Courtyard Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Davis, California.
- Location
- 1850 East 8th Street, Davis, California 95616
- CMS Provider Number
- 055922
- Inspections on file
- 50
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Courtyard Health Care Center during CMS and state inspections, most recent first.
Two residents with multiple medical diagnoses, including surgical aftercare and respiratory failure, reported physical abuse by a CNA. The facility submitted initial incident reports to CDPH but did not provide the required 5‑day investigation results within the mandated timeframe. In addition, after one resident’s abuse allegation, nursing staff did not complete or document the immediate assessment required by facility policy, as confirmed by the DON.
A resident with CKD, schizophrenia, and bipolar disorder, who was cognitively intact, was found with bruising on the face and reported that a CNA had hit her and pulled her hair during care. Another CNA had been told of this allegation the prior day when the resident pointed out the facial bruise and described being hit and having her hair pulled at night, but the CNA did not report the allegation immediately, stating she did not know what to do and did not believe the resident. The facility’s abuse policy required staff to immediately report any actual or potential abuse to a supervisor or the administrator, and leadership confirmed this incident was reportable and should have been reported without delay.
Surveyors observed that clean utensils had food particles and water residuals, and utensil holders contained black particles. A dietary aide handled clean kitchenware without washing hands after working with dirty dishes. The dietary manager and registered dietician confirmed these practices did not meet sanitation standards, and facility policy requiring proper dishwashing and hand hygiene was not followed.
A resident was not adequately prepared for a safe transfer or discharge, as the facility did not ensure the process met the individual's needs and preferences.
A resident with severe cognitive impairment and recent brain surgery was discharged to a hotel without home health services in place, contrary to physician orders. The required 30-day discharge notice was not provided in advance, and necessary post-discharge follow-up and documentation, including a physician discharge summary and MDS assessment, were missing. The resident was later found confused and hospitalized, and facility staff confirmed these failures.
A resident with severe cognitive impairment and a history of wandering exited the facility without staff authorization and was found offsite. Facility staff did not complete an elopement risk assessment, care plan, or document the incident as required by policy.
Three residents with specific dietary preferences and medical conditions did not receive their requested meal items, including double protein portions, green salad, and fresh fruit, as documented on their meal tickets. These omissions were confirmed by both the residents and dietary staff, indicating a failure to honor resident food preferences during meal service.
Surveyors found that refrigerated food items, including yogurt, were left at room temperature for several hours after delivery and not promptly stored as required. Additionally, staff failed to document freezer temperatures during one shift, contrary to facility policy. These actions did not meet professional standards for food safety.
A resident with hemiplegia and no memory impairment was physically struck multiple times by another resident with severe memory impairment and bipolar disorder, as witnessed by staff. The incident caused physical pain, facial redness, and emotional distress, with the affected resident becoming tearful and upset. Staff acknowledged the event as physical abuse, and facility records confirmed the altercation and its impact.
Sixteen meal tickets containing residents' names, allergies, and therapeutic diets were left unattended in the memory unit dining area. Both the RD and DON confirmed this was a HIPAA violation, as facility policy requires safeguarding and proper disposal of PHI.
Licensed nurses did not administer medications on time, failed to verify resident identity or explain medications before administration, and did not follow physician orders for continuous gastrostomy feeding. These deficiencies were observed in multiple residents with complex medical needs, and staff acknowledged not following required procedures.
During an EHR system outage, nursing staff were not provided with timely instructions and were unaware of the contingency procedures, resulting in delays in medication administration. The DON and ADM confirmed that no mock drills for EHR outages had been conducted, and staff had not been trained on the emergency plan, despite facility policies requiring such preparation.
The facility did not maintain documentation or evidence of QAPI meetings for three consecutive quarters, and multiple staff members were unaware of the required QAPI activities. The Administrator confirmed the absence of records and meetings, and the facility's policy requiring ongoing documentation was not followed.
Surveyors found that infection control practices were not followed, including improper storage of a CPAP mask, lack of Enhanced Barrier Precautions for multiple residents with invasive devices or wounds, and failure to label and date medical equipment such as oxygen tubing, feeding tubes, and IV bags. Staff were also observed not performing hand hygiene between resident contacts and during medication administration, with both a CNA and an LPN confirming they forgot to do so.
Several residents with complex medical needs reported and were observed experiencing late meal service, with some waiting up to 1 to 2 hours for meals. Staff confirmed the delays, and the posted dining schedule lacked specific meal times. The facility's policy required timely meal delivery in line with resident preferences and community norms, but this was not followed, resulting in resident dissatisfaction and potential impacts on care.
Surveyors found that food service staff failed to label, date, and monitor refrigerated and frozen foods, with expired and improperly stored items present. Temperature logs for all cold storage units were incomplete. In the dry storage area, fruit flies and improperly sealed food items were observed. Additionally, a dietary aide was seen assembling trays without a beard net, exposing facial hair near uncovered food. These failures were confirmed by the Dietary Manager and Registered Dietician.
Surveyors observed a brownish frozen residue in a freezer, ovens and stove burners with food and burnt residue, and a boilerless steamer leaking liquid onto the floor. The Dietary Manager and Registered Dietician confirmed these unsanitary conditions, and the Maintenance Assistant stated the steamer was broken and not repaired. Facility policies required regular cleaning and maintenance, which was not followed.
Three non-English speaking residents with documented language barriers and care plans requiring communication boards did not have these aids available at their bedside. Staff confirmed that communication boards in the residents' primary languages should have been present, but observations showed they were missing, with only English-language materials available in one case. This was not in accordance with facility policy or the residents' care plans.
A resident reported and staff confirmed unsanitary conditions in a shower room, including a dark brown substance on the floor, and four rooms in the memory care unit had dirty, worn curtains with brown discolorations. Facility policy required clean, intact linens and prompt reporting of areas needing cleaning, but these standards were not met.
A resident who was bedbound and dependent on staff for mobility did not receive regular turning and repositioning as required for pressure ulcer prevention. Despite being at risk for skin breakdown and unable to reposition independently, the care plan lacked specific interventions for two-hourly turning, and staff interviews confirmed the resident was not consistently turned. This failure to follow professional standards and facility policy placed the resident at risk for pressure injuries.
A resident with multiple complex medical conditions, including dementia and dysphagia, experienced significant unaddressed weight loss after admission. Despite care plans and facility policies requiring weekly weight monitoring and prompt intervention for significant changes, a weight entry was missed, and the resident was not included in weight review meetings. This failure to monitor and address the resident's weight loss resulted in further decline.
Two residents with significant pain-related diagnoses did not receive timely pain assessments or administration of prescribed pain medications. One resident was left in severe pain and unable to participate in therapy, while another experienced prolonged discomfort due to delayed medication administration. Staff did not follow care plans or facility policies regarding pain management and medication timing.
The facility did not maintain proper destruction logs for discontinued controlled medications and failed to reconcile controlled drug records when original narcotic sheets went missing for 11 residents. The DON confirmed that medications were not properly documented or scanned into the pharmacy system, and no reconciliation was performed when the original records were recovered, contrary to facility policy.
Surveyors found expired tube feeding formulas, unlabeled medical supplies, and improper storage of medications in medication rooms and carts. Non-narcotic medications were kept in narcotic cabinets, expired and unsealed medications were not discarded, and medications for discharged residents remained in carts. Opened over-the-counter medications lacked open dates, and narcotic count sheets were missing required nurse signatures, all contrary to facility policy as confirmed by the DON and pharmacy consultant.
A resident with diabetes and a recent amputation did not receive prescribed Novolin insulin on several occasions, with medication administration records left blank or marked as held without a physician's order. The DON confirmed there was no documentation or order to justify withholding the insulin, in violation of facility policy requiring proper medication administration and documentation.
The facility failed to maintain sanitary practices in the kitchen, with freezer temperatures out of range and incomplete cleaning schedules. Mold was found near the kitchen exit, and infection control practices were inadequate, as confirmed by the RD and Environmental Services staff.
A resident with anemia, depression, and diabetes did not receive their prescribed Vitamin D3 1000 IU due to the facility's failure to stock the medication. A nurse resorted to cutting unscored 2000 IU tablets, contrary to policy. The DON expected OTC medications to be stocked, but a refill request was pending.
The facility failed to follow food safety standards by improperly thawing frozen fish filets on a countertop and not labeling opened food items, including spices and beef base. The Dietary Supervisor confirmed these practices, which contradict the facility's policies on safe food handling and labeling.
A kitchen freezer in the facility was found with a broken seal gasket and ice buildup, potentially compromising food safety. The Dietary Supervisor confirmed the issue, noting that some food items were not properly frozen and had freezer burn. The facility's guidelines and FDA Food Code require equipment seals to be intact and free of ice buildup, which was not maintained.
A resident with dementia and other mental health conditions was punched by another resident while attempting to enter their room, as witnessed by staff. The incident occurred due to inadequate supervision, allowing the resident to access the courtyard. Both residents had care plans indicating the need for monitoring, which were not effectively implemented, leading to the altercation.
A resident with a history of disruptive behavior and cognitive impairments was unsupervised in the courtyard, leading to an altercation with another resident. Despite protocols requiring supervision and locked doors, the resident accessed the courtyard and was punched by another resident, resulting in a fall.
A resident with Type 2 diabetes was struck multiple times by another resident with moderate memory impairment and hemiplegia after a minor collision in the hallway. The incident, witnessed by staff and other residents, resulted in no physical injury but impacted the victim's self-esteem. Facility staff acknowledged the incident as abuse, as it affected the resident's mental well-being.
The facility failed to provide a resident with recommended Restorative Nursing Aide (RNA) services after discharge from Physical Therapy (PT), leading to a decline in the resident's ability to use a walker. Despite a care plan and PT discharge summary recommending RNA services, these were not implemented, resulting in decreased mobility and frustration for the resident.
The facility failed to protect resident information when meal tickets containing personal and medical details were discarded into the garbage and subsequently into an outside dumpster. This practice was confirmed by the dietary manager and the assistant director of nursing, who stated that tray cards should be shredded. The facility's policy indicated that PHI must be safeguarded and disposed of using methods that render it unusable.
The facility failed to ensure adequate indications for the use of psychotropic medications for two residents. One resident was administered olanzapine despite no documented indicators of psychosis, and another was given aripiprazole without proper documentation. Non-pharmacological interventions were not adequately considered, and the documentation did not support the use of these medications.
A facility failed to ensure a medication error rate below 5% when a nurse administered a resident's medications through a gastrotomy tube in a manner not consistent with standard practices or facility policy, resulting in a 30.3% error rate. The nurse mixed multiple medications together and did not flush between administrations, contrary to the resident's medication orders and facility policy.
The facility failed to ensure medications were stored in a clean and sanitary environment and labeled correctly with open and discard dates. Loose pills and improperly labeled medications were found in medication carts, and a medication blister pack was displaced. The ADON acknowledged these issues and stated that the night shift should be responsible for checking and cleaning the carts.
The facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety. Issues included non-functional thermometers, incomplete temperature logs, improperly labeled and expired food items, unsanitary kitchen equipment, and inadequate hand hygiene practices by kitchen staff. These failures decreased the facility's potential to prevent foodborne illness for the residents who ate facility-prepared food.
The facility failed to obtain informed consent for the use of psychotropic medication from the responsible party (RP) for a resident. The resident, who had multiple diagnoses including dementia and major depressive disorder, was prescribed quetiapine. The physician increased the dosage, but there was no documented informed consent from the RP for this change. The absence of documented informed consent was confirmed by the ADON and SSD during the survey.
The facility failed to develop and implement person-centered comprehensive care plans for three residents requiring oxygen therapy. One resident was receiving oxygen at a higher rate than prescribed, while two others had no care plans reflecting their need for oxygen therapy, despite having physician orders.
The facility failed to revise care plans for two residents in a timely manner, impacting their potential to receive appropriate interventions. One resident with a gastrostomy tube had a discrepancy in tube feeding orders, while another resident with a urinary tract infection had no active antibiotic orders despite the care plan indicating otherwise. Additionally, a resident with absence epileptic syndrome had issues with oxygen therapy compliance, with the nasal cannula tubing found on the floor and not connected to the resident.
The facility failed to ensure professional standards of quality in nursing care for a resident by not obtaining informed consent for psychotropic medication, not having a physician's order to flush a midline catheter, and not following the prescribed oxygen administration order.
The facility failed to ensure proper pharmacy services when a medication was improperly disposed of in an open trash can on the side of the medication cart. A Licensed Nurse acknowledged the safety hazard, and the Assistant Director of Nursing confirmed that the practice did not align with the facility's policy for medication disposal.
The facility failed to ensure pureed foods were prepared according to standardized recipes, affecting their nutritional value and flavor. Cook 1 used unmeasured amounts of tap water and canned liquid instead of the specified low sodium broth, gravy, or milk. The Dietary Manager confirmed that staff are expected to follow recipes to maintain nutritional value and flavor.
The facility failed to maintain two reach-in freezers and two reach-in refrigerators in safe operating condition, compromising food safety and quality for 103 residents. The seals on the equipment were found to be torn or covered with tape, and the Maintenance Director could not provide proof of progress in obtaining replacements.
Failure to Timely Report Abuse Investigation Results and Assess Resident After Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of abuse investigation results to the California Department of Public Health (CDPH) and failed to complete a required nursing assessment following an abuse allegation. One resident, admitted in September 2025 with multiple diagnoses including surgical aftercare, and another resident, admitted in December 2024 with multiple diagnoses including respiratory failure, each reported physical abuse by a CNA. Incident reports for these allegations were submitted to CDPH on 1/26/26 and 1/28/26. However, the facility’s 5‑day investigation results for both incidents were not submitted to CDPH until 2/10/26, which exceeded the required five working days. The Administrator confirmed that the results of the investigations were not provided within the regulatory timeframe, despite facility policy stating that allegations of abuse will be reported to state or federal agencies within applicable regulatory timeframes. The facility also failed to perform and document a nursing assessment for the resident with respiratory failure after the abuse allegation on 1/28/26. Review of this resident’s medical record showed no documentation that a nurse assessed the resident following the reported abuse. In an interview, the DON confirmed that an assessment was not completed after the allegation and stated that the expectation was for an assessment to be done. The facility’s abuse prevention policy specified that a licensed nurse will immediately examine a resident upon receiving reports of alleged physical abuse and that the findings of the examination shall be recorded in the resident’s medical record, which did not occur in this case.
Failure to Timely Report Resident’s Allegation of Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported within the required timeframe after a cognitively intact resident reported being injured by staff during care. The resident, admitted with chronic kidney disease, schizophrenia, and bipolar disorder, was observed by a charge nurse late in the evening with purple and yellow discoloration on the right cheek. When questioned, the resident stated that a CNA assigned to her had hit her in the face and pulled her hair after she touched the CNA without notice, though she could not recall the exact date, time, or identity of the staff member involved. The resident later described that the CNA thought she was acting out in aggression, grabbed her hands, hit her in the face, and pulled her hair, which made her feel scared and hurt. Investigation documents showed that another CNA (CNA 2) became aware of the resident’s allegation the day before the charge nurse noted the bruising, when the resident asked if she saw the bruise and reported that a CNA had hit her and pulled her hair in the middle of the night. CNA 2 did not report this allegation at that time, stating she did not know what to do with the information and did not believe the resident because of things the resident says, and instead waited until the next day to ask the resident again, who repeated the same story. The facility’s abuse policy required staff with knowledge of an actual or potential violation to report it to a supervisor or the administrator immediately, and stated that all allegations of abuse, neglect, misappropriation, or exploitation should be reported immediately to the administrator. The Executive Director confirmed this was a reportable incident and that his expectation was that staff report such allegations to the charge nurse within the required timeframe.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in food service, as evidenced by observations of unclean utensils and improper hand hygiene practices among dietary staff. During an inspection, multiple small black particles were found on utensil holders, and several forks and spoons had visible food particles and water residuals. Both the Dietary Manager and Registered Dietician confirmed that these utensils were not properly cleaned and acknowledged that utensils used for residents should be free of food particles. The facility's policy requires all dishes to be properly sanitized and gross food particles to be removed before washing, which was not followed in this instance. Additionally, a Dietary Aide was observed manually washing kitchenware and then handling clean kitchen containers without performing hand hygiene in between tasks. The aide confirmed that he did not wash his hands before touching the clean side of the dishwashing area, despite being the only person assigned to dishwashing at the time. The Registered Dietician stated that two people should be involved in dishwashing to prevent cross-contamination and that handwashing is required before handling clean items. The facility's policy also specifies the need to wash hands and change gloves to prevent cross-contamination, which was not adhered to during the observed events.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Ensure Safe and Appropriate Discharge for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge for a resident with severe cognitive impairment and a history of brain tumor and craniotomy. The facility did not follow physician discharge orders, as the resident was discharged to a hotel without home health services being established, despite orders for home health RN, PT, and OT. The required 30-day discharge notice was not provided in advance but was instead given at the time of discharge, depriving the resident of the opportunity to appeal. Additionally, the facility did not develop or document post-discharge follow-up for a neurology referral, and there was no physician discharge summary in the resident's medical record. Further review revealed that the MDS discharge assessment was incomplete and not submitted, and cognition and mood assessments were not performed. The resident, who had documented severe cognitive deficits and required maximum cues for memory and following directions, was found confused and non-verbal after discharge, leading to hospitalization. Facility staff, including the Social Services Director, MDS Coordinator, DON, and Administrator, confirmed these deficiencies and acknowledged that the discharge was not conducted safely or in accordance with facility policy and federal requirements.
Failure to Assess and Intervene After Resident Elopement
Penalty
Summary
A resident with a history of severe cognitive impairment, including a brain tumor, cognitive communication deficit, and memory impairment, was admitted to the facility. The resident's records indicated difficulty following directions and a need for maximum cues. Despite these documented cognitive deficits and a known tendency to wander, the resident was able to exit the building without staff authorization and was later found at a liquor store by facility staff. Review of the resident's medical records revealed there was no documented evidence of an elopement care plan, elopement risk assessment, or change of condition assessment following the incident. Interviews with facility staff, including a licensed nurse, the Social Services Director, and the Administrator, confirmed that the facility did not assess or implement interventions for the resident's elopement risk as required by facility policy. Additionally, there was no documentation of the incident or follow-up actions in the resident's record, contrary to the facility's elopement and missing resident policy.
Failure to Accommodate Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to accommodate the documented food preferences of three residents during a lunch meal service. One resident, with a history of anemia and vitamin D deficiency, did not receive the double portion of protein as specified on her meal ticket and confirmed this during an interview. The Dietary Manager also verified that the lunch tray did not include the required double protein portion. Another resident, also diagnosed with anemia, had a preference for a green vegetable with every meal, specifically requesting a green salad, but did not receive any salad with her lunch. This was confirmed by both the resident and the Dietary Manager upon review of the meal tray. A third resident, with a diagnosis of vitamin D deficiency, had a preference for fresh fruit for dessert, as indicated on her meal ticket. During observation and interview, it was noted that no fresh fruit was provided on her lunch tray, and the resident expressed concern about its absence. The Registered Dietician confirmed that the fresh fruit was not included and acknowledged that residents' food preferences should have been honored according to their choices. The facility's policy requires staff to determine and provide for residents' food preferences at meals, but this was not followed for these three residents.
Plan Of Correction
This plan of correction constitutes the facility's written 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 of the facts alleged or the conclusion set forth on the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because required by the provisions of the health and safety code section 1280 and 42 CFR 483. Immediate corrective action(s) for those Residents affected by the deficient practice: Dietary Manager (DM) and Resident 1 communicated to clarify this resident's preference as it was stated small portions and double protein. Residents requested to maintain small portions and remove double protein. Dietary Manager updated resident's preferences. Registered Dietitian (RD) clarified with Resident 2 that she wants green vegetables with lunch and a spinach salad during dinner, no green vegetable with breakfast. Resident's meal ticket updated with these preferences. In addition to a preference on her meal ticket, RD added Resident's request to the standing daily meal request list to ensure our staff prepare and serve this each meal. RD clarified with Resident 3 who confirmed she wants fresh fruit with all meals, and this Resident's meal ticket updated reflecting this. Plan / Process to identify other residents potentially affected by the same deficient practice and corrective action(s) to be taken; All residents have the potential to be negatively affected if Resident's preferences aren't followed. Facility measures and systemic changes to ensure the deficient practice does not recur; Systemic changes to address the deficient practice include, but are not limited to auditing all current residents' preferences regarding double protein, green vegetables with every meal, and fresh fruit for dessert. RD to clarify that double protein requests are nutritionally appropriate. Dietary Manager will create a list of residents who request green vegetables with every meal and fresh fruit for dessert and assign a Dietary Aide to prepare an adequate number of items prior to meal service. Each of the following team members will audit 2 meal services per week by pulling 4 random trays prior to each meal cart exiting the kitchen. The attached audit form will be utilized for this audit.
Failure to Store and Monitor Food Safely
Penalty
Summary
The facility failed to store food in a sanitary manner for its residents. On the day of the survey, two boxes containing 48 cups each of yogurt were observed left on the kitchen floor at room temperature for over three hours after delivery. The Dietary Manager confirmed that the yogurt, along with other refrigerated items such as milk and eggs, should have been placed in the refrigerator immediately upon arrival but were not. Both the Dietary Manager and the Registered Dietician acknowledged that the yogurt should have been discarded due to the risk of foodborne illness. Facility policy requires that potentially hazardous foods be put away quickly to minimize contamination and bacterial growth. Additionally, the facility did not monitor and document the temperature of a freezer during an evening shift, as required by their policy. The Dietary Manager confirmed that the freezer temperature log was missing an entry for the specified shift, and stated that accurate documentation is necessary to ensure food is held at safe temperatures. The facility's policy mandates that cooler and freezer temperatures be checked and recorded daily using internal thermometers.
Plan Of Correction
Facility plan to monitor corrective actions & sustain compliance; Integrate QA Process; RD will compile data from these audits and present to monthly QAPI meetings for 3 months to ensure substantial compliance. F0812 - Immediate corrective action(s) for those residents affected by the deficient practice; Dietary staff threw the yogurt out that wasn't properly stored within two hours of delivery. Plan / Process to identify other residents potentially affected by the same deficient practice and corrective action(s) to be taken; All residents have the potential to be affected if time sensitive foods aren't properly stored after delivery within 2 hours. Facility measures and systemic changes to ensure the deficient practice does not recur; Dietary Manager (DM) completed an in-service focusing on the urgency of prioritizing time sensitive foods on 7/29/25 for dietary staff that manage food delivery. In-service conducted on 8/7/25 covering proper procedure for logging fridge and freezer temperatures. The DM or designee will audit to ensure that all time sensitive items have been properly stored one hour after food delivery (Tuesdays and Fridays). If any item is found to still be out, DM or designee will assist Dietary Aide to ensure time sensitive items are stored properly within 2 hours of delivery. Freezer temperature logs will be audited daily by the DM and Assistant Dietary Manager daily. Facility plan to monitor corrective actions & sustain compliance; Integrate QA Process; Audit results will be presented at monthly meetings for a minimum of three months to the QAPI committee to ensure compliance.
Resident-to-Resident Physical Abuse Resulting in Pain and Emotional Distress
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and no memory impairment was physically abused by another resident with severe memory impairment and a diagnosis of bipolar disorder. Staff, including a CNA, witnessed the second resident striking the first resident multiple times on the hand and face. The incident resulted in the first resident experiencing physical pain, redness on the face, and emotional distress, as documented in progress notes and interviews. The affected resident was observed to be tearful, upset, and uncomfortable following the altercation. The facility's own policy states that each resident has the right to be free from abuse, including physical abuse such as hitting. Multiple staff members, including the CNA, Social Services Director, and DON, acknowledged that the first resident was a victim of physical abuse by another resident. The incident was documented in the SBAR form and progress notes, and the emotional impact on the resident was significant enough to warrant a referral to psychiatry.
Resident Meal Tickets with PHI Left Unattended in Memory Unit
Penalty
Summary
Sixteen resident meal tickets containing sensitive information, including residents' names, allergies, and therapeutic diets, were left unattended on a table in the facility's memory unit dining area. This was observed during a visit with the Registered Dietician, who acknowledged that the meal tickets should not have been left out and should have been taken to the shredder, identifying the situation as a HIPAA violation. The Director of Nursing also confirmed that leaving meal tickets unattended constitutes a HIPAA violation and that such documents need to be shredded. Review of the facility's policy indicated that employees are required to safeguard protected health information (PHI) and ensure proper disposal to prevent unauthorized access.
Failure to Adhere to Medication Administration and Feeding Protocols
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted professional standards of clinical practice in several key areas. Licensed nurses did not administer medications in a timely manner to multiple residents, with medication administration times significantly delayed beyond the facility's policy of one hour before or after the scheduled time. For example, medications scheduled for early morning were not given until late morning or early afternoon for several residents with complex medical conditions, including Parkinson's disease, diabetes, heart failure, stroke, and hypertension. These delays were confirmed through review of medication administration records and direct interviews with staff, who acknowledged the late administration. Additionally, licensed nurses did not follow proper procedures for verifying resident identity or explaining medications prior to administration. Observations showed that nurses prepared and administered medications to several residents without checking identification or informing them about the medications being given. When questioned, the nurses admitted to omitting these steps. Facility policy requires verification of resident identity and explanation of medications, but these procedures were not followed during the observed medication passes. The facility also failed to follow physician orders for continuous gastrostomy feeding for a resident dependent on tube feeding. Observations revealed that the resident's feeding pump was repeatedly beeping with a hold error, and the feeding formula volume remained unchanged over several hours, indicating that the prescribed nutrition was not being delivered. The nurse responsible confirmed that the pump should have been running continuously, and the DON stated that staff are expected to monitor and respond to feeding pump alarms. The facility's policy requires medications and treatments to be administered in accordance with prescriber orders, but this was not done in this case.
Failure to Implement EHR Downtime Contingency Plan and Staff Training
Penalty
Summary
The facility failed to implement its facility assessment and ensure staff adherence to the established contingency plan during an electronic health record (EHR) system downtime. When the EHR became inaccessible due to an internet outage, nursing staff were not provided with timely direction and were unaware of the procedures to follow. The Director of Nursing (DON) stated that nurses were expected to print medication administration records (MARs) from a backup computer, but the backup computer was also not functioning, requiring staff to use a different computer. Multiple licensed nurses reported that upon arrival, they were informed of the system outage by the night nurse, but had not received any guidance from management and were not aware of the contingency plan for EHR outages. There was no prior notification from management regarding the outage, and staff were left waiting for instructions. Interviews with the DON and Administrator (ADM) confirmed that no mock drills had been conducted for an EHR outage, despite facility policies indicating that such drills should be performed. Review of the facility's assessment and policies showed that procedures and drills for EHR outages were outlined, but these were not followed or communicated to staff during the incident. As a result, there were delays in medication administration, with the potential to affect the health and safety of the facility's 104 residents.
Failure to Maintain and Document QAPI Program Activities
Penalty
Summary
The facility failed to ensure an effective and comprehensive Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) program was performed for a census of 104 residents. During interviews, multiple staff members, including the Director of Staff Development, Social Services Director, Infection Preventionist, and Minimum Data Set Manager, were either unaware of or unable to provide documentation for the previous three quarterly QAPI meetings. The Administrator confirmed that there were no records of QAPI meetings for the last three quarters and acknowledged that QAPI meetings had not been conducted prior to their arrival. The facility's policy requires maintaining documentation and evidence of ongoing QAPI activities, but this was not followed. Record review and staff interviews revealed that the facility did not maintain documentation or present evidence of QAPI meetings as required. The lack of documentation and awareness among staff indicated that QAPI activities were not being consistently performed or tracked. The Minimum Data Set Manager noted ongoing issues with resident rehospitalization rates, suggesting that performance improvement activities were not being effectively evaluated or revised. The absence of QAPI meeting records and lack of staff knowledge about the process contributed directly to the deficiency.
Infection Control Lapses in Device Management, EBP Implementation, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. One deficiency involved a resident's CPAP mask, which was not stored in a microbial bag as required by facility policy. Instead, the mask was left on top of the CPAP machine, exposing it to potential contamination. The Director of Nursing and Infection Preventionist confirmed that the mask should have been stored in a microbial bag to prevent infection, as per standard practice. Another deficiency was observed regarding the lack of Enhanced Barrier Precautions (EBP) for several residents with invasive medical devices or wounds. Residents with urinary catheters, gastrostomy tubes, suprapubic catheters, and pressure ulcers did not have EBP signage posted, nor was personal protective equipment (PPE) available inside or outside their rooms. Medical records for these residents did not document EBP implementation, despite facility policy requiring EBP for residents with such conditions. The Infection Preventionist confirmed that EBP, including gown and glove use during high-contact care, should have been in place for these residents. Additional deficiencies included the failure to label and date medical equipment such as oxygen tubing, feeding tubes, and IV bags and tubing for several residents. Staff were observed not performing hand hygiene between resident contacts in the dining room and during medication administration. Both a CNA and a licensed nurse admitted to forgetting to perform hand hygiene, which was confirmed as a requirement by the facility's policies. These lapses in infection control practices were directly observed and verified by staff interviews.
Failure to Serve Meals Timely According to Resident Needs and Preferences
Penalty
Summary
The facility failed to serve meals and snacks at times consistent with resident needs, preferences, and requests, as well as with community norms, for five sampled residents. Multiple residents reported that meals were consistently late, with some waiting up to 1 to 2 hours for their food. Observations confirmed that meal trays were not served at the scheduled times, and staff interviews acknowledged the delays. The posted dining schedule did not indicate specific meal times, and on several occasions, meal trays had not arrived or been served at the expected times. Residents expressed dissatisfaction, noting that meals were sometimes cold and that the lack of a consistent schedule made it difficult to plan their day. The affected residents had various medical conditions, including type 2 diabetes with hypoglycemia, hypomagnesia, hypokalemia, acute kidney failure, myopathy, paraplegia, anemia, and hyperlipidemia. Some residents had impaired cognition, while others were cognitively intact. Staff, including a registered dietician, CNA, dietary consultant, and the DON, confirmed awareness of the late meal service and acknowledged that it could impact medication administration and resident satisfaction. Review of facility policy indicated that meals should be served according to routine schedules and resident preferences, but these procedures were not followed.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure food service staff adhered to current standards of practice for food safety in several key areas. Surveyors observed that staff did not consistently label, date, or monitor refrigerated and frozen foods, with expired items and items lacking expiration dates found in multiple refrigerators and freezers. Additionally, temperature logs for all refrigerators and freezers were incomplete, with missing entries for several days. The Dietary Manager confirmed these findings and acknowledged that expired food should be discarded and that failure to do so could result in residents becoming ill. In the dry storage area, surveyors observed the presence of fruit flies and flies, as well as improperly stored food items such as an uncovered container of sugar, unsealed boxes of instant hot cereal mix, and bags of oats and cereal with ripped openings. The Registered Dietician confirmed that these conditions could lead to food contamination and stated that expired food should be thrown out and food should be stored in sealed containers. Both the DM and RD confirmed the missing temperature log entries and agreed that temperatures should be checked and logged regularly. Additionally, staff failed to adhere to standards of practice regarding personal hygiene, as a dietary aide was observed assembling resident trays without wearing a beard net, with facial hair protruding from a face mask and later exposed while calling out tray orders over uncovered food. The RD confirmed that beard nets are required and that the facility had run out of them. Review of facility policy and the FDA Food Code indicated that all perishable food items must be properly stored, labeled, and dated, and that staff must wear appropriate hair restraints to prevent contamination.
Failure to Maintain Kitchen Equipment in Safe and Sanitary Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe and sanitary operating condition. Observations revealed a brownish frozen residue on the bottom shelf of a freezer, which was confirmed by the Dietary Manager, who stated that there should not be any residue or crumbs present. Additionally, two ovens were found with brownish-black residue, and all four stove burners had food and black burnt residue. Three of the burners were in use at the time, with a pot containing a clear golden liquid with sediment. The Registered Dietician confirmed these findings and noted that the boilerless steamer was leaking clear liquid onto the floor, pooling at the base of a metal panel, and described the equipment as unstable and in disrepair, an issue that had been ongoing for weeks. The Maintenance Assistant confirmed the drainage and leaking from the boilerless steamer, stating that it was broken and not fixed. The Dietary Manager reiterated that the expectation is for equipment to be in clean working order and not leaking. Review of facility policies indicated that equipment should be cleaned and sanitized regularly to prevent foodborne illness, with specific cleaning schedules for freezers and stoves, and that maintenance tasks should ensure all equipment is safe and functional. These observations and staff interviews demonstrate a failure to adhere to the facility's own sanitation and maintenance policies.
Failure to Provide Communication Boards for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide communication boards at the bedside for three residents who did not speak English, despite care plans indicating the need for such aids due to language barriers. Resident 19, whose primary language was Russian and who had chronic kidney disease and hemiplegia, was observed without a communication board in the room. Resident 24, with congestive heart failure and a primary language of Cantonese, also did not have a communication board available. Resident 58, diagnosed with Alzheimer's disease and dementia and whose primary language was Mandarin, had only an English-language poster in the room, with no communication board in Mandarin present. Interviews with staff confirmed that communication boards in the residents' primary languages should have been available in their rooms. The facility's policies emphasized the importance of dignity, respect, and non-discrimination, including the provision of free language services and information in other languages. However, during observations and interviews, it was evident that these communication supports were not in place for the identified residents, contrary to both care plan interventions and facility policy.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a homelike environment as evidenced by unclean and worn conditions in resident areas. In one instance, a resident with myopathy and paraplegia, who was cognitively intact, reported that the shower rooms were dirty and unsanitary, specifically noting the presence of mold and dirt in the grout. Direct observation confirmed a dark brown substance on the floor of a shower room, which was acknowledged by a licensed nurse, who stated that staff should have notified housekeeping. The Infection Preventionist confirmed that shower rooms should always be clean to prevent infection and support residents' psychosocial wellbeing. Additionally, four rooms in the memory care unit were found to have curtains by the sliding doors that were worn and had visible brown discolorations. The Director of Staff Development described the curtains as dirty, old, and stained, and the Director of Nursing stated that curtains should be clean and intact to maintain a homelike environment. Review of facility policy indicated that stained or worn linens should be removed upon discovery and that areas needing cleaning should be reported to housekeeping, but these practices were not followed.
Failure to Provide Timely Turning and Repositioning for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when staff failed to implement regular and timely turning and repositioning for a resident who was dependent on assistance for bed mobility and at risk for pressure ulcers. The resident, admitted with multiple diagnoses including hematoma of the skin, chronic kidney disease, muscle weakness, and limited mobility, was assessed as being at risk for skin breakdown and unable to turn or reposition independently. The care plan identified the need for assistance with activities of daily living and bed mobility, but did not include specific interventions for turning and repositioning every two hours. Multiple observations and interviews revealed that the resident remained in the same position for extended periods and was not aware of the need for regular repositioning. Staff interviews confirmed that the resident had not been turned as required, despite facility policy and professional standards indicating the necessity of such care for immobile residents. The lack of consistent implementation of pressure injury prevention measures placed the resident at risk for skin breakdown.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to address and monitor significant weight loss for one resident. The resident, who had multiple diagnoses including metabolic encephalopathy, Alzheimer's disease, dementia, hypothyroidism, hyperosmolality, hypernatremia, and dysphagia, was dependent on staff for feeding. Upon admission, the resident's usual body weight was around 125 lbs, and care plans were in place to monitor for malnutrition and significant weight changes, including weekly weight checks for the first month and notification of the physician if significant changes occurred. However, a weight entry was missing for the week following admission, and the resident experienced a 13.5% weight loss over a week and a half, dropping from 124 lbs to 107.2 lbs, which was not promptly identified or addressed. Further review revealed that the resident continued to lose weight, reaching 102.6 lbs, and was not included in the most recent weekly weight meeting. The facility's policies required weekly weight monitoring for new admissions and for residents with significant unplanned weight loss, but these procedures were not followed. The registered dietician confirmed the lack of timely monitoring and intervention, which resulted in continued weight loss for the resident.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to pain assessment and timely administration of pain medication. One resident, admitted with multiple fractures and osteoarthritis, had a care plan indicating the need for pain medication before therapy and as needed for pain. Despite this, the resident reported severe pain in the morning, rated as 10 out of 10, and stated that they had been requesting pain medication since waking. The resident was observed in discomfort and unable to participate in therapy exercises due to pain. The nurse confirmed that the resident had not been assessed or given pain medication, and the occupational therapist had not communicated the resident's pain to nursing staff. Another resident with chronic pain conditions, including intervertebral disc degeneration, rheumatoid arthritis, and osteoarthritis, was observed in visible distress, moaning and expressing pain. The resident's scheduled pain medications, including opioids and other analgesics, were not administered at the prescribed times. Staff interviews revealed that the nurse had not been able to administer any scheduled morning medications, and the resident continued to experience pain for an extended period. The delay in medication administration was confirmed by both the resident's family and staff, and the facility's medication administration audit showed that medications were given significantly later than scheduled. Both cases demonstrated a lack of timely pain assessment and intervention consistent with the residents' care plans and professional standards of practice. The facility's own policies required pain management and medication administration within specific timeframes, but these were not followed, resulting in unmanaged pain and discomfort for the affected residents.
Failure to Maintain Controlled Substance Accountability and Documentation
Penalty
Summary
The facility failed to maintain proper pharmacy services for 11 residents by not documenting destruction logs for discontinued controlled medications and not reconciling controlled drug records when original narcotic sheets went missing. During an observation and record review, it was found that 11 controlled medications stored in the DON's office lacked destruction logs, and the medications were not scanned or recorded into the pharmacy website upon receipt from the nurses. The DON confirmed these omissions and acknowledged that the controlled drugs in the locked cabinet were not properly accounted for at the time of transfer from nursing staff. Additionally, the original controlled drug sheets for medication cart A2 went missing and were replaced with photocopied handwritten narcotic sheets. When the original sheets were later found, no reconciliation was performed to check for discrepancies. The DON verified that the reconciliation process was not completed, and the facility's consultant pharmacist confirmed that both a destruction log and reconciliation between two nurses were required by facility policy. The facility's policy also stated that all controlled substances must be fully accounted for and any discrepancies resolved by the end of the shift.
Deficient Medication Storage, Labeling, and Accountability Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management and storage practices. In the medication room, expired tube feeding formulas and unlabeled medical supplies, such as anti-embolic stockings, suction catheter trays, and tracheostomy care kits, were found. These items lacked use-by dates or were past their expiration, and the DON confirmed that such items should have been disposed of according to facility policy. The facility's policy requires routine checks and removal of expired or opened items, which was not followed. Further observations in medication carts revealed additional deficiencies. In medication cart A1, non-narcotic medications were stored in the narcotic cabinet, expired and unsealed medications were present, and medications belonging to discharged residents were not removed. Some medications, such as Doxycycline and Famotidine, were found in cups without resident labels or original packaging. Treatment supplies were also stored in the medication cart instead of the designated treatment cart. The pharmacy consultant and DON confirmed these practices were not in line with facility policy and could lead to medication errors. In medication cart A2, opened over-the-counter medications lacked open and discard dates, and the narcotic count sheet was missing required signatures from both incoming and outgoing licensed nurses. Facility policy mandates that all opened medications be labeled with the date opened and that narcotic count sheets be signed by both shifts to ensure accountability. These lapses in documentation and storage practices were confirmed by interviews with nursing staff and the DON.
Failure to Administer Insulin as Prescribed and Inadequate Documentation
Penalty
Summary
The facility failed to administer insulin as prescribed for one resident with diabetes and a recent surgical amputation. The resident had a physician's order for Novolin Insulin 90 units subcutaneously twice daily. Review of the Medication Administration Record (MAR) for March showed that on two occasions, the initial boxes for insulin administration were left blank with no documentation explaining the omission. Additionally, on two other occasions, the licensed nurse documented codes indicating the insulin was not given due to blood sugar being outside parameters or being held, but there was no physician's order allowing the insulin to be withheld for any parameters. The Director of Nursing (DON) confirmed these findings during interviews and record reviews, acknowledging the lack of documentation and absence of physician orders to hold the insulin. The facility's policy required staff to follow the MAR and document medication administration according to regulations, which was not done in these instances. The failure to administer insulin as ordered and to properly document or obtain appropriate physician orders for withholding medication constituted a deficiency in pharmaceutical services.
Sanitary Practices Lapse in Kitchen
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, which could potentially lead to foodborne illness. During an observation, the freezer temperatures were found to be out of the acceptable range, with one freezer at the entrance of the kitchen observed at 10 degrees Fahrenheit and another next to the dishwashing area at 38 degrees Fahrenheit. The Registered Dietician (RD) confirmed these temperatures were out of range and should have been reported to environmental services immediately. The facility's policy indicated that freezer temperatures should be maintained at 0 degrees Fahrenheit or below. Additionally, the Registered Dietician Consultant (RDC) noted that the freezer door was left open, contributing to the temperature issue, and reported that two freezers and two refrigerators needed replacement. Unsafe infection control practices were also observed in the kitchen. The cleaning schedule was incomplete, with only three signatures and blank sheets, and the RD could not provide documentation of staff sanitizing kitchen areas. A sanitizer bucket and log were observed, but it was unclear if the sanitizer was replaced throughout the day as required. Mold was found near the kitchen exit door, confirmed by the Environmental Services Director and Manager, who stated it was not sanitary for a food preparation area. The Infection Preventionist noted issues with freezer temperature checks and other infection control practices during audits. The Executive Director stated that the dietary supervisor manages kitchen cleaning and staffing, but no documentation was provided to confirm daily cleaning activities.
Deficiency in Medication Availability for Resident
Penalty
Summary
The facility failed to ensure the availability of routine medications for a resident, leading to a deficiency in pharmaceutical services. The resident, admitted in November 2024 with conditions including anemia, depression, and diabetes, had a prescribed order for Vitamin D3 1000 IU to be administered daily. However, the facility did not have the Vitamin D3 tablets in the required dosage in stock. This lack of availability was confirmed during an interview with a licensed nurse, who indicated that due to the absence of the correct dosage, she resorted to cutting unscored 2000 IU tablets to meet the resident's medication order. Further investigation revealed that a refill request for the Vitamin D3 1000 IU was placed, but the medication was still not available at the time of the survey. The Director of Nursing expressed an expectation that over-the-counter medications should be stocked adequately. A review of the facility's policy indicated that unscored tablets should not be split, highlighting a deviation from the established medication administration procedures. This deficiency had the potential to impact the resident's therapeutic needs or exacerbate their medical conditions.
Improper Food Thawing and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as observed during a survey. Two packages of frozen salmon filets and two packages of frozen cod filets were found thawing on a kitchen table countertop, which is not in accordance with the facility's policy and procedure for safe food handling. The policy specifies that frozen foods should be thawed during the cooking process, under refrigeration, or by immersion under running potable water at a temperature of 70 degrees Fahrenheit or lower. This improper thawing method was confirmed by the Dietary Supervisor during an observation and interview. Additionally, the facility did not comply with its policy on labeling and dating food items. Nine opened bottles of dry spices, one opened bottle of beef base, and one bag of opened pink lemonade powder were found unlabeled. The Registered Dietitian indicated that proper labeling is crucial for kitchen staff to know when food was prepared and when it expires. The facility's policy requires that all opened food products be labeled with the date they were opened, which was not followed in this instance.
Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically a kitchen freezer, which was found to have a broken seal gasket and ice buildup on its ceiling. This issue was observed during a survey with the Dietary Supervisor, who confirmed the freezer's poor condition. The broken gasket seal and ice buildup were noted to potentially affect the quality of food stored within, as evidenced by five bags of hash browns that were not frozen solid and one bag of vegetables that had freezer burn. The facility's document on kitchen sanitation and food storage required that freezer seals be tight and free of ice buildup, which was not adhered to in this instance. The Registered Dietitian confirmed that a poor seal could lead to ice buildup and affect the freezer's ability to maintain consistent temperatures, potentially compromising food safety. The 2022 Federal Food and Drug Administration Food Code also mandates that equipment components such as seals be kept intact and tight to ensure proper operation, which was not the case here.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when Resident 4 punched Resident 5. This incident was witnessed by two staff members as Resident 5 attempted to enter Resident 4's room from the courtyard. Resident 5, who has multiple diagnoses including dementia, major depressive disorder, bipolar disorder, and undifferentiated schizophrenia, fell to the ground and began yelling at the nurse during an assessment. Resident 4, who also has dementia, bipolar disorder, and Alzheimer's disease, confirmed the altercation, stating that he knocked Resident 5 down. The facility's policy and procedure on abuse prevention and reporting were not effectively implemented, as evidenced by the lack of supervision in the Activity Room, which allowed Resident 5 to access the courtyard. Resident 5's care plan included monitoring for behaviors such as intrusiveness and wandering, as well as regular checks for safety, but these measures were not adequately followed. Resident 4's care plan, initiated after the incident, noted a risk for psychosocial decline related to resident-to-resident altercations. The facility's failure to monitor and intervene in situations likely to lead to conflict contributed to the occurrence of this incident.
Failure to Supervise Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for Resident 5, who has a history of disruptive behavior and cognitive impairments, resulting in an altercation with Resident 4. Resident 5, admitted in 2016 with diagnoses including dementia, major depressive disorder, bipolar disorder, and undifferentiated schizophrenia, was found unsupervised in the courtyard, an area where residents from the locked memory care unit are not allowed without supervision. Resident 5 attempted to enter Resident 4's room from the courtyard, leading to Resident 4, who also has severe cognitive impairments and a history of aggressive behavior, punching Resident 5, causing him to fall to the ground. Interviews with facility staff, including the Administrator, CNA, Activity Assistant, and Sr Regional Director Clinical, confirmed that residents from the locked memory care unit should not be in the courtyard unsupervised and that the sliding glass doors should always be locked. Despite these protocols, Resident 5 accessed the courtyard through the sliding glass doors in the Activity Room, which were supposed to be locked. The facility's policy on abuse prevention emphasizes the need for a safe environment and monitoring residents with behaviors that may lead to conflict, which was not adhered to in this instance.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident struck him multiple times in the chest and face. Resident 1, who has Type 2 diabetes and no memory impairment, was involved in an incident where he accidentally bumped into Resident 2's wheelchair in the hallway. In response, Resident 2, who has moderate memory impairment and hemiplegia following a stroke, struck Resident 1 in the face and chest three times. Although Resident 1 was not physically injured, the incident negatively impacted his self-esteem. Interviews conducted with staff and residents revealed that the incident was witnessed by others, including a licensed nurse who heard the altercation and a resident who saw the physical confrontation. The Social Services Director and the Assistant Director of Nursing acknowledged that the incident constituted abuse, as it affected Resident 1's mental well-being. The facility's policy on abuse emphasizes the right of each resident to be free from abuse, including resident-to-resident abuse that results in physical injury, pain, or mental anguish.
Failure to Provide Recommended Restorative Nursing Aide Services
Penalty
Summary
The facility failed to ensure that Resident 43 received services to maintain her mobility as recommended by a Physical Therapist (PT). Resident 43, who was readmitted with multiple diagnoses including spinal stenosis, osteoarthritis, and muscle weakness, had a care plan that included goals for improving her ability to walk. Despite these goals, the facility did not provide the necessary Restorative Nursing Aide (RNA) services after her discharge from PT, which led to a decline in her ability to use a walker. This was confirmed through interviews and record reviews, which showed that the recommendation for RNA services was not followed through in the electronic health record (EHR) and care plan assessments. During interviews, Resident 43 expressed frustration and anger over her declining mobility, stating that she was doing well with the walker while receiving PT but had not received any assistance with the walker since PT services stopped. The Area Director of Rehabilitation (ADOR) and the Minimum Data Set Licensed Nurse (MDS LN) both confirmed that Resident 43's PT discharge summary included a recommendation for RNA services, which was not implemented. The MDS LN acknowledged that the lack of RNA services could lead to a decline in the resident's functioning, and the Assistant Director of Nursing (ADON) stated that residents recommended for RNA should be initiated into the program within a month. Further interviews with Certified Nursing Assistants (CNAs) revealed that they had not assisted Resident 43 with her walker for over a month, corroborating the resident's account. The facility's policy on Restorative Nursing Programs indicated that residents should receive RNA services upon discharge from therapy to maintain or improve their abilities. However, this policy was not followed, resulting in a decline in Resident 43's physical functioning and psychosocial well-being.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information when meal tickets containing personal and medical details were discarded into the garbage and subsequently into an outside dumpster. During a visit to the kitchen, a dietary aide was observed throwing meal tickets, which included resident names, room numbers, diet orders, food allergies, food preferences, and special dietary needs, into the trash as part of the usual process for setting up for dishwashing. This practice was confirmed by the dietary manager, who acknowledged that the trash is brought to an outside dumpster accessible to the public, thus constituting a HIPAA violation. Further interviews revealed that the assistant director of nursing stated that tray cards should be shredded and not disposed of in regular trash. The facility's policy on safeguarding protected health information (PHI) indicated that PHI must be reasonably safeguarded to limit incidental uses or disclosures and that the disposal of records should comply with federal and state laws, using methods that render the PHI unusable. This failure had the potential to compromise the information of 103 residents receiving facility-provided meals out of a census of 109.
Inadequate Indications for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents had adequate indications for the use of psychotropic medications. Resident 80 was administered olanzapine, a psychotropic medication indicated for psychosis, despite having no documented indicators of psychosis. The resident exhibited behaviors such as yelling and agitation, but these were deemed manageable through redirection by staff. The resident's responsible party initially consented to the medication but later requested its discontinuation due to increased distress. Interviews with staff and medical professionals revealed that non-pharmacological interventions were not adequately considered before prescribing the medication, and the documentation did not support the use of olanzapine for this resident's symptoms. Resident 93 was administered aripiprazole, another psychotropic medication indicated for psychosis, despite having no documented indicators of psychosis. The resident had a history of depression and anxiety and was noted to have mood improvements when engaged in social activities. The resident experienced an episode of suicidal ideation and was subsequently prescribed aripiprazole upon return from the hospital. Interviews with staff indicated that the resident's mood could be managed through social interaction and non-pharmacological means. The documentation did not support the use of aripiprazole, and the resident was not on the maximum dose of the previously prescribed anti-anxiety medication, buspirone. The facility's policy on psychotropic medication use requires a comprehensive assessment and documentation of clinical indications for such medications. However, in both cases, the documentation did not support the use of antipsychotic medications, and non-pharmacological interventions were not adequately explored. This failure decreased the facility's potential to prevent residents from experiencing adverse effects such as sedation, falls, and abnormal involuntary movements from the use of antipsychotic medications.
Medication Administration Error
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed 5% for one resident when a licensed nurse administered medications not in accordance with standard nursing principles and practices or the facility policy. During an observation, the nurse was seen crushing six pills together and mixing them with two liquid medications and two powdered medications, then administering the mixture in a bolus through a gastrotomy tube without flushing between administrations. This resulted in a medication error rate of 30.3% for the resident. The resident's medication orders required each medication to be administered separately with flushing between each administration. The nurse admitted to always mixing all the resident's medications together and was unaware of the facility's policy and procedure for gastrotomy tube medication administration. The Assistant Director of Nursing confirmed that the expectation was to administer each medication separately and flush between administrations, as outlined in the facility's policy dated January 2022.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in a clean and sanitary environment and labeled correctly with open and discard dates. During an inspection of medication cart two, a loose pill was found, and a medication cup containing 11 loose pills was stored in the top drawer without any resident's name or drug identifiers. The Assistant Director of Nursing (ADON) acknowledged these issues, stating that the night shift should be responsible for checking and cleaning the carts. Additionally, the ADON confirmed that nurses should not pre-pour pills and should administer medications directly in front of the resident after proper identification. Further inspection revealed that three bottles of eye drops and one inhaler in medication cart two were not labeled with open or discard dates. The ADON acknowledged this issue, stating that the expectation was to label pharmaceutical products with an open date and dispose of them after 28 days. The facility's policy and procedure indicated that medications with shortened expiration dates should be labeled with the date opened and the date to expire. However, the facility was unable to provide a policy addressing the 28-day discard date requirement. Additionally, a medication blister pack was found displaced in the back of medication cart one. The ADON acknowledged that the blister pack should not be there and stated it was a safety concern. The ADON reiterated that the night shift should be responsible for checking the carts for loose pills and blister packs. These failures decreased the facility's potential to prevent drug diversion and medication administration errors.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety. During a kitchen observation, it was found that there were no functional thermometers for dry storage room monitoring and for internal temperature monitoring for freezer #1. Additionally, the temperature logs for refrigerators, freezers, and the dry storage area were incomplete, with several missing entries. This lack of proper temperature monitoring could lead to food being stored at unsafe temperatures, increasing the risk of foodborne illness among residents. The Dietary Manager (DM) confirmed these observations and acknowledged the need for functional thermometers and complete temperature logs to ensure food quality and safety. Food items in the kitchen were not properly labeled or sealed, and expired foods were not discarded. During an initial kitchen tour, it was observed that multiple food items lacked proper labels for received, use by, or expiration dates. Additionally, some food items were mislabeled, and expired food, such as a gallon of milk, was found in the refrigerator. The DM confirmed these observations and stated that food items should be labeled correctly to prevent the risk of having expired food items in the kitchen. The facility's policy and procedure indicated that food should be inspected for contamination and labeled with the date it was transferred to a new container. The facility also failed to maintain cleanliness and proper sanitation in the kitchen. The racks in two refrigerators had rust on the surface and were unable to be readily sanitized. The facility did not install or maintain a drain air gap in the sink used to prepare fruits and vegetables. The can opener had dark residue buildup around the blade, and the exterior surface of the dishwasher and drawers containing kitchen utensils were not clean. Additionally, kitchen surfaces were stained, had chipped paint, and missing floor tiles. Kitchen staff did not perform hand hygiene when moving from dirty to clean surfaces, and they did not properly fill the red sanitizer bucket with the correct concentrations of sanitizer. The logs for the red sanitizer bucket and dishwasher disinfectant were incomplete, and kitchen staff were unable to verbalize the manual dishwashing procedure with the correct sanitizer solution used. These failures decreased the facility's potential to prevent foodborne illness for the residents who ate facility-prepared food.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medication from the responsible party (RP) for one resident. Resident 73, who was admitted in April 2022 with multiple diagnoses including hemiplegia, hemiparesis, dementia with psychotic disturbance, anxiety disorder, personality disorder, and major depressive disorder, was prescribed quetiapine. The physician increased the dosage of quetiapine from 50 mg to 75 mg daily on 12/28/23, but there was no documented informed consent from the RP for this change in medication dosage. The resident's medical chart and nursing progress notes did not indicate that the RP was informed or that an informed consent was completed before administering the increased dosage of quetiapine. The Assistant Director of Nursing (ADON) and the Social Services Director (SSD) confirmed the absence of documented informed consent in the resident's records. During an initial tour of the facility, Resident 73 was observed to be in bed, receiving oxygen, and exhibiting confusion and a flat affect. The facility's policy on psychotropic medication management and an All Facilities Letter (AFL) both require that informed consent be obtained and documented before administering psychotropic medications. Despite these requirements, the facility did not have the necessary documentation to show that the physician had informed the RP of the risks and benefits of the increased dosage of quetiapine. This failure was confirmed by the ADON and SSD during the survey, and no additional physician's notes or documentation were provided by the conclusion of the survey.
Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for three residents, which decreased the facility's potential to provide appropriate interventions for residents to maintain their highest medical and physical practicable level of function. Resident 30 was admitted with diagnoses including adult failure to thrive and generalized weakness, and had an order for oxygen at 2 liters per minute through a nasal cannula. However, a review of Resident 30's care plans indicated that there was no comprehensive or person-centered care plan that included the use of oxygen. Similarly, Resident 53, who was admitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, had an order for oxygen at 3 liters per minute through a nasal cannula, but did not have a comprehensive or person-centered care plan that included the use of oxygen. Both residents were observed receiving oxygen as per their physician's orders, but their care plans did not reflect this need for oxygen therapy. Resident 73, admitted with COPD, had a physician's order for oxygen at 2 liters per minute via nasal cannula, but was observed receiving oxygen at 6 liters per minute. The Licensed Nurse confirmed the discrepancy and adjusted the oxygen flow rate to the prescribed 2 liters per minute. The Associate Director of Nursing confirmed that residents should have an established care plan for the use of oxygen and that staff should be aware of the oxygen conditions. The facility's policies on oxygen administration and comprehensive care plans were not followed, leading to the deficiencies observed.
Failure to Revise Care Plans in a Timely Manner
Penalty
Summary
The facility failed to revise care plans for two residents in a timely manner, which decreased the potential to provide appropriate interventions for maintaining their highest medical and physical practicable level of function. Resident 38, admitted in August 2017 with diagnoses including dysphagia and the presence of a gastrostomy tube, had a tube feeding order that started on December 24, 2019. However, during an observation in May 2024, the resident was found receiving Jevity 1.2 at 55 ml per hour, contrary to the care plan revised in February 2024, which indicated 75 ml per hour. This discrepancy was confirmed by the Assistant Director of Nursing (ADON), who stated that care plans should be revised within 72 hours if there is a change in condition or update to the resident's physician orders, including nutritional status. Resident 82, admitted in April 2024 with diagnoses including a urinary tract infection and muscle weakness, had a care plan initiated on May 6, 2024, indicating antibiotic therapy for the infection. However, a review of the resident's Order Summary Report (OSR) on May 23, 2024, did not show any active orders for antibiotics. The ADON confirmed that care plans should be updated within 72 hours of any change in condition or physician orders. The facility's policy and procedure on comprehensive care plans, dated December 2017, also indicated that resident progress should be regularly evaluated and approaches revised or updated as appropriate. Additionally, Resident 77, admitted in late 2023 with diagnoses of absence epileptic syndrome, had a new order for oxygen via nasal cannula at 2 liters per minute starting on May 15, 2024. However, during observations on May 21, 2024, the resident's nasal cannula tubing was found on the floor, and the resident was not using the oxygen. The Certified Nursing Assistant (CNA) and Licensed Nurse (LN) confirmed that the tubing should be clean and connected to the resident, and that care plans should indicate the need for continuous oxygen. The care plan for Resident 77 was revised on May 21, 2024, to indicate non-compliance with the plan of care and refusal of oxygen via nasal cannula. The ADON reiterated that care plans should be updated quarterly, with any change of condition, and within three days or right away to ensure proper care direction.
Failure to Ensure Professional Standards of Quality in Nursing Care
Penalty
Summary
The facility failed to ensure nursing care was provided per professional standards of quality for one resident when Licensed Nurses did not obtain informed consent from the resident's Responsible Party (RP) before administering psychotropic medication. The resident, who had multiple diagnoses including dementia and major depressive disorder, had their quetiapine dosage increased without documented informed consent from the RP. The Assistant Director of Nursing (ADON) and the Social Services Director (SSD) confirmed that there was no documentation of informed consent in the resident's medical records, which is a requirement according to the facility's policy and state regulations. Additionally, the facility did not obtain a physician's order to flush the resident's midline catheter, which is necessary for administering intravenous medication. The resident had a midline catheter inserted for the administration of IV rocephin, but there was no documentation indicating that the midline catheter had been flushed as required. The Licensed Nurse (LN) confirmed that only Registered Nurses (RNs) are authorized to flush midline catheters and that there was no record of this procedure being performed. Furthermore, the facility did not follow the prescribed physician's order for oxygen administration. The resident, who had a diagnosis of COPD, was observed receiving oxygen at a rate of 6 liters per minute (l/min) instead of the prescribed 2 l/min. The LN confirmed the discrepancy and adjusted the oxygen flow rate accordingly. The facility's policy on oxygen administration requires adherence to the physician's order, which was not followed in this case.
Improper Disposal of Medication
Penalty
Summary
The facility failed to ensure proper pharmacy services for a census of 109 residents when a medication was improperly disposed of in an opened, regular trash can on the side of the medication cart. During an inspection of medication cart two, a Licensed Nurse (LN) was observed disposing of a loose pill in an open trash can. The LN acknowledged that this practice could pose a potential safety hazard, as unauthorized individuals could retrieve the pill. The Assistant Director of Nursing (ADON) confirmed that pills should not be disposed of in a regular trash can and stated that the proper procedure was to use a pill buster for non-narcotic medications. The facility's policy and procedure for the disposal of expired or discontinued medications indicated that medications should be placed in a designated, secured location and disposed of in a manner that limits access by unauthorized personnel and residents. The ADON acknowledged that the observed practice was a safety concern and did not align with the facility's policy. This failure decreased the facility's potential to prevent unauthorized access to prescription drugs, drug diversion, and medical adverse consequences.
Failure to Follow Standardized Recipes for Pureed Foods
Penalty
Summary
The facility failed to ensure pureed foods were prepared in a manner that conserved nutritive value and palatability. During an observation, Cook 1 was seen preparing pureed roast beef by adding an unmeasured amount of hot tap water instead of the recommended low sodium broth or gravy. Additionally, Cook 1 prepared mashed sweet potatoes using liquid from the can instead of milk as specified in the recipe. These actions were not in accordance with the facility's standardized recipes, which specify measured amounts of appropriate liquids to maintain nutritional value and flavor. The Dietary Manager confirmed that the expectation was for dietary staff to follow the recipes in the book. The DM stated that for pureed diets, staff should count out portions, grind down the meat, add measured amounts of gravy or broth, blend, and add small amounts of liquid as needed. The failure to follow these recipes can affect the nutritional value and flavor of the food provided to residents, thereby not meeting their nutritional needs.
Failure to Maintain Refrigerator and Freezer Seals
Penalty
Summary
The facility failed to maintain two reach-in freezers and two reach-in refrigerators in safe operating condition. During an initial kitchen tour, it was observed that the seals on freezer #1 and freezer #3 had gaps in various corners, and the seals on refrigerator #2 and refrigerator #3 were either torn or covered with black tape. The Dietary Manager confirmed that the seals were broken and needed replacement, and the Maintenance Director acknowledged the issue but could not provide any quotes or written proof of progress in obtaining new seals. The FDA Food Code 2022 requires that equipment be maintained in a state of repair and condition that meets specific requirements, including keeping components such as doors and seals intact and tight. The failure to maintain these seals compromised the facility's ability to ensure food safety and quality for 103 residents who consumed facility-prepared meals. The Maintenance Director stated that efforts were being made to find suitable replacement parts, but no concrete progress had been documented.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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