Despite a waiver request and CNA's ability to provide care, the rooms were noted to be tight, potentially impacting care delivery.
A facility failed to create a comprehensive care plan for a resident who refused to be changed after becoming soiled with urine, increasing the risk of UTIs. Despite being incontinent and at risk for recurrent UTIs, the resident's care plan did not address their refusal behavior. Staff interviews confirmed the resident's refusal to be changed, and the ADON acknowledged the lack of a care plan addressing this issue, contrary to facility policy.
A resident with functional quadriplegia was unable to reach the overhead light pull cord, leading to a trash can liner being tied to it as a makeshift solution. The facility's maintenance staff was not informed of the issue, and there was no documentation in the Maintenance and Repair Log. The Assistant Director of Nursing confirmed that the pull cord should have been replaced to ensure a safe and comfortable environment.
A resident with severe cognitive impairment and multiple health issues was verbally and physically abused by a CNA. The incident was witnessed by two sitters who reported that the CNA grabbed the resident's head, used derogatory language, and threatened the resident with a bed remote. The facility's policies on abuse were not effectively implemented, leading to this deficiency.
Two residents experienced delays in receiving abdominal X-ray results, leading to a three-day interruption in G-tube feeding and medication. Despite multiple follow-ups, the facility's new diagnostic company failed to provide timely results, necessitating one resident's transfer to a hospital for confirmation. Staff interviews highlighted previous timely service from a different provider.
The facility failed to provide necessary in-service training to several LVNs before they signed forms indicating they had received training on topics such as Dementia, Care of Visually Impaired Residents, Abuse, and Medication Administration. Interviews revealed that LVNs were instructed to sign the forms without attending training sessions, and the Director of Staff Development admitted there was no system to track completed training.
Two residents with severe cognitive impairments and physical limitations did not receive adequate incontinence care, as required by their care plans. Facility staff failed to check and change the residents every two hours, leading to instances where residents were found soaked with urine. This failure was attributed to staffing shortages and high workloads, as reported by CNAs. The facility's policy on incontinence care was not consistently followed, posing a risk of UTIs and skin breakdown.
The facility failed to provide adequate staffing to ensure timely incontinence care for two residents, leading to potential risks of skin breakdown and UTIs. Both residents were dependent on staff for toileting and were always incontinent. Interviews with CNAs revealed that residents were often found soaked with urine due to staffing shortages, particularly during night shifts. The facility's policies emphasized the need for sufficient staffing, but the staffing levels were inadequate to meet residents' needs.
The facility did not post actual worked nursing hours at the start of each shift as required by their policy. An observation revealed outdated staffing information, and the Director of Staff Development confirmed the oversight, stating that postings were projections and not updated for staff call-offs.
The facility failed to ensure the safe use of a Hoyer lift for transferring residents, leading to a risk of falls and injury for four residents. CNAs did not follow proper procedures, with one CNA holding a resident by the feet during a transfer, and another operating the lift alone without assistance. The facility's policy requires two staff members for such transfers, especially for residents with tracheostomies, to prevent potential harm.
The facility failed to conduct a reference check for a CNA before hiring, as required by their P&P on Abuse, Neglect, and Exploitation. The CNA's file lacked documentation of reference checks, which the DSD confirmed were not performed. This oversight placed 70 residents at risk, as the facility's policy mandates screening for a history of abuse, neglect, or exploitation.
A housekeeping staff member failed to follow the facility's infection control policies by not wearing gloves on both hands and neglecting hand hygiene while handling soiled linen. The staff member transported an uncovered barrel of soiled linen through the hallway, contrary to the facility's procedures, which could lead to cross-contamination and infection spread.
The facility failed to maintain a homelike environment by not ensuring cleanliness in two shower rooms. Observations revealed chipped paint and a black substance in the shower room of SNF 1, confirmed by the Maintenance Supervisor as dirt buildup. The Housekeeping Supervisor also noted the black substance in both SNF 1 and SA shower rooms, acknowledging it was the housekeeping department's responsibility to clean the showers. The facility's policy required maintaining a sanitary environment, which was not followed.
A resident with moderate cognitive impairment reported that a CNA failed to clean them properly, left them soiled, and spoke disrespectfully, violating their dignity. Another resident confirmed hearing the CNA yell at the affected resident. The DON acknowledged that staff should not raise their voices at residents, aligning with the facility's policy on maintaining resident dignity.
A resident with functional quadriplegia and moderate cognitive impairment was unable to reach their call light, which was found on the floor behind their bed. The resident had to yell for help due to the call light's inaccessibility. A CNA confirmed the improper placement, and the DON highlighted the importance of accessible call lights for resident safety.
A resident with severe cognitive impairment was physically abused by another resident with a history of agitation and psychosis. The incident occurred after a verbal altercation, and staff intervention was required to separate the residents. Despite existing policies to prevent abuse, the facility failed to prevent this incident.
A resident with dementia physically grabbed another resident, but the incident was not reported to authorities within the required timeframe. Despite staff recognizing the event as abuse, the Administrator delayed reporting for 15 days, contrary to facility policy requiring immediate notification to protect resident safety.
A resident with mobility issues and occasional incontinence was not provided with appropriate toileting assistance, leading to unnecessary incontinence. Despite being able to verbalize the need for help, staff instructed the resident to urinate in briefs instead of offering alternatives like a bed pan. Interviews revealed that staff found it difficult to use the Hoyer lift, and the resident felt trapped and like a burden. The facility's policy to maintain continence was not followed, resulting in the resident being forced into incontinence.
A resident with functional quadriplegia and mobility issues was not provided with appropriate toileting assistance, leading to feelings of depression and indignity. Despite being able to control bladder functions, the resident was instructed by CNAs to urinate in an incontinence brief instead of being offered a bed pan or assistance to the toilet. This failure to uphold the resident's dignity was acknowledged by staff, who recognized the importance of offering alternatives to maintain the resident's continence and independence.
Incomplete and Inaccurate Documentation During Resident Change in Condition
Penalty
Summary
The deficiency involves incomplete and inaccurate medical record documentation for one resident who had serious medical conditions, including acute pulmonary edema, ESRD, and severe sepsis with septic shock. The resident was dependent on staff for ADLs and could make needs known but could not make medical decisions. On the date of the incident, a Change in Condition Evaluation (CICE) form was initiated at 9:35 PM for altered mental status, but it only contained previously recorded vital signs from earlier that afternoon and did not include current vital signs at the time of the change in condition. The CICE form also lacked completed assessments of the resident’s behavioral, respiratory, cardiovascular, abdominal/gastrointestinal, genitourinary, and neurological status, and there was no documentation that the primary physician had been notified of the change in condition. A progress note by an LVN, timed at 11 PM, documented that at 9:30 PM the resident was found pale with shallow breathing and an O2 sat of 88% on 2 L/min via NC, and that the RN supervisor reassessed the resident and called 911 at 7:37 PM, with paramedics arriving within 5 minutes. This documentation conflicted with the RN’s later interview statements about the timing of events. In an interview, the RN stated that around 9 PM the LVN reported the resident was breathing fast with an O2 sat of 86%, that the RN placed the resident on a non-rebreather mask, the O2 sat increased to 90%, 911 was called after 9 PM, and the resident was placed on continuous O2 sat and heart rate monitoring while the RN remained at the bedside until paramedics arrived. None of the RN’s assessment findings, the initiation of the non-rebreather mask, the continuous monitoring, or the physician notification were documented in the resident’s medical record. The DON confirmed on review that the CICE form was incomplete and emphasized the importance of accurate and complete documentation, as required by the facility’s policies on documentation and notification of changes.
Lack of Competency Assessment for Nurses Managing Pleurx Catheters
Penalty
Summary
The facility failed to ensure that six licensed nurses responsible for the care and management of Pleurx catheters had completed competency assessments to demonstrate their ability to safely handle these devices. Interviews revealed that although in-service training on pleural effusion and Pleurx catheters had been provided, there was no documentation or recollection of formal competency assessments for these nurses. The Director of Staff Development confirmed the absence of such documentation and acknowledged that without competency assessments, there was no verification that staff could properly manage Pleurx catheters. A review of the facility's policies and facility assessment tool indicated that the facility is required to validate staff competencies, especially for specialized care such as catheter management, upon hire and routinely thereafter. The policies also state that training and competency validation should be tailored to the needs of the resident population and any new conditions or procedures. Despite these requirements, the facility did not have evidence that the nurses responsible for Pleurx catheter care had demonstrated the necessary competencies, as required by their own policies and regulatory standards.
Failure to Develop Admission Care Plan for Resident with Pleurx Catheter
Penalty
Summary
The facility failed to develop a care plan upon admission for a resident who had a Pleurx catheter in place. The resident was admitted and re-admitted with diagnoses including malignant neoplasm of the prostate, pleural effusion, and neutropenia. Documentation showed that the resident required partial to full assistance with activities of daily living and mobility. Medical records indicated the Pleurx catheter was placed prior to admission due to recurrent pleural effusion. Despite this, no care plan specific to the management of the Pleurx catheter was created at the time of admission. Interviews with facility staff, including a Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Staff Development, confirmed that a care plan addressing the Pleurx catheter was not developed upon admission. Staff acknowledged the importance of timely care planning for medical devices to ensure proper monitoring, drainage, infection prevention, and clear staff guidance. Facility policies reviewed also required comprehensive, person-centered care plans to be developed upon admission, especially for residents with medical devices, but this was not followed in this case.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Document G-Tube Stoma Condition in Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not documenting redness and leaking from the resident's gastrostomy tube (G-tube) stoma in the Progress Notes under Advanced Skilled Evaluation (PN ASE) over several days. The resident, who had a history of chronic respiratory failure with hypoxia, tracheostomy, and was dependent on staff for all activities of daily living, was readmitted with a G-tube in place. A Change in Condition Evaluation noted the presence of redness and leaking around the G-tube stoma, but subsequent PN ASE entries by licensed nurses did not include any documentation of these findings. Interviews with multiple licensed vocational nurses (LVNs) confirmed that it was standard practice to document head-to-toe assessments, including skin assessments, in the PN ASE. The LVNs acknowledged that redness and leaking from a G-tube stoma should have been documented in the skin assessment section, and failure to do so could result in other staff being unaware of the issue. The Director of Nursing (DON) also stated that it was the responsibility of all licensed nurses to document skin issues every shift in the PN ASE to ensure accurate and timely care. A review of the facility's policy and procedure on documentation indicated that each resident's medical record should provide a comprehensive picture of the resident's progress, with all assessments, observations, and services documented accurately and completely. Despite this policy, the required documentation regarding the resident's G-tube stoma condition was missing from the medical record during the specified period.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its own infection prevention and control policies and procedures regarding hand hygiene and Enhanced Barrier Precautions (EBP) for a resident with significant medical needs, including a gastrostomy tube and tracheostomy. During an observation, two sitters providing care to the resident were seen wearing gowns but not gloves while repositioning the resident and handling the tracheostomy tubing. The sitters were unable to explain the importance of wearing gloves or performing hand hygiene before care, and only donned gloves after being prompted, without performing hand hygiene beforehand. Further, the sitters admitted they did not perform hand hygiene before entering the resident's room, despite signage indicating that hand hygiene and the use of gowns and gloves were required for anyone entering. The sitters also demonstrated a lack of understanding of EBP and its significance in preventing the spread of multidrug-resistant organisms (MDROs), especially for residents with devices such as feeding tubes and tracheostomies. The Director of Nursing confirmed that staff are expected to perform hand hygiene before entering rooms, before and after care, and before donning PPE, and acknowledged the importance of glove use for residents on EBP. Review of facility policies confirmed these requirements, including that hand hygiene must be performed prior to donning gloves and immediately after removing them, and that EBP training is required for staff. The observed failures had the potential to transmit and spread infection within the facility.
Mechanical Lift Transfer Conducted Without Required Two-Person Assistance
Penalty
Summary
A deficiency occurred when a staff member used a mechanical lift to transfer a resident without the required assistance of a second staff member, as mandated by the facility's policy and procedure for safe resident handling and transfers. During an observation, a restorative nursing assistant was seen operating the mechanical lift alone while transferring a resident who was dependent on two-person assistance for all activities of daily living, including transfers. The resident was lifted above the bed using a sling attached to the mechanical lift, with no other staff present in the room. The resident involved had multiple medical conditions, including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, and acute pulmonary edema. The resident's care plan and assessment indicated a need for total assistance from two staff members for transfers due to confusion and impaired balance. Both the staff member involved and the Director of Staff Development confirmed that facility policy requires two staff members to be present when using a mechanical lift, with one operating the lift and the other supporting the resident. The facility's policy, revised in December 2022, explicitly states that two staff must be utilized for mechanical lift transfers to ensure safety.
Failure to Maintain Safe and Sanitary Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary bathroom environment for four residents, as observed during a survey. The bathroom shared by these residents exhibited several issues, including a dark black substance on the corners and baseboard near the toilet, warped baseboards, a brown substance and cracked wall around the water shut-off valve, and a cracked tile floor. Additionally, the safety grab bar had cracked and peeling plaster with an exposed screw, and there was a black substance and crack where the sink met the wall. Under the sink, there was a brown substance and cracked plaster, and the baseboard was also cracked and unpainted. The maintenance logs from January 2024 to February 2025 did not indicate any repairs or maintenance checks for the bathroom in question. During an interview, the Maintenance Supervisor acknowledged the need for repairs due to the hazardous conditions. The residents using this bathroom had respiratory diagnoses, such as COPD and chronic respiratory failure with hypoxia, making them particularly vulnerable. The facility's policies required regular maintenance inspections to ensure a safe and sanitary environment, but these were not followed, leading to the observed deficiencies.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure proper accountability and administration of medications, leading to two deficiencies. Firstly, the facility did not maintain accurate records for narcotic medications stored in one of the medication carts (Med Cart #2) during shift changes on March 1, 2025. The off-going nurse's signature was missing from the Controlled Substances Shift Count Log (SCL) for both the AM and PM shifts, which is necessary to confirm that narcotics were counted and accounted for by both the off-going and on-coming nurses. This lapse in procedure could potentially lead to the diversion of narcotic medications. Secondly, the facility did not administer the correct dose of Polyvinyl Alcohol Ophthalmic Solution to a resident (Resident 50) as ordered by the physician. The resident, who had severe cognitive impairment and was dependent on staff for various activities, was prescribed two drops of the solution in each eye every 12 hours. However, during a medication administration observation, the nurse administered only one drop per eye. This failure to follow the physician's order resulted in the resident not receiving the adequate dose of medication, which could affect the treatment of the resident's eye condition.
Infection Control Lapses in PPE Usage
Penalty
Summary
Facility staff failed to implement proper infection control practices in two separate instances, leading to potential risks of infection spread. In the first instance, a Respiratory Therapist (RT) did not properly wear an isolation gown while performing tracheostomy care on a resident under enhanced barrier precautions. The RT donned the gown but failed to secure the ties at the back, leaving their clothing exposed and in contact with the resident's bed. This oversight was acknowledged by the RT, who admitted that a loose gown could lead to contamination and potential infection spread. In the second instance, a Certified Occupational Therapy Assistant (COTA) did not wear the required personal protective equipment (PPE) while assisting a resident on contact isolation. The resident was being evaluated for Clostridium difficile (C. diff) infection, and the care plan required staff to wear gloves and a gown. However, the COTA was observed assisting the resident without these protective measures. The COTA acknowledged the need for proper PPE to prevent infection spread. Both instances were in violation of the facility's policies and procedures for infection control. The facility's Enhanced Barrier Precautions policy mandates the use of gowns and gloves during high-contact activities to prevent the transmission of multidrug-resistant organisms. Similarly, the Transmission-Based Precautions policy requires donning PPE upon room entry and discarding it before exiting to contain pathogens. These deficiencies highlight lapses in adherence to established infection control protocols, potentially affecting the health of residents and staff.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, safe, sanitary, and homelike environment, affecting multiple areas including the kitchen, resident rooms, and a shared bathroom. In the kitchen, surveyors observed cracked and bubbled plaster on the ceiling near the food preparation area, and worn, cracked, and chipped floor tiles. The Dietary Supervisor acknowledged these issues and stated that the Maintenance Department had been informed, but repairs had not been completed. The Maintenance Supervisor confirmed the need for repairs, recognizing the potential health hazards posed by the unsanitary conditions. In two resident rooms, unpainted plaster and peeling paint were observed, which had not been addressed by the Maintenance Department. Certified Nursing Assistant 6 and Licensed Vocational Nurse 8 were unaware if these issues had been reported, and the maintenance logs did not reflect any repairs or reports for these rooms. The Maintenance Supervisor admitted to previously repairing a wall but failing to paint it, acknowledging the oversight. The unaddressed repairs posed a health risk to the residents, particularly due to the potential for plaster dust exposure. In a shared bathroom, multiple issues were noted, including a dark black substance near the toilet, warped baseboards, cracked and peeling plaster, and exposed screws on a safety grab bar. The Maintenance Supervisor acknowledged the need for repairs, as the conditions were not only unsanitary but also not homelike for the residents. The maintenance logs did not indicate any repairs or inspections for the bathroom, highlighting a lack of adherence to the facility's policy and procedure for maintaining a safe and comfortable environment.
Inadequate GT Care and Infection Control Lapses
Penalty
Summary
The facility failed to provide adequate gastrostomy tube (GT) treatment and services for two residents receiving enteral feedings. For Resident 40, the GT was observed disconnected from the feeding pump, resulting in enteral feeding spilling onto the floor. This incident occurred after Licensed Vocational Nurse (LVN) 7 had powered off the GT feeding pump and disconnected the resident for a bed bath, but the disconnection was not communicated to the incoming Certified Nursing Assistant (CNA) 4. The Director of Nursing (DON) acknowledged that such disconnections could lead to a loss of track of the amount of enteral feeding received, potentially causing weight loss. For Resident 20, the facility failed to follow infection control precautions, as the tip of the resident's GT touched the floor. Additionally, CNA 1 improperly handled the GT feeding pump by disconnecting the feeding and turning the machine on and off, actions that were against the facility's policy. The DON confirmed that CNAs were not permitted to disconnect or operate the GT feedings and emphasized the importance of preventing GT tubing from touching the floor to avoid contamination. Both residents had severe cognitive impairments and were dependent on staff for various activities of daily living. Resident 40 had a history of chronic respiratory failure and dysphagia, while Resident 20 had a diagnosis related to gastrostomy and swallowing difficulties. The facility's policy on the care and treatment of feeding tubes, revised in December 2022, was not adhered to, leading to these deficiencies.
Failure to Label IV Sites as per Policy
Penalty
Summary
The facility failed to ensure proper labeling of peripheral IV sites for two residents, Resident 52 and Resident 116, as per the facility's policy and procedure on Intravenous Therapy. On March 3, 2025, observations revealed that the IV sites for both residents were not labeled with the date and time of the dressing change. This omission was confirmed during interviews with the Infection Prevention Nurse and the Director of Nursing, who acknowledged that the IV sites should have been labeled to prevent infections and to track when the dressing was last changed. Resident 52, who had severe impaired cognition and was dependent on staff for various activities of daily living, had a physician order to restart the IV every 96 hours and change the dressing with site change. Similarly, Resident 116, with moderately impaired cognition and also dependent on staff, had a physician order to rotate the IV site every 7 days. Both residents were admitted with diagnoses including chronic respiratory failure and pneumonia. The lack of labeling on their IV sites had the potential to result in complications and infections, affecting their well-being.
Improper Nasal Cannula Placement for Resident
Penalty
Summary
The facility failed to ensure proper placement of a nasal cannula for a resident, identified as Resident 50, who was dependent on supplemental oxygen due to chronic respiratory failure with hypoxia. During an observation, it was noted that the nasal cannula was positioned on the resident's forehead instead of being placed inside the nostrils as required for effective oxygen delivery. This improper placement was confirmed by the facility's Infection Prevention Nurse, who acknowledged that the nasal cannula needed to be inside both nostrils to maintain the resident's oxygen saturation levels as ordered by the physician. Resident 50, who had severe cognitive impairment and was dependent on staff for various activities of daily living, was at risk due to this oversight. The facility's Director of Nursing also confirmed that the nasal cannula must be correctly positioned to ensure the resident receives the necessary oxygen therapy. The facility's policy on oxygen administration, revised in May 2024, mandates that oxygen is administered under a physician's order and consistent with professional standards, which was not adhered to in this instance.
Incompetent GT Care by CNA
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 1) was competent in providing gastrostomy tube (GT) care for a resident (Resident 20) in accordance with the facility's policy and procedure. Resident 20 was admitted with a gastrostomy and severe impaired cognition, requiring staff assistance for various daily activities. The resident had a physician's order for a specific nutritional formula to be administered via GT at a set rate and duration. During an observation, CNA 1 was seen disconnecting the GT feeding from Resident 20 and turning the machine off and on, actions that were outside the CNA's scope of practice. Interviews with Licensed Vocational Nurse 1 and the Director of Nursing confirmed that CNAs were not trained or authorized to perform these tasks. The facility's policy on feeding tube care, revised in December 2022, indicated that feeding tubes should be utilized in accordance with current clinical standards, which CNA 1 did not adhere to.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure accurate documentation of active diagnoses on the Minimum Data Set (MDS) for a resident, leading to an inaccurate assessment. Resident 168 was administered Aripiprazole for five days to treat schizophrenia, despite not having a documented diagnosis of schizophrenia in their Admission Record. The resident's Admission Record listed other diagnoses, including metabolic encephalopathy, acute and chronic respiratory failure with hypercapnia, depression, and unspecified psychosis, but not schizophrenia. The MDS for Resident 168, dated 3/3/25, indicated that the resident was cognitively intact and had moderate depression, with no indicators of hallucinations or delusions. The active diagnoses selected under Psychiatric/Mood Disorder were depression and psychotic disorder, excluding schizophrenia. However, the Medication Administration Record (MAR) showed that Aripiprazole was administered for schizoaffective disorder, and the care plan noted the use of psychotropic medications for psychosis. Interviews with the MDS Coordinator and the Director of Nursing revealed that the hospital notes upon admission mentioned schizophrenia, but this was not reflected in the MDS. The Director of Nursing acknowledged the error, stating that the MDS should have indicated schizophrenia as an active diagnosis, given the administration of antipsychotic medication. The facility's policy requires accurate coding of assessments, following guidelines from the Resident Assessment Instrument Manual, which was not adhered to in this case.
Failure to Develop Care Plan for IV Therapy
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 52, which included the management of intravenous (IV) therapy. This deficiency was identified during a review of the resident's medical records and interviews with facility staff. Resident 52 had severe impaired cognition and was dependent on staff for various activities of daily living. The resident was admitted with chronic respiratory failure and pneumonia, and there was a physician's order to restart IV therapy. However, there was no clinical documentation indicating that a care plan was initiated or implemented for the management of the IV therapy. Interviews with Registered Nurse 1 and the Director of Nursing confirmed the absence of a comprehensive care plan for Resident 52's IV therapy. The facility's policy and procedure on comprehensive care plans, revised in December 2022, required the development and implementation of a person-centered care plan with measurable objectives and timeframes to meet the resident's needs. The lack of a care plan for IV therapy had the potential to result in unmet individualized needs and affect the resident's physical well-being.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions for a resident, identified as Resident 18, who was at high risk for falls. Resident 18, admitted with Alzheimer's disease and rheumatoid arthritis, had a history of falls and required maximal assistance for mobility. Despite a fall risk score indicating a high risk and a history of unassisted falls, the facility did not ensure continuous supervision as per their Fall Prevention Program policy. On 2/27/2025, Resident 18 experienced an unwitnessed fall, which was not prevented due to the absence of a sitter, a measure that had been previously implemented after a prior fall. Interviews with facility staff, including a Licensed Vocational Nurse, the Director of Staff Development, and the Director of Nursing, revealed that the sitter intervention was not consistently maintained, particularly during the night shift when the fall occurred. The facility's policy required the implementation of interventions based on the resident's risk assessment, which included the use of a sitter. However, there was no documentation to confirm the presence of a sitter at the time of the fall, and staff acknowledged that the fall could have been prevented with proper supervision.
Infection Control Lapse with Indwelling Catheter
Penalty
Summary
The facility failed to adhere to appropriate infection control guidelines for a resident with an indwelling urinary catheter, leading to a potential risk of urinary tract infections. During an observation, the catheter bag of Resident 167 was found lying on the floor, which is against the facility's policy and standard infection control practices. The resident, who was admitted with multiple complex medical conditions including anoxic brain damage, chronic respiratory failure, and neuromuscular dysfunction of the bladder, was at risk due to this oversight. The care plan for Resident 167 specifically included interventions to prevent catheter-related infections, such as ensuring the catheter bag and tubing were positioned below the bladder and away from the floor. Interviews with staff, including the Infection Preventionist Nurse and a Certified Nursing Assistant, confirmed that the catheter bag should not have been on the floor as it posed a contamination risk. The staff acknowledged the issue and recognized the potential for infection if the catheter bag was contaminated. The facility's policy on the use of indwelling catheters emphasized the importance of preventing complications through proper positioning and maintenance, which was not followed in this instance.
Failure to Ensure Specific Indication for Ativan Use
Penalty
Summary
The facility failed to ensure a specific indication for the use of Ativan for one of the residents, as required by their policy and procedure on the use of psychotropic medications. The resident, who was admitted with diagnoses including difficulty with walking and chronic respiratory failure with hypoxia, was prescribed Ativan via gastrostomy tube every six hours as needed for agitation. However, the indication for use, 'agitation,' was not considered a specific diagnosis, which is a requirement for administering such medication according to the facility's policy. During a review of the resident's medical records, the Director of Nurses acknowledged that the indication for Ativan use was not specific enough, as agitation does not qualify as a specific diagnosis. The facility's policy mandates that psychotropic drugs should only be administered when necessary to treat a specific condition that is diagnosed and documented in the clinical record. This oversight had the potential to lead to the use of unnecessary psychotropic drugs and could result in an adverse drug event for the resident.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling practices during a lunch tray line observation. A cook was observed wearing blue nitrile gloves and using silver oven mittens while assisting a dietary assistant with plating lunch food. The cook used the oven mittens to remove hot plates from the oven and then touched various surfaces, including the table and the top of the oven mittens, without changing gloves. Subsequently, the cook sliced bread with the same gloves, which had been in contact with potentially contaminated surfaces, and then handled ready-to-eat food without changing gloves. This practice was identified as a potential source of cross-contamination, which could lead to foodborne illness for 31 of the 64 residents receiving food from the kitchen. The Dietary Supervisor confirmed during an interview that the cook should have changed gloves before handling the bread to prevent cross-contamination. The facility's policy and procedure on personal hygiene and food safety emphasize the importance of using gloves when handling ready-to-eat foods and changing them after touching surfaces that could cause contamination. The U.S. Food and Drug Administration Food Code also supports these guidelines, stating that single-use gloves should be used for one task only and discarded when soiled. The failure to adhere to these practices was observed and documented, highlighting a deficiency in the facility's food handling procedures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was kept within reach for a resident, which was contrary to the facility's policy and procedure titled 'Call Lights: Accessibility and Timely Response.' The resident, who was admitted with diagnoses including difficulty with walking and chronic respiratory failure with hypoxia, was identified as being at risk for falls due to being chair-bound, taking multiple medications, and having several predisposing disease conditions. The resident's care plan indicated a need for the call light to be within reach and for staff to encourage its use for assistance. During an observation, the resident was found lying in bed with the call light hanging on a pole out of reach. The resident expressed an inability to find the call light. A Licensed Vocational Nurse confirmed that the call light was not within reach and acknowledged the necessity for it to be accessible for safety and assistance. The Director of Nursing also stated that call lights should always be within reach for residents. The facility's policy, implemented and revised in December 2022, required staff to ensure call lights were within reach and secured as needed.
Failure to Provide Advance Directive Information to Resident's Representative
Penalty
Summary
The facility failed to provide information regarding an Advance Directive (AD) to the responsible party (RP) of a resident with severe cognitive impairment. The resident, who was admitted with conditions including a gastrostomy and dysphagia, had an AD Acknowledgement Form in their medical record indicating that an AD was executed. However, during an interview, the social worker admitted that the form was filled out incorrectly and that neither the resident nor the RP had executed an AD. The social worker acknowledged that the AD should have been discussed and explained to the RP upon admission. The Director of Nursing confirmed that the social worker needed to discuss AD Acknowledgement forms with residents or their RPs upon admission. The facility's policy and procedure stated that if a resident is unable to formulate an AD due to cognitive impairment, the facility should provide information and education to the resident's representative. The RP of the resident stated they were unaware of what an AD was, as the facility had not discussed it with them. This oversight had the potential to result in a lack of knowledge regarding care and treatment decision-making.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that 11 out of 32 resident rooms met the minimum requirement of 80 square feet per resident in rooms with more than one resident. Specifically, rooms 115, 116, 117, 118, 119, 120, 129, 130, 131, 132, and 133 were identified as having three beds each, with a total room size of 190 square feet, which equates to approximately 63.33 square feet per resident. This deficiency was identified through a review of the facility's Census List and Client Accommodation analysis, which confirmed the inadequate space allocation per resident. During an observation and interview with a Certified Nursing Assistant (CNA), it was noted that the rooms were tight, although care could still be provided, including the use of a hoyer lift for residents with limited mobility. The facility had submitted a room waiver request letter, indicating that the arrangement was in accordance with the special needs of the residents and maintained their best interest. However, the deficiency in room size had the potential to result in inadequate space for nursing care or resident care devices.
Failure to Address Resident's Refusal to Change Leads to Deficiency
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who exhibited behavior of refusing to be changed after becoming soiled with urine. This deficiency was identified during a review of the resident's care plan, which did not include interventions to address the resident's refusal to be changed. The resident, who was admitted and readmitted to the facility with diagnoses including metabolic encephalopathy, functional quadriplegia, and hypertension, was at risk for recurrent urinary tract infections (UTIs) due to incontinence. The care plan indicated that staff were to ensure the resident was clean and dry every two hours, but it did not address the resident's refusal behavior. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), confirmed that the resident often refused to be changed when wet with urine, sometimes delaying changes until after lunch. The Assistant Director of Nursing (ADON) acknowledged that the resident's medical record lacked a care plan addressing the refusal behavior, despite the facility's policy requiring comprehensive care plans that include measurable objectives and timeframes. The policy also stated that alternate methods for refusal of treatment should be attempted and documented, which was not done in this case.
Improper Modification of Overhead Light Pull Cord
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident when a trash can liner was tied to the end of the pull cord for the resident's overhead light. This makeshift solution was implemented because the resident, who had been admitted with conditions including metabolic encephalopathy, functional quadriplegia, and hypertension, was unable to reach the pull cord. The resident required substantial assistance for personal hygiene and dressing and was dependent on staff for toileting hygiene and bathing. The issue was identified during a review of the resident's admission record and a telephone interview with the resident's responsible party, who observed the trash bag tied to the pull cord. The Assistant Director of Nursing confirmed that maintenance staff should have replaced the pull cord to accommodate the resident's needs, but there was no documentation in the facility's Maintenance and Repair Log indicating that the pull cord needed to be lengthened. The Maintenance Supervisor later replaced the pull cord, acknowledging that it was too short and that they had not been informed of the issue until the surveyor's observation.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was admitted with chronic respiratory failure, profound intellectual disability, and anxiety disorder. The resident was severely impaired in cognitive skills and dependent on staff for personal care. On the day of the incident, the resident was agitated and had two sitters assigned for supervision. The abuse occurred when the CNA was providing care to the resident, who was trying to get out of bed. The incident was reported by two sitters who witnessed the CNA's actions. According to the sitters, the CNA grabbed the resident's head and jaw, yelled at the resident, and used derogatory language. The CNA also threatened the resident with a bed remote, shaking it in the resident's face. The sitters described the CNA's behavior as abusive and inappropriate, making them feel uncomfortable. The CNA denied being rough or using foul language but was suspended pending an investigation. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents' health, welfare, and rights. It prohibits any form of abuse, including verbal and physical abuse, and requires the implementation of policies to prevent such incidents. Despite these policies, the facility failed to prevent the abuse of the resident, as evidenced by the actions of the CNA and the observations of the sitters.
Delayed X-ray Results Impact Resident Care
Penalty
Summary
The facility failed to ensure timely receipt of abdominal X-ray results for two residents, leading to a delay in the confirmation of gastrostomy tube (G-tube) placement. Resident 1, who was admitted with chronic respiratory failure and dysphagia, had a dislodged G-tube that was replaced by a wound care consultant. An abdominal X-ray was ordered to confirm the placement, but the results were delayed, preventing the resumption of tube feeding and medication for three days. Despite multiple follow-up calls to the diagnostic company, the results were not received, and the resident had to be sent to a general acute care hospital for confirmation. Similarly, Resident 2, also admitted with chronic respiratory failure and dysphagia, experienced a dislodged G-tube that was replaced, necessitating a stat X-ray for confirmation. The X-ray results were delayed for three days, during which the resident could not receive tube feeding. The facility's licensed nurses repeatedly contacted the diagnostic company, but the results were not available until three days later, delaying the resumption of feeding and medication. Interviews with facility staff, including licensed vocational nurses and the Director of Nursing, revealed that the facility previously received X-ray results within 24 hours from a different diagnostic company. The change in diagnostic service providers resulted in significant delays, impacting the residents' care. The facility's policy requires timely laboratory services to meet residents' needs, which was not adhered to in these cases.
Failure to Provide Required In-Service Training to LVNs
Penalty
Summary
The facility failed to ensure that four of six sampled Licensed Vocational Nurses (LVNs) received the necessary in-service training before signing the facility's In-Service Form, which indicated that they had received such training. The training topics included Dementia, Care of Visually Impaired Residents, Abuse, and Medication Administration. Interviews with LVNs revealed that they were instructed by facility management to sign the forms without actually receiving the training. LVNs reported that the forms were left at the nurse's station, and they were told to sign them, which they did without attending any training sessions. The Director of Staff Development (DSD) acknowledged the importance of in-service training for staff to ensure proper care for residents and stated that staff should not sign the forms without receiving training. However, the DSD admitted there was no system in place to track which training each staff member had completed. The facility's policy and procedure on training requirements emphasized the need for an effective training program and documentation system, but this was not implemented, leading to the deficiency.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for two residents, identified as Residents 8 and 9, who were incontinent of bladder, leading to a potential risk of urinary tract infections (UTIs). Both residents were dependent on staff for toileting, dressing, and bathing due to severe cognitive impairments and physical limitations. The care plans for both residents required staff to check for incontinence and provide care every two hours, including cleaning the perineal area and changing clothing as needed. Observations and interviews revealed that the facility staff did not consistently adhere to the two-hour incontinence check and care schedule. Certified Nursing Assistants (CNAs) reported instances where residents were found soaked with urine, particularly during shifts when the facility was short-staffed. CNA 3 admitted to not being able to change residents frequently enough due to a high workload, and CNA 4 confirmed that Resident 8 was not checked for incontinence for over four hours, resulting in the resident being wet with urine. The Assistant Director of Nursing (ADON) acknowledged that both residents were always incontinent and unable to communicate their needs, emphasizing the importance of regular checks to prevent skin breakdown and UTIs. The facility's policy on incontinence care, dated 12/19/2022, required appropriate treatment and services for incontinent residents to prevent infections, which was not consistently followed, leading to the identified deficiency.
Inadequate Staffing Leads to Incontinence Care Deficiency
Penalty
Summary
The facility failed to provide sufficient staffing to ensure timely incontinence care for two residents, leading to potential risks of skin breakdown and urinary tract infections. Resident 8, admitted with chronic respiratory failure, COPD, and encephalopathy, was dependent on staff for toileting and was always incontinent of bowel and bladder. The care plan for Resident 8 required staff to check and clean the perineal area every two hours, but this was not consistently done due to staffing shortages. Similarly, Resident 9, who had multiple sclerosis, chronic respiratory failure, and paraplegia, was also dependent on staff for toileting and was always incontinent. The care plan for Resident 9 included similar interventions as Resident 8, but these were not consistently followed. Interviews with CNAs revealed that residents were often found soaked with urine, particularly during shifts when staffing was inadequate. This was corroborated by the Director of Staff Development, who acknowledged the staffing challenges, especially during weekends. The facility's policies and procedures emphasized the need for sufficient staffing to meet residents' needs and prevent infections. However, the facility's staffing levels were insufficient to meet these requirements, as evidenced by the experiences of the CNAs and the condition of the residents. The Assistant Director of Nursing confirmed that both residents were incontinent and unable to communicate their needs, highlighting the importance of regular checks and care to prevent adverse outcomes.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post actual worked nursing hours at the start of each shift for one of three days, as required by their policy and procedure titled 'Nurse Staffing Posting Information' dated August 2022. During an observation, it was noted that the nurse staffing posting was dated several days prior and did not include the current date's information. This oversight was confirmed during an interview with the Director of Staff Development (DSD), who acknowledged that the nurse staffing information should be updated by the night shift for the upcoming day. The DSD admitted to not knowing why the staffing information was not posted for the observed date and explained that the postings were generally projections rather than actual hours worked. The facility's policy requires that the nurse staffing sheet be updated at the beginning of each shift, including any changes due to staff call-offs, which was not being adhered to. This failure had the potential to result in residents and visitors not being informed of the facility's nurse staffing information.
Improper Use of Hoyer Lift Puts Residents at Risk
Penalty
Summary
The facility failed to ensure the safe use of a Hoyer lift, a mobile patient lift, for transferring residents, which put four residents at risk for falls and injury. Certified Nurse Assistants (CNAs) 5 and 7 did not use the Hoyer lift appropriately when transferring Resident 6 from the bed to a geri-chair. Instead of following the proper procedure, CNA 7 held Resident 6 by the feet during the transfer, which is against the facility's policy and procedure. The Director of Staff Development (DSD) confirmed that the correct procedure involves one staff member operating the lift and another guiding the resident by holding the sling, not the feet, to ensure safety. Additionally, CNA 4 operated the Hoyer lift alone for Residents 2, 4, and 5, despite the facility's policy requiring two staff members for such transfers. CNA 4 admitted to transferring these residents without assistance multiple times, citing a lack of available help from other staff members. This practice was particularly concerning for residents with tracheostomies, as it posed a risk of dislodging the tracheostomy or causing respiratory distress. The Director of Nursing (DON) and a Respiratory Therapist (RT) emphasized the importance of having two staff members present during transfers, especially for residents with tracheostomies. The facility's policy, titled "Safe Resident Handling/Transfers," mandates the use of two staff members for transfers involving a mechanical lift and requires staff to be trained on safe handling practices. However, the facility did not have a specific policy on operating the Hoyer lift, which may have contributed to the improper use observed. The lack of adherence to established procedures and inadequate staffing during transfers led to the identified deficiencies, putting residents at risk of injury.
Failure to Conduct Reference Check for CNA
Penalty
Summary
The facility failed to conduct a reference check before hiring a Certified Nursing Assistant (CNA), which was a requirement according to their Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation. This policy, dated 5/31/2024, mandates that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. The CNA's employee file contained a blank Pre-Employment Check List, which should have documented at least two references for the applicant. The Director of Staff Development (DSD) confirmed that the reference checks were not conducted as instructed by the Pre-Employment Check List. The DSD acknowledged the importance of conducting reference checks to ensure that new staff do not have a history of abusing residents and to determine if it is safe for them to care for residents at the facility. The failure to conduct these checks placed 70 residents at risk for abuse by the CNA. The facility's P&P also stated that background, reference, and credentials checks should be conducted on potential employees, and documentation of proof that the screening occurred should be maintained. However, this was not done in the case of the CNA in question.
Infection Control Breach in Handling Soiled Linen
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, specifically in the areas of hand hygiene and handling soiled linen. During an observation, a housekeeping staff member was seen transporting an uncovered barrel labeled as soiled linen through the facility's hallway. The staff member only wore a glove on one hand and did not perform hand hygiene before and after handling the soiled linen. This practice was contrary to the facility's policy, which requires staff to wear gloves on both hands and perform hand hygiene before and after handling soiled items. Interviews with the housekeeping staff member, the Infection Preventionist, and the Housekeeping Supervisor confirmed the deviation from the established procedures. The Infection Preventionist emphasized the importance of covering the soiled linen barrel during transport to prevent cross-contamination. The facility's policies, revised in December 2022, clearly state the necessity of hand hygiene and the use of personal protective equipment to prevent the spread of infection. The failure to follow these procedures had the potential to result in cross-contamination and the spread of infection throughout the facility.
Failure to Maintain Cleanliness in Shower Rooms
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring cleanliness in two shower rooms. During an observation, the shower room in Skilled Nursing Facility 1 (SNF 1) was found to have chipped paint on the tiles inside the shower stall and a black colored substance in the far-right corner of the shower stall. The Maintenance Supervisor (MS) confirmed the presence of peeling paint and black substance, describing it as dirt buildup. The MS acknowledged missing the chipping paint and stated that housekeeping was responsible for cleaning the shower rooms. Further observations with the Housekeeping Supervisor (HS) revealed the presence of a black substance in the corners and between tiles in both the SNF 1 and Subacute (SA) shower rooms. The HS confirmed that it was the housekeeping department's responsibility to clean the showers and stated that the black substance should not be present. The facility's Policy & Procedure, titled 'Safe & Homelike Environment,' indicated that housekeeping and maintenance services should maintain a sanitary, orderly, and comfortable environment, which was not adhered to in this instance.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 4, which violated their right to be treated with respect. Resident 4, who was readmitted with diagnoses including dysphagia, functional quadriplegia, and noninfective gastroenteritis and colitis, was found to have moderate cognitive impairment and was dependent on staff for personal care. During an interview, Resident 4 reported that a Certified Nurse Assistant (CNA) did not clean them properly, only cleaning the front and leaving them soiled. The CNA allegedly pulled off Resident 4's covers, pointed a finger at them, and instructed them to stop yelling because others were sleeping, which made Resident 4 feel awful and angry. Another resident, identified as Resident 2, corroborated the incident by stating they heard the CNA yell at Resident 4, denying that Resident 4 was wet. The Director of Nursing (DON) confirmed that staff should not raise their voices at residents, as it could cause emotional issues and make residents feel disrespected. The facility's policy on promoting and maintaining resident dignity emphasized treating residents with respect and dignity, speaking respectfully, and avoiding discussions about residents that could be overheard. This incident highlights a breach in the facility's policy and procedure regarding resident dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light for one of the residents was within reach, which could potentially delay care. The resident, who was readmitted with diagnoses including dysphagia, functional quadriplegia, and moderate cognitive impairment, was unable to locate or reach the call light due to mobility issues. During an interview, the resident expressed that they had to yell for help because the call light was placed on the side they could not move. An observation confirmed that the call light was on the floor behind the resident's bed, making it inaccessible. A CNA acknowledged that the call light should not have been placed there and suggested that it might have been moved by a previous CNA. The Director of Nursing emphasized the importance of keeping call lights within reach to ensure residents can alert staff when assistance is needed. The facility's policy requires staff to ensure call lights are accessible to residents, but this was not adhered to in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, specifically involving Resident 1 and Resident 2. On June 5, 2024, Resident 2 hit Resident 1 on the right upper arm after an altercation where Resident 1 allegedly called Resident 2 a 'stupid idiot.' Resident 2, who was admitted on March 15, 2024, had no cognitive impairment according to the Minimum Data Set (MDS) but exhibited paranoid delusions and poor impulse control as noted in an Initial Psychiatric Evaluation on the day of the incident. Resident 2 was on medication for psychosis, including Risperidone, and had a history of agitation and disagreements with other residents. Resident 1, admitted on March 20, 2024, had severe cognitive impairment and was dependent on staff for most activities of daily living. The incident was documented in Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form, which noted the physical altercation. Interviews with staff, including a Certified Nursing Assistant (CNA), the Assistant Director of Nursing (ADON), and a Respiratory Therapy Supervisor (RTS), revealed that Resident 2 was known to have episodes of forgetfulness and agitation, and the RTS witnessed the altercation and intervened to separate the residents. The facility's policy on Abuse, Neglect, and Exploitation, dated December 19, 2022, mandates the prevention of abuse through written policies and procedures. The policy defines abuse as the willful infliction of injury and requires the facility to implement measures to prevent abuse, including identifying and addressing situations where abuse is more likely to occur. Despite these policies, the facility failed to prevent the altercation between Resident 1 and Resident 2, resulting in physical abuse.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse within the required timeframe. On 4/22/2024, Resident 4, who had a history of physical aggression due to dementia, grabbed Resident 2's right upper arm. This incident was reported to the Administrator (ADM) by the staff, but the ADM did not report it to the Department of Public Health until 5/7/2024, 15 days later. The ADM did not consider the incident as abuse, despite the facility's policy requiring such incidents to be reported within two hours. Resident 4 was admitted with diagnoses including dementia and type II diabetes mellitus, and had a care plan indicating a potential for physical aggression. Resident 2, who was grabbed, had Huntington's disease and difficulty walking. The incident was initially reported by a certified nurse assistant to a Licensed Vocational Nurse (LVN), who then informed the Registered Nurse Supervisor and the Director of Nursing (DON). The facility's policy mandates that any allegations of abuse be reported immediately to protect residents' health and well-being. Interviews with the ADM, LVN, and DON revealed that the ADM, who is the facility's abuse coordinator, failed to report the incident as required. The ADM acknowledged that grabbing another resident could be considered abuse and that such allegations should be reported within two hours. The facility's policy on abuse, neglect, and exploitation emphasizes the importance of timely reporting to prevent further incidents and ensure resident safety.
Failure to Provide Appropriate Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore continence for a resident who was occasionally incontinent of urine and had mobility issues. The resident, who was admitted with functional quadriplegia and gait abnormalities, was able to verbalize the need for assistance and was continent of bowel and bladder function according to the care plan. However, the staff did not offer alternative methods for toileting, such as a bed pan, and instead instructed the resident to urinate in the incontinence brief, which was then changed afterward. Interviews with the resident and staff revealed that the resident felt trapped and like a burden, as staff found it too difficult to use the Hoyer lift for transfers. The CNAs admitted to not offering a bed pan or other alternatives, despite the resident's ability to control urination. The LVN and MDS Coordinator confirmed that the resident was mostly continent and should have been offered toileting assistance to maintain or improve continence status. The lack of a toileting program or schedule further contributed to the resident's unnecessary incontinence. The Director of Nursing acknowledged that the resident should have been assisted with toileting to promote independence and reduce the risk of infections and falls. The facility's policy indicated that residents should receive appropriate treatment to maintain continence, but this was not followed in the case of the resident. The failure to provide necessary assistance and alternatives for toileting led to the resident being forced into incontinence, which was not reflective of their actual continence status.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as Resident 1, by not providing appropriate toileting assistance. Resident 1, who was admitted with functional quadriplegia and mobility issues, was able to control bowel and bladder functions and could verbalize the need for assistance. Despite this, Certified Nursing Assistants (CNAs) 1 and 2 instructed Resident 1 to urinate in an incontinence brief rather than offering alternative methods such as a bed pan or assisting with a transfer to the toilet. This approach was contrary to the resident's care plan, which indicated that staff should assist with toileting. Interviews with Resident 1 revealed feelings of depression and being a burden, as the resident was made to feel like an animal due to the lack of proper toileting assistance. The CNAs admitted to not offering a bed pan or other alternatives, citing the difficulty of using a Hoyer lift for transfers. This neglect in providing appropriate care was acknowledged by the CNAs, who recognized that offering a bed pan could improve the resident's independence and continence status. Further interviews with the Licensed Vocational Nurse (LVN) and the MDS Coordinator confirmed that Resident 1 was occasionally incontinent but had control over bladder functions most of the time. They emphasized the importance of offering toileting assistance to maintain and potentially improve continence. The Director of Nursing (DON) also stated that the practice of telling Resident 1 to urinate in the brief was not acceptable and did not accurately reflect the resident's continence status, potentially leading to feelings of helplessness and depression.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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