Covina Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Covina, California.
- Location
- 261 W. Badillo Street, Covina, California 91723
- CMS Provider Number
- 055449
- Inspections on file
- 49
- Latest survey
- May 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Covina Rehabilitation Center during CMS and state inspections, most recent first.
A resident who was fully dependent for transfers and had significant medical needs was being moved using a Hoyer lift by a CNA without the required second staff member, in violation of facility policy and training. During the transfer, the lift became unstable, causing the resident to fall, resulting in head and leg injuries that required hospital evaluation. Staff interviews and documentation confirmed that the CNA acted alone due to short staffing, despite knowing two-person assistance was mandatory for mechanical lift use.
The facility did not provide enough CNAs per its own policy and assessment, resulting in staff being assigned up to 25 residents each on some shifts. On one occasion, a resident who was dependent for transfers fell while being moved with a Hoyer lift by a single CNA, rather than the required two staff, due to short staffing. The resident sustained injuries and required hospital evaluation. Staff and leadership confirmed that inadequate staffing contributed to the inability to provide safe care.
A CNA attempted to transfer a dependent resident alone using a Hoyer lift, despite facility policy and training requiring two-person assistance. The resident, who had significant medical needs and required total help with transfers, fell during the process, resulting in injuries to the head, neck, and leg. Staff interviews and documentation confirmed the CNA was aware of the policy but proceeded alone due to short staffing.
Three residents with severe cognitive and physical impairments, all assessed as high fall risk, were found with call lights or pad sensors out of reach, contrary to their care plans and facility policy. Staff confirmed the devices were not accessible, and facility policies require call lights to be within easy reach to ensure timely assistance.
The facility failed to accurately assess and code the nutritional status of two residents in their MDS assessments, resulting in incorrect documentation of weight loss when both residents had actually experienced weight gain. Staff responsible for completing the MDS did not verify weight records prior to data entry, leading to inaccurate reporting to CMS.
Two residents with IV catheters did not have their dressings changed or labeled according to physician orders and facility policy, with one resident's dressing left unchanged for at least 14 days and another's gauze dressing lacking required labeling. Nursing staff confirmed the lapses, and both residents' care plans specified regular dressing changes to prevent infection.
The facility did not meet the required 2.4 CNA direct care hours per patient day on two weekend days, as confirmed by PBJ staffing data and verified by the DSD and DON. Staffing records showed actual CNA hours below the mandated minimum, and facility policies requiring compliance with staffing standards were not met.
Two residents with anemia received multiple doses of Epogen injections despite physician orders to hold the medication when hemoglobin levels exceeded 10 g/dl. Nursing staff failed to check current lab results or review orders before administration, resulting in significant medication errors. Facility policy required adherence to physician parameters, which was not followed in these cases.
Staff failed to follow infection control protocols by not changing gowns and gloves between care of two residents on Enhanced Barrier Precautions, and did not keep a resident's oxygen tubing off the floor as required by facility policy. These lapses were observed during care of residents with significant medical needs, including those with gastrostomy tubes, stage 4 pressure ulcers, and oxygen therapy.
A resident dependent on staff for all ADLs and receiving G-tube feedings was exposed when the DSD checked the G-tube site without closing the privacy curtain, leaving the resident's abdominal area and lower extremities visible to others. Both the care plan and facility policy required staff to maintain privacy during care, and the DON confirmed that privacy curtains should be used.
A resident admitted with mobility and blood pressure issues, requiring moderate assistance with daily activities, was discharged home without a required discharge MDS assessment being completed or transmitted to CMS within the mandated timeframe. The MDS Coordinator acknowledged the oversight, resulting in incomplete reporting and potential gaps in care documentation.
A resident with chronic kidney disease, diabetes, hypertension, severely impaired cognition, and a preferred language of Tagalog did not have an individualized communication care plan addressing their language needs. Staff confirmed the absence of a communication board and reported challenges in communicating with the resident, despite facility policy requiring comprehensive care plans.
A resident with severe cognitive impairment and high fall risk was left without a functioning bed alarm due to missing batteries. Staff confirmed the alarm was nonfunctional and necessary for alerting them when the resident attempted to get up. There was no effective system in place to ensure bed alarms were regularly checked, and maintenance staff only checked alarms monthly, contrary to facility policy.
A resident with end stage renal disease and other medical conditions did not have their face mask for breathing treatments changed every seven days as required by facility policy and physician orders. The mask was observed to be in use well past the recommended replacement interval, and staff interviews confirmed the expectation for weekly changes to prevent infection.
Staff did not attempt alternative interventions or obtain informed consent before installing bed rails for a resident with severe cognitive impairment and multiple diagnoses. Documentation and interviews confirmed that required steps outlined in facility policy, including assessment, education, and consent, were not completed prior to the use of side rails.
A resident with impaired cognition and multiple comorbidities was prescribed a Low Air Loss (LAL) mattress for wound care, with physician orders requiring monitoring every shift. However, the Treatment Administration Record (TAR) lacked documentation of the LAL mattress use and monitoring on several shifts. Interviews with nursing staff and the DON confirmed the missing documentation, resulting in incomplete medical records for the resident.
A CNA did not receive a required annual performance evaluation, as confirmed by interviews and a review of the employee file. The DSD acknowledged the evaluation was not completed, despite facility policy mandating annual reviews for all staff.
The facility did not post the total number of licensed and unlicensed nursing staff responsible for resident care per shift as required by policy. Observations and interviews with the DSD and DON confirmed that daily staffing postings at two nursing stations were missing this information for multiple shifts.
A resident with a history of severe cognitive impairment and seizure disorder experienced a seizure, during which an LVN improperly inserted a tongue depressor into the resident's mouth, contrary to facility policy. The care plan, which should have been revised following the seizure, was not updated, leading to potential inconsistencies in treatment. Facility staff confirmed the oversight, acknowledging the need for ongoing assessments and timely care plan revisions.
A resident with a history of respiratory failure and anoxic brain injury experienced a seizure, during which an LVN inserted a wrapped tongue depressor into the resident's mouth, contrary to the facility's seizure management policy. The policy, reviewed by staff, clearly states not to place objects in a resident's mouth during a seizure. This action was acknowledged as unsafe by the LVN and other staff members.
A resident was not readmitted to the facility after hospitalization due to issues with Medi-Cal eligibility verification. Despite verbal confirmation of eligibility and a new Medi-Cal number, the facility's Admissions Coordinator could not verify eligibility on the portal. Consequently, the resident's bed was given to another resident, and no bed was available when eligibility was confirmed.
A resident did not receive their prescribed Norco for severe pain due to the facility running out of the medication. Despite the resident's ability to communicate pain, the medication was unavailable for two days because of a delay in the pharmacy's refill process, which required an authorization form from the nurse practitioner. The facility's pain management policy emphasizes quick response to pain reports, which was not adhered to in this case.
A resident in an LTC facility did not receive timely refills of Norco for severe pain due to incomplete authorization forms from the physician, resulting in a two-day delay in medication delivery. The resident expressed frustration over the unavailability of the medication, which was not restocked promptly as required by the facility's policy.
A facility failed to maintain a comfortable environment for residents due to malfunctioning AC units, resulting in room temperatures exceeding the facility's guidelines. Three residents with various medical conditions, including multiple sclerosis and acute respiratory failure, reported discomfort and health concerns due to the heat. The issue persisted over three days despite attempts to repair the AC units.
The facility failed to promptly notify physicians of changes in condition for two residents. One resident experienced bleeding and blood clots after catheter removal, leading to a hospital transfer without timely physician notification. Another resident fell and sustained injuries, but the physician was not informed, and the oncoming shift was not notified of the communication lapse.
A resident with multiple health issues did not have a comprehensive care plan addressing the use of a freedom splint, skin conditions, or fall risk. The facility failed to include the restraint in the care plan, leading to improper use, and did not create plans for the resident's skin wounds or update the care plan after a fall, leaving the resident without necessary interventions.
The facility failed to document and assess incidents involving two residents accurately. One resident sustained a cut during nail trimming, and the incident was not documented. Another resident experienced two falls, with incomplete assessments and documentation, including delayed neuro checks and uncompleted SBAR forms. These deficiencies could lead to inadequate care and monitoring.
The facility failed to ensure proper PPE use by a maintenance worker and a family member before entering COVID-19 positive rooms. The maintenance worker entered a room without a face shield, and the family member was observed without a face shield and gloves. Both instances occurred despite clear signage and facility policy requiring specific PPE. The lack of adherence to PPE protocols posed a risk of spreading COVID-19 within the facility.
The facility failed to screen and offer the COVID-19 vaccine to four residents, as required by their policy. This oversight was identified through interviews and record reviews, revealing that these residents were not screened for the vaccine upon admission, nor was it offered to them. The Infection Prevention Nurse confirmed the lack of documentation, and the residents' vaccination records were incomplete. This failure potentially exposed the residents to the risk of contracting COVID-19 and developing serious complications.
A resident with hemiplegia and hemiparesis was unable to reach the call light due to it being placed on the side of the bed they could not move. The resident, dependent on staff for daily activities, was observed motioning for help as the call light was inaccessible. An LVN confirmed the call light should have been on the resident's left side, as per facility policy, to ensure timely assistance.
A resident with dementia was readmitted to a facility without an updated inventory of personal belongings, contrary to facility policy. Staff interviews revealed that the Inventory List - Resident Clothing and Possessions (ILRCP) form was not completed upon readmission, posing a risk of loss or theft of the resident's items.
A resident with significant medical needs was improperly restrained using a freedom splint with a towel wrapped inside, further restricting elbow movement. Nursing staff used the towel to prevent the resident from pulling out life-sustaining tubes, but this was not part of the intended use. The facility failed to document monitoring of the restraint, and no care plan was developed for its use, contrary to facility policy.
A resident at high risk for falls fell and sustained injuries due to a non-functioning bed alarm. The resident, with conditions like muscle weakness and confusion, attempted to get out of bed without supervision as the alarm failed to alert staff. The facility's policies required alarms to assist in fall prevention, but staff did not ensure its functionality, leading to the incident.
A facility failed to provide education about the Flu vaccine to a resident with dementia or their responsible party before administering the vaccine. The resident's Immunization Report showed no documentation of education, contrary to the facility's policy requiring such information to be provided and recorded. Interviews with staff confirmed the oversight, highlighting a lapse in following established procedures.
A long-term care facility failed to follow infection prevention and control practices, as staff members did not perform hand hygiene or wear appropriate PPE when caring for residents on enhanced barrier precautions. This included CNAs, a housekeeper, and therapists who neglected to don gowns and gloves, posing a risk of cross-contamination and infection spread among residents with conditions like Alzheimer's, diabetes, and severe pressure ulcers.
A resident with Alzheimer's and other conditions experienced a change in condition, including bruising and a fracture, which was not promptly communicated to their responsible party (RP) by the facility staff. The delay in notification prevented the RP from participating in care decisions, contrary to the facility's policy requiring timely communication of such changes.
A resident with severe cognitive impairment was found with bruises and a fracture, but the LTC facility failed to report the injury of unknown origin within the mandated timeframe. The CNA reported the bruising to an LVN, who informed the hospice nurse but not the Administrator or DON immediately. The facility's policy requires immediate reporting to authorities, which was not followed, potentially compromising the resident's safety.
The facility failed to follow its nail care policy for two residents, resulting in overgrown and unclean nails. A resident requiring substantial assistance had long, discolored fingernails and toenails, while another resident with severe cognitive impairment had overgrown toenails. The facility's policy for regular nail maintenance was not adhered to, and necessary notifications to LVNs and the podiatrist were not made, leading to potential health risks.
A facility failed to provide a resident's medical records to their legal representative within the required timeframe, resulting in a six-day delay. The resident, who had chronic obstructive pulmonary disease and lacked decision-making capacity, had an authorized representative who requested the records. The facility's policy required records to be available within two working days, but this was not met, as confirmed by the Medical Record Assistant and Director.
The facility failed to ensure that residents' Advance Directives (AD) and Consent for Medical Treatment (CMT) were discussed and documented for three residents. One resident with severe cognitive impairment had an incomplete AD form, and the responsible party was not asked about an existing AD. Another resident with diabetes and osteoarthritis had incomplete AD and CMT forms, with no record of these being offered upon admission. A third resident with moderate cognitive impairment and a pressure ulcer also lacked documentation regarding an AD. The facility's policies on resident rights and advance directives were not followed.
The facility failed to provide adequate care for three residents with stage 4 pressure ulcers. One resident was not repositioned every two hours as required, remaining in the same position for hours. Another resident refused repositioning, and the CNA did not inform the nurse to reinforce the need. Additionally, a resident's Low Air Loss mattress was improperly set to static, which should only be used for positioning. These deficiencies potentially delayed the healing of the residents' pressure ulcers.
The facility failed to ensure nursing staff had the necessary competencies for pressure ulcer prevention and management. Two CNAs lacked training in this area, as confirmed by their competency checklists and the Director of Staff Development. Additionally, the facility's training calendar and in-service materials did not include training on the use of low air loss mattresses, despite the facility's policy requiring competency in necessary skills for resident care.
A long-term care facility failed to maintain a safe and sanitary environment, leading to potential infection risks for eight residents. The facility did not provide necessary Enhanced Standard Precaution signage and PPE carts for residents with gastrostomy tubes and Foley catheters. Additionally, staff, including an Infection Preventionist Nurse and an LVN, did not adhere to proper glove changing and hand hygiene protocols between resident care activities, increasing the risk of cross-contamination.
A resident's responsible party did not make an informed decision regarding financial responsibility for non-covered services after Medicare Part A coverage ended. The SNF ABN was signed without selecting a care option, placing the resident at risk for out-of-pocket expenses. The facility's BOM failed to ensure the selection was made before signing.
A CNA failed to close the privacy curtain while cleaning a resident, exposing them to their roommate and violating their right to privacy. The resident, with severe cognitive impairment and dependent on assistance for daily activities, was observed undressed with the curtain open. Interviews with staff confirmed the expectation to maintain privacy, as outlined in the facility's policy.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to provide two-person physical assistance while transferring a resident using a Hoyer lift, contrary to the facility's policy and recent in-service training. The resident, who had morbid obesity and acute respiratory failure with hypoxia, was fully dependent on staff for activities of daily living, including transfers. On the day of the incident, the CNA attempted to transfer the resident alone from bed to a shower gurney using the Hoyer lift, despite knowing that two staff were required for such transfers. During the transfer, the Hoyer lift became unstable and tilted, causing the resident to fall to the floor. The resident's head and neck struck the floor, and the right lower leg was pinned between the shower gurney and the lift. The incident resulted in visible injuries, including a bump on the back of the head, bruising and swelling of the right lower leg, and a bruised finger. The resident was subsequently transferred to a hospital for evaluation of possible head injury, leg trauma, and other complications, especially given the use of blood thinners. Interviews with the resident, staff, and review of records confirmed that only one CNA was present during the transfer, and the CNA did not request assistance due to short staffing. Both the Director of Nursing and Director of Staff Development confirmed that facility policy and training required two staff for Hoyer lift transfers to ensure safety. The CNA involved acknowledged awareness of this requirement but proceeded alone due to perceived staffing shortages.
Failure to Provide Sufficient Nursing Staff Resulting in Unsafe Resident Assignments and Fall Incident
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its own policy and Facility Assessment Tool, resulting in certified nursing assistants (CNAs) being assigned more residents than permitted on multiple occasions. Specifically, on several dates, CNAs working the night shift in Station 3 were assigned between 24 and 25 residents each, despite the facility's policy and assessment indicating that no CNA should be assigned more than 12 residents per shift. Interviews with CNAs and facility leadership confirmed that this was a recurring issue, with staff reporting that such assignments made it impossible to provide safe and effective care, including timely repositioning, changing, and ensuring a safe environment for residents. On one morning shift, the facility assigned only five CNAs to Station 3 when the Facility Assessment Tool recommended seven. During this shift, a resident with morbid obesity and acute respiratory failure, who was dependent on staff for all transfers and personal care, experienced a fall while being transferred with a Hoyer lift. The CNA operating the lift did so alone, contrary to the facility's policy requiring two staff for such transfers. The CNA reported not asking for help due to the short staffing and the high workload. The resident fell from the lift, striking their head and leg, and required transfer to an acute care hospital for evaluation. Interviews with the resident, involved staff, and facility leadership confirmed that the short staffing directly contributed to the incident. The resident described the fall as traumatic and painful, noting that typically two staff would assist with Hoyer lift transfers, but only one was available due to staffing shortages. Facility leadership acknowledged that the staffing levels on the cited dates did not meet the facility's own standards or the needs of the residents, and that such staffing patterns posed a significant risk to resident safety.
Failure to Ensure Two-Person Assist During Hoyer Lift Transfer Results in Resident Fall
Penalty
Summary
Nursing staff failed to follow facility policy and procedure regarding the use of a Hoyer lift for transferring a resident who required total assistance with activities of daily living. The facility's policy and in-service training required two-person physical assistance when using a Hoyer lift, and staff were trained and had acknowledged this requirement. Despite this, a certified nursing assistant (CNA) attempted to transfer a resident alone using the Hoyer lift, citing short staffing as the reason for not obtaining a second staff member. The resident involved had a history of morbid obesity and acute respiratory failure with hypoxia, and was dependent on staff for all transfers and personal care. During the transfer, the resident was suspended in the Hoyer lift by the CNA alone, which resulted in the lift tilting and the resident falling to the floor. The resident's head and neck struck the floor, and the right lower leg became pinned between the shower gurney and the lift. The incident was witnessed by another staff member who responded to calls for help and observed the aftermath, including the resident's injuries and the malfunction of the lift. Documentation and interviews confirmed that the CNA had attended the required in-service training and was aware of the two-person assist policy. Both the Director of Staff Development and the Director of Nursing stated that two staff are required for safe operation of the Hoyer lift and that failure to follow this protocol could result in injury. The facility's policy emphasized the need for sufficient and competent staffing to meet resident needs, but this was not adhered to during the incident, directly leading to the resident's fall and injuries.
Penalty
Summary
Empty report provided.
Penalty
Summary
Empty report provided.
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Empty report provided.
Penalty
Summary
Empty report provided.
Penalty
Summary
Empty report provided.
Failure to Ensure Call Lights and Pad Sensors Were Within Reach for High-Risk Residents
Penalty
Summary
The facility failed to ensure that pad sensors and call lights were within reach for three residents who were assessed as high risk for falls and had significant cognitive and physical impairments. For one resident with dementia, osteoporosis, and a traumatic fracture, the care plan required the call light to be kept within easy reach and encouraged its use for assistance. However, during observation, the pad sensor was found hanging on the left siderail, out of reach, despite the resident being stronger on the right side. The assigned CNA confirmed the resident could not reach the pad sensor and acknowledged it should have been placed on the resident's strong side. Another resident with dementia, muscle weakness, and left-sided hemiparesis was also found with the call light on the floor on the left side of the bed, which was not accessible due to the resident's inability to use the left arm and hand. The LVN present confirmed the call light should have been placed on the resident's strong side for timely assistance. Both the Director of Nursing and the LVN stated that facility policy requires call lights to be within easy reach of residents, especially those at high risk for falls. A third resident with metabolic encephalopathy, Parkinson's disease, and muscle weakness was observed with the call light on the floor and not within reach. Staff interviews confirmed the call light should not be on the floor due to infection control and accessibility concerns. Facility policies reviewed indicated that residents must be provided with a means to call for assistance from their bed, and alternative communication methods should be documented in the care plan if needed. These observations and interviews demonstrated a failure to follow care plans and facility policies regarding resident safety and supervision.
Inaccurate MDS Coding of Nutritional Status for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessment and coding of the swallowing and nutritional status for two residents, resulting in incorrect information being entered into their Minimum Data Set (MDS) assessments. For one resident with Alzheimer's disease and convulsions, the MDS indicated significant weight loss, while a review of the resident's weight records showed a substantial weight gain over both one- and six-month periods. The MDS nurse confirmed that the MDS should have been coded to reflect weight gain, not loss, and acknowledged the need for accurate reporting to CMS. Similarly, another resident with dysphagia and respiratory failure was incorrectly coded in the MDS as having experienced weight loss, despite weight records showing consistent weight gain during the relevant periods. The MDS coordinator admitted to not verifying the resident's weight records before entering data into the MDS, resulting in inaccurate assessment documentation. Both cases demonstrate failures in verifying and accurately recording resident assessment data as required by facility policy.
Failure to Change and Label IV Catheter Dressings as Required
Penalty
Summary
The facility failed to ensure the timely and appropriate changing of intravenous (IV) catheter dressings for two residents, as required by their care plans and the facility's policies and procedures. For one resident with a history of osteomyelitis and diabetes, the physician's order and care plan specified that the central line and midline catheter dressings should be changed every seven days. However, observation and record review revealed that the midline IV catheter dressing had not been changed for at least 14 days, and staff confirmed that the dressing change had not occurred as ordered. The facility's policy also required weekly dressing changes and proper labeling, which was not followed in this case. For another resident with diabetes and hemiplegia, the care plan required dressing and securement device changes every seven days, or every 48 hours if using gauze. During observation, the resident was found with a midline IV covered by a white gauze dressing that was not labeled with the date of insertion or last change. The nurse present acknowledged that the dressing should have been labeled to track when it was last changed, in accordance with facility policy. The DON confirmed that dressings should be changed every seven days and labeled appropriately to maintain infection control. Both residents were assessed as having intact cognition but required varying levels of assistance with activities of daily living. The failure to change IV dressings as ordered and per policy, as well as the lack of proper labeling, was confirmed through interviews with nursing staff and review of facility procedures. These actions and omissions had the potential to result in infection and negatively impact the residents' health conditions.
Failure to Meet Minimum CNA Staffing Hours on Two Weekend Days
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the required 2.4 Certified Nursing Assistant (CNA) direct care hours per patient day on two weekend days during the first quarter of 2024. Payroll Based Journal (PBJ) Staffing Data Reports and supporting documentation confirmed that on these dates, the actual CNA hours per patient day were 2.04 and 2.15, both below the mandated minimum. The Director of Staff Development (DSD) verified these figures during a review of staffing assignment sheets, sign-in sheets, and census data, and confirmed that the data was accurately reported to the California Department of Public Health (CDPH). During interviews, the DSD and the Director of Nursing (DON) acknowledged the shortfall in CNA hours and indicated that the facility had been struggling to meet staffing requirements during the specified period. The facility's policies and procedures require compliance with minimum staffing standards, including the 2.4 CNA hours per patient day, but these standards were not met on the identified dates. No specific residents or their medical conditions were mentioned in relation to the deficiency.
Significant Medication Errors: Epogen Administered Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that two residents were not administered Epoetin Alfa-epbx (Epogen) injections outside of the parameters specified in their physician orders. Both residents had orders to hold Epogen injections if their hemoglobin (Hgb) levels exceeded 10 g/dl. Despite these clear instructions, staff administered multiple doses of Epogen to both residents when their Hgb levels were above the prescribed threshold. One resident, with a history of end stage renal disease, dependence on dialysis, and anemia, received 19 unnecessary doses of Epogen over a period when their Hgb level was documented at 11.5 g/dl. The medication administration records and interviews with licensed vocational nurses revealed that the nurses did not check the most recent Hgb levels or review the physician's order before administering the medication. The nurses acknowledged that they failed to follow the order to hold the medication and recognized this as a medication error. Another resident, with a history of kidney transplant and anemia, received three unnecessary doses of Epogen when their Hgb levels were 12.3 g/dl and 12.9 g/dl. The nurse responsible admitted to not checking the latest Hgb level or reading the physician's order accurately before administration. The Director of Nursing confirmed that the facility did not follow the physician's orders and that licensed nurses were required to check current Hgb levels before administering Epogen. Facility policy required medications to be administered as prescribed, including adherence to any parameters set by the physician.
Removal Plan
- Notify the pharmacist regarding Resident 35 receiving extra doses of Epogen injections.
- Communicate with the Nephrologist to have the dialysis center administer Epogen injections based on lab work during dialysis treatments.
- Follow up with Resident 35's Primary Physician to clarify the order for Epogen to be given at the dialysis center.
- Assess Resident 35 for overall health condition and status.
- Notify Resident 89's Primary Physician regarding Resident 89 receiving extra doses of Epogen injections when Hgb was above the prescribed parameter.
- Continue the Epogen order for Resident 89 with the same parameter (hold Epogen injections when Hgb > 10 mg/dl), pending a complete blood count result.
- Notify the pharmacist regarding Resident 89 receiving Epogen injections when Hgb was above the prescribed parameter.
- Assess Resident 89 for overall health condition and status.
- Notify the Medical Director of the Immediate Jeopardy and develop a removal plan.
- Notify all licensed nurses of the Immediate Jeopardy findings and provide in-services regarding the Medication Administration policy and procedure, including checking/verifying resident and medication information, holding/discontinuing medication per parameters, and notifying physicians of medication-related issues.
- Notify the specific RN and LVNs responsible for the identified findings and provide one-on-one in-services regarding medication administration policy, focusing on Epogen injection administration based on parameters, following disciplinary action.
- Complete in-services regarding medication administration policy and procedure for all licensed nurses.
- Initiate a Quality Assurance and Performance Improvement (QAPI) plan to address the findings.
- Review all current residents with Epogen injection orders.
- Provide in-service regarding medication administration policy and procedure for all licensed nurses.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed to ensure compliance.
- Create an Epogen injection administration log including resident name, Epogen injection order, medication administration following parameter, and laboratory monitoring.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed, and document findings with corrective action on the monitoring log.
- Review the QAPI program and adjust measures to ensure effective and ongoing compliance with State and Federal regulations.
Failure to Follow Infection Control Protocols and Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the development and transmission of communicable diseases for three of five sampled residents. Staff did not follow the facility's Enhanced Barrier Precaution (EBP) policy, which requires the use of a gown and gloves during high-contact care activities for residents with certain conditions. Specifically, a Licensed Vocational Nurse (LVN) provided care to two residents on EBP precautions—one with a gastrostomy tube and another with a stage 4 pressure ulcer—without changing gown and gloves between residents, despite both the facility policy and staff interviews confirming this was required to prevent cross-contamination. Additionally, the facility did not ensure that a resident's oxygen tubing was kept off the floor. During observation, the oxygen tubing for a resident receiving oxygen therapy was found lying on the floor. Both the LVN and the Director of Nursing (DON) acknowledged that oxygen tubing should not be on the floor, as stated in the facility's policy and for infection control purposes. These deficiencies were identified through observation, interview, and record review, and involved residents with significant medical needs, including severe cognitive impairment, respiratory failure, gastrostomy, stage 4 pressure ulcers, and chronic obstructive pulmonary disease. The failures were directly related to staff not adhering to established infection prevention and control procedures during resident care activities.
Failure to Provide Privacy During G-Tube Care
Penalty
Summary
Staff failed to provide privacy for a resident during a G-tube site check. The Director of Staff Development (DSD) entered the resident's room, pulled up the resident's gown, and checked the G-tube site without closing the privacy curtain. This resulted in the resident's abdominal area and lower extremities being exposed to the roommate and potentially to the hallway. The DSD acknowledged during an interview that the privacy curtain was not closed and stated that it should have been used during activities of daily living (ADLs) to provide privacy. The resident involved had a history of dysphagia and required a G-tube for feeding, with orders for Jevity 1.2 to be administered via enteral pump. The resident was dependent on staff for all ADLs and had moderately impaired cognition. The care plan and facility policy both indicated that staff should maintain resident privacy and dignity during care and treatment procedures, including ensuring bodily privacy. The Director of Nursing (DON) also confirmed that privacy curtains should be closed during care to maintain dignity and privacy.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for a resident who was admitted with diagnoses including difficulty in walking and hypertension. The resident required partial to moderate assistance with personal hygiene, lower body dressing, and rolling. The resident was discharged home, but the required discharge MDS was not completed or transmitted to CMS within the mandated timeframe. The MDS Coordinator acknowledged forgetting to complete the discharge MDS, which was due within 14 days of discharge. Facility documentation specified that discharge assessments must be completed and encoded within specific timeframes following a resident's discharge. The omission of the discharge MDS assessment resulted in incomplete reporting to CMS and the potential for the resident not to receive necessary care and services, as the resident's health condition and discharge status were not properly updated in the system.
Failure to Develop Individualized Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop an individualized and comprehensive communication care plan for a resident with a language barrier. The resident, who was readmitted with chronic kidney disease, Type 2 diabetes mellitus, and essential hypertension, was documented as having severely impaired cognition and a preferred language of Tagalog. The resident did not have the capacity to make medical decisions. Despite these needs, a review of the medical record revealed that no care plan was created to address the resident's language needs. Additionally, during observation, there was no communication board available at the resident's bedside, and staff interviews confirmed the absence of appropriate communication tools. Staff members, including CNAs and the Infection Preventionist, stated that the resident only spoke Tagalog and did not understand English. One CNA recalled that a communication board with pictures had previously been available but was no longer present, and there was uncertainty about its replacement. Staff also reported difficulty communicating with the resident and the need to seek a translator. The facility's policy required comprehensive care plans to be developed within seven days of assessment, but this was not done for the resident's communication needs.
Failure to Maintain Functional Bed Alarm for High Fall Risk Resident
Penalty
Summary
The facility failed to maintain a bed alarm in proper working condition for a resident identified as high risk for falls. The resident, who had diagnoses including metabolic encephalopathy, Parkinson's disease, and muscle weakness, was assessed as having severely impaired cognition and required substantial to maximal assistance with activities of daily living. The resident's care plan required the use of a sensor pad alarm when in bed or wheelchair due to a tendency to attempt to get up unassisted. During observation, the bed alarm was found hanging on the side of the bed without batteries, rendering it nonfunctional. Both the LVN and DON confirmed that the bed alarm was not operational and emphasized its importance in alerting staff when the resident attempted to get up. Interviews revealed that there was no effective system in place to ensure bed alarms were consistently checked and maintained. The maintenance supervisor stated that bed alarms were only checked once a month and was unsure how to implement a monitoring system. The facility's policy indicated that the maintenance department was responsible for keeping equipment safe and operable at all times, but this was not followed in practice. As a result, the resident was left without a functioning bed alarm, placing them at risk for a preventable fall or accident.
Failure to Timely Change Respiratory Equipment for a Resident
Penalty
Summary
The facility failed to follow its policy and procedure regarding the timely replacement of respiratory equipment for a resident requiring breathing treatments. Specifically, a face mask used for nebulizer treatments was observed on a resident's bedside stand with a date indicating it had not been changed for over a month, despite facility policy requiring such equipment to be changed every seven days. This was confirmed during an interview with a Licensed Vocational Nurse, who stated that the face mask should be changed weekly for infection control purposes. The resident's medical orders also specified that the nasal cannula or mask should be changed every seven days. The resident involved had a history of end stage renal disease, dependence on renal dialysis, and anemia, and required partial to moderate assistance with activities of daily living. The resident was cognitively intact and able to communicate needs. The Director of Nursing confirmed that staff are expected to change respiratory equipment weekly and as needed, and acknowledged that failure to do so could result in infection. Review of the facility's policy further supported the requirement for weekly changes of oxygen delivery devices and proper storage when not in use.
Failure to Attempt Alternatives and Obtain Consent Before Bed Rail Use
Penalty
Summary
Staff failed to follow the facility's policy and procedure regarding bed safety and bed rails for one resident. Specifically, staff did not attempt alternative interventions before installing bilateral upper half side rails for a resident with severe cognitive impairment, dependence on staff for all activities of daily living, and multiple diagnoses including respiratory failure, dementia, and parkinsonism. During observation, the resident was found in bed with the side rails up, and staff confirmed the resident was confused. Record review and staff interviews revealed there was no documented evidence that alternative interventions were tried and found ineffective prior to the use of bed rails. Additionally, there was no signed informed consent for the use of the side rails in the resident's chart or electronic medical record. Both the LVN and DON confirmed that informed consent should have been obtained and documented, and that alternative interventions should have been attempted before installing side rails, as required by the facility's policy.
Failure to Document Use and Monitoring of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident who was prescribed a Low Air Loss (LAL) mattress for wound care and management. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD), was dependent on staff for all activities of daily living and had moderately impaired cognition. A physician's order required the use and monitoring of the LAL mattress every shift. However, review of the Treatment Administration Record (TAR) for January 2025 revealed that documentation regarding the use and monitoring of the LAL mattress was missing for several shifts. During interviews, the treatment nurse confirmed that the TAR lacked documentation for the specified dates and shifts, and was unable to explain why the licensed nurses had not completed the required entries. The DON stated that staff are required to check off and sign the TAR immediately after performing treatments as per physician's orders, and that the LAL mattress should be monitored every shift to ensure it is functioning correctly. The facility's policy indicated the use of pressure-reducing mattresses to prevent or minimize skin pressure. The lack of documentation resulted in the resident's medical record being incomplete.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of eight sampled employees, a Certified Nurse Assistant (CNA). During interviews, the CNA reported not receiving an annual performance evaluation in the previous year and could not recall the last time one was completed. A review of the CNA's employee file confirmed that the annual evaluation had not been conducted. The Director of Staff Development acknowledged the omission, stating that either the DSD or the DON was responsible for ensuring annual evaluations were completed. The facility's policy and procedure required that each employee's job performance be reviewed and evaluated at least annually, with the evaluation to coincide with the employee's compensation review.
Failure to Post Daily Nurse Staffing Totals per Shift
Penalty
Summary
The facility failed to post the total number of licensed and unlicensed nursing staff directly responsible for resident care per shift on a daily basis, as required by its own policy and procedure. During observations on multiple dates, staffing postings at two nursing stations did not indicate the total number of licensed and non-licensed nursing staff working for all three posted shifts. This omission was confirmed during interviews and record reviews with the Director of Staff and Development (DSD), who acknowledged that the postings did not include the required totals for the specified dates. Further interviews with the DSD consultant and the Director of Nursing (DON) confirmed the importance of posting the total number of licensed and non-licensed staff responsible for resident care per shift. Review of the facility's policy indicated that daily postings should include this information for each shift. The deficiency was limited to the failure to include the total number of staff on the daily postings, as observed and confirmed by facility leadership.
Failure to Revise Care Plan After Seizure Event
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a seizure, as required by their policies and procedures. The resident, who had a history of respiratory failure, tracheostomy, and anoxic brain injury, was admitted to the facility with severely impaired cognition and required substantial assistance for daily activities. The care plan for the resident's seizure disorder, initiated in August 2022, included interventions to provide a safe environment and prevent injury. However, the care plan was not updated following a seizure event in October 2024. During the seizure event, a Licensed Vocational Nurse (LVN) improperly managed the situation by inserting a tongue depressor into the resident's mouth, contrary to the facility's emergency procedure for seizure management. The facility's policy clearly stated that no objects should be placed in a resident's mouth during a seizure. Interviews with facility staff, including another LVN and a Registered Nurse (RN), confirmed that the care plan should have been revised following the resident's change in condition. The facility's policies and procedures emphasized the importance of ongoing assessments and timely revisions of care plans to reflect changes in residents' conditions. Despite these guidelines, the care plan for the resident was not updated after the seizure incident, which could lead to inconsistent treatment and unmet needs. The failure to revise the care plan was acknowledged by the facility's administrator during the review of the relevant policies.
Unsafe Seizure Management in LTC Facility
Penalty
Summary
The facility failed to provide safe seizure management for a resident, as outlined in their policy and procedure titled 'Emergency Procedure - Seizure Management.' The incident involved a Licensed Vocational Nurse (LVN) who, during a seizure episode experienced by the resident, inserted a wrapped tongue depressor into the resident's mouth. This action was contrary to the facility's policy, which explicitly states not to place objects in a resident's mouth during a seizure. The resident, who had a history of respiratory failure, tracheostomy, and anoxic brain injury, was at risk for injury and ineffective breathing patterns due to seizure activity. Interviews and record reviews confirmed that the LVN acknowledged the action was unsafe and not in compliance with the facility's procedures. The facility's policy, revised in August 2018, was reviewed by multiple staff members, including another LVN, a Registered Nurse (RN), and the Administrator, all of whom confirmed that the policy prohibits placing objects in a resident's mouth during a seizure. The resident's care plan also emphasized the need for a safe environment, highlighting the risk of injury and ineffective breathing patterns during seizures.
Failure to Readmit Resident After Hospitalization Due to Medi-Cal Eligibility Issues
Penalty
Summary
The facility failed to readmit a resident from a General Acute Care Hospital (GACH) after the resident was cleared to return. The resident, who had been admitted to the facility with diagnoses including respiratory failure, quadriplegia, and type 2 diabetes mellitus, was sent to GACH for treatment. Upon being ready for discharge from GACH, the facility refused to readmit the resident due to issues with the resident's Medi-Cal eligibility. Despite receiving verbal confirmation from Medi-Cal and a new Medi-Cal number indicating eligibility, the facility's Admissions Coordinator found that the eligibility did not appear on the Medi-Cal portal. The facility's policy stated that Medicaid residents who exceed the state's bed-hold limit should be permitted to return to the facility if they require the services and are eligible for Medicaid nursing services. However, the facility did not accept the resident back, citing the lack of visible eligibility on the portal. Consequently, the resident's previous bed was given to another resident, and by the time the resident's eligibility was confirmed, no bed was available for them. This resulted in the potential denial of the resident's right to return to the facility.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident received their prescribed pain medication, Norco, as ordered by the physician. The resident, who was admitted with diagnoses including respiratory failure, difficulty in walking, and dysphagia, was dependent on staff for toileting and bathing. Despite having no cognitive impairments and being able to communicate pain, the resident did not receive Norco for severe pain on a specific date, as the facility had run out of the medication. The resident expressed feeling mad due to the unavailability of the medication, which was confirmed by interviews with nursing staff who stated that the medication was not available due to a delay in the pharmacy's refill process. The pharmacy had received a refill request but required an authorization form from the resident's nurse practitioner, which was delayed and incomplete. This resulted in the resident's Norco supply being empty for two days. The facility's Director of Nursing acknowledged that medications should be available when ordered. The facility's pain management policy emphasized the importance of effective pain control and quick response to pain reports, highlighting a failure in adhering to these guidelines.
Failure to Timely Refill Pain Medication
Penalty
Summary
The facility failed to ensure the timely refill and availability of pain medication for a resident, leading to a deficiency in pharmaceutical services. The resident, who was admitted with diagnoses including respiratory failure, difficulty in walking, and dysphagia, had a physician's order for Norco to be administered as needed for severe pain. However, the medication was not available when requested by the resident on the morning of September 26, 2024, due to the facility running out of the supply. The issue arose because the facility did not have the necessary authorization form completed by the resident's physician or nurse practitioner, which delayed the pharmacy's ability to refill the medication. Despite the pharmacy being contacted, the authorization form was incomplete, causing a delay in the delivery of the medication. The resident expressed frustration and reported that the medication was unavailable for two to three days, during which the nursing staff indicated that the medication was on its way. Interviews with facility staff and the pharmacy revealed that the refill request was made on September 22, 2024, but the authorization form was not received by the pharmacy until September 26, 2024, and was still missing information. The new supply of Norco was eventually delivered on September 27, 2024. The facility's policy required that medications be available for residents as ordered, but this was not adhered to in this instance, resulting in the deficiency.
Facility Fails to Maintain Comfortable Environment Due to AC Malfunction
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by the unsafe and uncomfortable air temperatures in nine out of 20 resident rooms. This deficiency was observed over a period of three days, affecting three sampled residents. The facility's policy and procedure titled 'Homelike Environment,' revised in February 2021, stipulates that residents should be provided with a safe, clean, comfortable, and homelike environment, including maintaining room temperatures between 71°F and 81°F. However, temperatures in the affected rooms ranged from 83°F to 89°F, exceeding the facility's guidelines. Resident 4, who has multiple sclerosis, quadriplegia, and congestive heart failure, reported that the high temperatures could exacerbate their condition. Resident 5, diagnosed with acute respiratory failure, chronic kidney disease, and insomnia, felt weak due to the heat and was unable to engage in activities like painting. Resident 6, with type 2 diabetes mellitus, an infection of an amputation stump, and cerebral infarction, expressed discomfort and reported feeling sweaty due to the warm temperatures. The issue was attributed to malfunctioning air conditioning units, specifically one unit that had a burned-out motor and another with a broken motor. The Maintenance Supervisor confirmed that the air conditioning units on the roof were not functioning correctly, particularly the unit labeled 307-315, which was not operating as expected. Despite the facility's efforts to address the issue by calling an AC technician, the problem persisted, leading to uncomfortable conditions for the residents.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician for two residents who experienced a change of condition. For Resident 3, the staff did not inform the primary physician when the resident exhibited bleeding and blood clots after the removal of a urinary catheter. This incident occurred on 6/18/2024 at 3 pm, but the physician was only notified after the resident was transferred to a hospital later that night. The delay in notification resulted in the resident developing tachycardia, scant urine output, hypovolemia, and hypotension, necessitating emergency medical services and hospital transfer. Resident 3 had a history of respiratory failure with hypoxia and an indwelling urinary catheter. The care plan required staff to monitor urine and notify the physician of any changes. However, the staff assumed the previous shift had already contacted the physician, leading to a lack of timely communication. Interviews with staff revealed that the bleeding was noted for 30 minutes, and a message was left for the responsible party, but the physician was not contacted until after the resident's condition worsened. For Resident 2, the facility failed to notify the physician after the resident fell and sustained injuries. The fall occurred on 8/28/2024 at 5:40 am, but the physician was not informed, and the oncoming shift was not notified of the lack of communication. Resident 2 had a history of difficulty walking and was at high risk for falls. The care plan required frequent observation and physician notification as needed. Despite the fall resulting in new injuries, the staff did not complete the necessary documentation or communicate effectively with the physician or the oncoming shift.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, leading to several deficiencies. The resident, who was admitted with multiple diagnoses including difficulty walking, muscle weakness, respiratory failure, and dependence on a respirator-ventilator, had an order for a freedom splint to prevent pulling out life-sustaining tubes. However, the care plan did not include this restraint, and staff were observed using a towel inside the splint, which was not part of the intended use and further restricted the resident's movement. This oversight in care planning and improper use of the restraint was acknowledged by the Director of Nursing, who stated that a care plan should have been developed to address potential injury or entrapment. Additionally, the facility did not create care plans for the resident's skin conditions, including a right forearm skin tear and a right-hand scab, which were first observed shortly after admission. Despite the presence of these wounds, there was no care plan to guide staff on interventions to prevent further deterioration. Licensed Vocational Nurse 6 confirmed the absence of care plans for these skin wounds, emphasizing the lack of a roadmap for staff to follow in providing necessary care. Furthermore, the facility failed to update the resident's care plan following a fall. The resident, who was at high risk for falls due to intermittent confusion and poor safety awareness, was found on the floor, yet no new interventions were developed to prevent future falls. The Director of Nursing confirmed that the care plan was not revised after the fall, which was a requirement according to the facility's policy and procedure. This lack of action left the resident vulnerable to further incidents without appropriate preventive measures in place.
Incomplete Documentation and Assessment After Resident Incidents
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the electronic medical records (EHR) for two residents, leading to potential lapses in care. For Resident 3, the staff did not complete or document a Change of Condition (COC) or Interact Assessment Form (SBAR) after the resident sustained a cut on the finger during a nail trimming incident. The incident was not documented in the resident's clinical records, and no care plan was updated to address the injury, despite the responsible party and a Certified Nursing Assistant acknowledging the event. Resident 2 experienced two falls, and the facility failed to document and assess the incidents properly. After the first fall, the staff did not perform or document a head-to-toe assessment, pain risk assessment (PRA), or neurological checks. The care plan was not updated to reflect the fall, and the necessary SBAR form was not completed. The Director of Nursing confirmed that these measures were not taken, which are crucial for preventing further falls and injuries. During the second fall, the facility again failed to complete necessary documentation and assessments. The neuro checks were delayed, and the SBAR and PRA forms were left incomplete. The Director of Nursing noted that the neuro checks were not performed according to the required schedule, potentially missing critical observations of head injuries. The lack of documentation and communication among staff led to inadequate monitoring and care for Resident 2, as confirmed by interviews with nursing staff and the Director of Nursing.
Failure to Ensure Proper PPE Use in COVID-19 Positive Rooms
Penalty
Summary
The facility failed to adhere to its COVID-19 policy by not ensuring that a Maintenance Worker (MW) and a Family Member (FM) donned the appropriate personal protective equipment (PPE) before entering COVID-19 positive rooms. On 8/27/2024, MW 1 was observed entering a COVID-19 positive room without a face shield, despite a sign indicating the requirement for an N95 mask, face shield, gown, and gloves. MW 1 admitted to being unaware of the need for a face shield, and both Registered Nurse (RN) 1 and the Infection Preventionist Nurse (IPN) confirmed the risk of virus spread due to improper PPE use. The facility's COVID-19 outbreak had started on 8/19/2024, and the lack of proper PPE use was identified as a potential contributor to the spread of the virus. Similarly, on 8/28/2024, FM 1 was observed inside a COVID-19 positive room without a face shield and gloves. FM 1 stated that no one had informed them of the PPE requirements. Licensed Vocational Nurse (LVN) 1 confirmed that FM 1 was not wearing the appropriate PPE and highlighted the risk of virus transmission. RN 3 reiterated the necessity for family members and staff to wear a face shield, mask, gloves, and gown when entering COVID-19 positive rooms. The facility's policy, dated 5/1/2024, required staff education on infection control and regular audits of PPE adherence, which were not effectively implemented in these instances.
Failure to Screen and Offer COVID-19 Vaccine
Penalty
Summary
The facility failed to screen and offer the COVID-19 vaccine to four of six sampled residents, as required by their COVID-19 Policy. This oversight was identified during interviews and record reviews, which revealed that Residents 1, 2, 4, and 5 were not screened for the COVID-19 vaccine upon admission, nor was the vaccine offered to them. The Infection Prevention Nurse (IPN) confirmed that there was no documentation indicating that these residents were screened for the vaccine, and the COVID-19 Vaccination Record Cards were not filled out. This failure to adhere to the facility's policy potentially exposed these residents to the risk of contracting COVID-19 and developing serious respiratory complications. Resident 1, who had severe cognitive impairment, was past due for the COVID-19 vaccine and later tested positive for the virus. Resident 2, who was alert and oriented, also tested positive for COVID-19, and their vaccination record was blank. Resident 4, with moderately impaired cognitive abilities, was past due for the vaccine and tested positive for COVID-19. Resident 5, with severe cognitive impairment, had not received a COVID-19 vaccine since 2021. Interviews with the IPN and a Registered Nurse (RN) highlighted the importance of screening and offering the vaccine to prevent complications, as residents are at higher risk for severe illness from COVID-19.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 6, who was admitted with significant medical conditions including hemiplegia and hemiparesis affecting the right side of the body, respiratory failure with hypoxia, and dysphagia. The resident was dependent on staff for various activities of daily living such as toileting hygiene, showering, and dressing. During an observation, it was noted that the call light was dangling off the bed on the right side, which the resident could not access due to the inability to move the right arm. The resident could only move the left arm and was seen motioning to indicate the inaccessibility of the call light. An interview with a Licensed Vocational Nurse (LVN) revealed that the resident typically called for assistance using the call light or by motioning to someone in the hallway. The LVN acknowledged the importance of having the call light on the resident's left side to ensure accessibility and timely assistance. The facility's policy and procedure on call lights required staff to ensure that the call light was within the resident's reach, which was not adhered to in this instance, potentially delaying care for the resident.
Failure to Inventory Resident's Personal Belongings
Penalty
Summary
The facility failed to protect the personal property of a resident by not completing an inventory list of the resident's belongings upon admission, as required by the facility's policy and procedure. The resident, who had a diagnosis of dementia and severely impaired cognitive abilities, was readmitted to the facility without an updated Inventory List - Resident Clothing and Possessions (ILRCP) form. This oversight was confirmed during interviews with the Registered Nurse (RN), Social Services Director (SSD), and Director of Nursing (DON), who all acknowledged that the ILRCP form was not completed upon the resident's readmission. The facility's policy, revised in March 2023, mandates that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary. However, the ILRCP form for the resident was last completed on a previous discharge date, and no recent form was found. The staff, including the RN, SSD, and DON, recognized the risk of not completing the ILRCP form, which could lead to the resident's belongings going missing and potentially affecting the resident's psychosocial well-being.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident remained free from physical restraints used for convenience, contrary to the facility's policy and procedure on physical restraints. The deficiency involved the improper use of a freedom splint on the resident's right arm, where a towel was wrapped around the arm inside the splint, further restricting the elbow's movement. This action was taken by several nursing staff members, including RNs, LVNs, and CNAs, who stated that the towel was used to prevent the splint from sliding and to stop the resident from pulling out life-sustaining tubes such as a tracheostomy and gastrostomy tube. The resident, who was admitted with diagnoses including generalized muscle weakness, respiratory failure, and attention to tracheostomy and gastrostomy tube, required significant assistance with daily activities and was not oriented to person, place, and time. Despite a physician's order for the use of a freedom splint to prevent the resident from pulling out tubes, there was no documented care plan for the use of the splint or restraint. Observations and interviews revealed that the towel inside the splint was not part of the intended use and caused more restriction than necessary, potentially leading to physical harm. The facility's Director of Nursing and Director of Staffing Development confirmed that the freedom splint was considered a restraint and required monitoring and documentation to ensure safety and prevent harm. However, the nursing staff did not document the monitoring of the restraint, and there was no in-service training provided on the proper application of the freedom splint. The facility's policy indicated that restraints should be used only for brief periods and required documentation of their use and effectiveness, which was not adhered to in this case.
Failure to Ensure Functioning Bed Alarm Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the proper functioning of a bed alarm for a resident at high risk for falls, leading to an incident where the resident fell and sustained injuries. The resident, who was admitted with conditions such as difficulty walking, generalized muscle weakness, and dependence on a respirator-ventilator, was identified as having a high risk for falls due to intermittent confusion and poor safety awareness. Despite these risks, the bed alarm, which was a part of the resident's care plan for safety, was not functioning on the morning of the fall. On the morning of the incident, the resident attempted to get out of bed, and the bed alarm failed to sound, which was supposed to alert the staff to provide assistance. The resident fell to the floor, resulting in bruises and a scab on the right hand, and was found with the medical pole on top of them. The resident was anxious, stressed, and in pain following the fall. Interviews with staff revealed that the alarm was not working, and no staff was present to supervise the resident at the time of the fall, as the CNA assigned to monitor the resident had left to attend to another resident. The facility's policies and procedures indicated that alarms should not be the sole intervention for preventing falls but should assist staff in identifying patterns and routines. However, the staff failed to ensure the alarm was functioning at the beginning of the shift, as required. The Director of Nursing acknowledged that the alarm was supposed to alert staff when a resident attempted to get out of bed, and its failure contributed to the resident's fall and subsequent injuries.
Failure to Provide Flu Vaccine Education
Penalty
Summary
The facility failed to provide education regarding the Influenza vaccine to a resident, identified as Resident 5, or their responsible party. Resident 5, who was diagnosed with dementia, chronic kidney disease, and hypertension, lacked the capacity to understand and make decisions. Despite this, the facility did not document any education provided about the benefits and potential side effects of the Flu vaccine before administering it on October 5, 2023. This omission was confirmed during a review of Resident 5's Immunization Report, which indicated that no education was provided prior to the vaccination. Interviews with the Infection Preventionist Nurse and a Registered Nurse revealed that the facility's policy required licensed staff to provide education and obtain consent before administering the Flu shot. The policy, dated 2021, stipulated that education should be documented in the resident's medical record. However, the failure to adhere to this policy resulted in Resident 5 and/or their responsible party being uninformed about the vaccine's potential side effects and the symptoms to report to staff.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices as outlined by their own policies and the CDC guidelines. Specifically, five out of seven sampled staff members, including CNAs and a Registered Nurse Supervisor, did not perform hand hygiene before entering residents' rooms or after providing care. This was observed in the care of three residents, all of whom required enhanced barrier precautions (EBP) due to their medical conditions, which included Alzheimer's disease, encephalopathy, dysphagia, Type 2 Diabetes Mellitus, acute kidney failure, hemiplegia, and severe pressure ulcers. The staff's failure to perform hand hygiene and don appropriate personal protective equipment (PPE) such as gowns and gloves posed a risk of cross-contamination and infection spread within the facility. In one instance, a CNA entered a resident's room without performing hand hygiene or donning a gown and gloves, despite the resident being on EBP. The CNA acknowledged the oversight and the potential risk of spreading germs to the resident and others. Similarly, two other CNAs entered the same resident's room without performing hand hygiene and only donned gloves, neglecting to wear gowns. They admitted to forgetting the necessary precautions, which are crucial to preventing infection spread. Additional observations revealed that a housekeeper, an occupational therapist, and a physical therapist assistant also failed to adhere to EBP requirements. The housekeeper entered a resident's room without performing hand hygiene, while the therapists provided care without wearing gowns. These actions were contrary to the facility's policies and the CDC's guidelines, which emphasize the importance of hand hygiene and appropriate PPE use to prevent infection transmission. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed the necessity of these practices to protect residents, particularly those with open wounds or indwelling medical devices, from infection risks.
Failure to Notify Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify the responsible party (RP) of a resident's change of condition, as required by their policy and procedure. The resident, who had been admitted with diagnoses including Alzheimer's Disease, encephalopathy, and dysphagia, was found to have bruising on the right knee by a CNA on 7/15/2024. This bruising was reported to an LVN, who notified the hospice nurse but failed to inform the resident's RP or other facility staff, including the Director of Nursing (DON), until the following day when the RP noticed the bruising during a visit. Further, the facility did not notify the RP of the results of an X-ray conducted on 7/17/2024, which revealed a fracture in the resident's right great toe. The RP was informed of the fracture by hospice staff on 7/18/2024, not by the facility staff. The delay in communication prevented the RP from being involved in decision-making regarding the resident's care plan. The facility's policy mandates that changes in a resident's condition be communicated to the resident's representative within 24 hours, except in medical emergencies. The failure to notify the RP promptly about the resident's bruising and subsequent fracture resulted in the RP being excluded from the care planning process, as acknowledged by the DON during the investigation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident within the mandated timeframe, as required by their policy and procedure. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was found with bruises on the right knee and foot, and later diagnosed with a fracture in the right toe. The initial bruise was reported by a CNA to an LVN, who then informed the hospice nurse but failed to notify the Administrator or the Director of Nursing immediately. The Director of Nursing was informed of the bruising a day later by the resident's responsible party, but the injury was not reported to the California Department of Public Health (CDPH) or other required authorities. The facility's policy mandates that any injury of unknown origin must be reported immediately to the Administrator and relevant authorities, but this was not done. The Director of Nursing acknowledged the failure to report and stated that the origin of the injury could not be determined. The facility's policy, revised in March 2023, clearly outlines the steps for reporting suspected abuse or injuries of unknown origin, including notifying the Administrator and other officials within specific timeframes. However, in this case, the policy was not followed, resulting in a violation of the mandated reporting timeframe and potentially compromising the resident's safety.
Failure to Follow Nail Care Policy for Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding nail care for two residents, leading to deficiencies in personal hygiene and potential health risks. Resident 1, who required substantial assistance with personal hygiene, had long and overgrown fingernails and toenails that were not trimmed or cleaned since admission. Observations revealed that Resident 1's fingernails were yellow with a black substance underneath, and the toenails were similarly overgrown and discolored. Despite the facility's policy for CNAs to clean and trim fingernails weekly and toenails monthly, these tasks were not performed, and the necessary notifications to LVNs and the podiatrist were not made. Resident 3, who required extensive assistance with activities of daily living due to severe cognitive impairment, also had overgrown toenails. Observations confirmed the toenails were not dirty but needed trimming. The CNA responsible for Resident 3 acknowledged the need to inform the licensed nurse about the overgrown toenails, but this step was not taken. The facility's policy required staff to conduct weekly body checks to assess nail conditions and ensure cleanliness and trimming, which was not followed in this case. Interviews with the Registered Nurse Supervisor and the Director of Nursing highlighted the facility's expectations for nail care, emphasizing the importance of maintaining clean and trimmed nails to prevent infections and injuries. However, the failure to implement these procedures for Residents 1 and 3 resulted in deficiencies that could potentially lead to health complications. The facility's policy on nail care was not effectively executed, as evidenced by the lack of timely intervention and communication among staff members.
Delay in Providing Medical Records to Resident's Representative
Penalty
Summary
The facility failed to provide copies of a resident's medical records as requested by the resident's legal representative, resulting in a delay of six days beyond the facility's policy timeframe. The resident, who was admitted with chronic obstructive pulmonary disease and lacked the capacity to make decisions, had an authorized representative who requested the medical records. The request was made on May 29, 2024, but the records were not provided within the facility's policy of two working days. Interviews with the Medical Record Assistant and the Medical Record Director confirmed the oversight, as both acknowledged the delay and the failure to adhere to the facility's policy. The facility's policy stated that records should be made available within two working days, but the records were not sent out in the required timeframe. The policy also indicated that records should be available for review within 24 hours and copies provided within 48 hours, contingent upon payment of costs.
Failure to Ensure Advance Directives and Consent for Treatment
Penalty
Summary
The facility failed to ensure that residents' Advance Directives (AD) and Consent for Medical Treatment (CMT) were discussed and documented, as required by their policy and procedure. This deficiency was identified for three residents. Resident 18 was admitted with severe cognitive impairment and required total dependence for daily activities. The AD Acknowledgement Form for Resident 18 was not completed, and interviews with the Social Service Director (SSD) and Assistant Social Service Director (ASSD) revealed that the responsible party had not been asked about an existing AD. The facility's policy indicated that residents have the right to formulate an AD, which was not adhered to in this case. Resident 192 was admitted with diabetes mellitus and osteoarthritis, and their AD and CMT forms were also incomplete. Interviews with the Registered Nurse Supervisor 2 (RN Sup 2) and RN Sup 3 confirmed that these forms were not completed upon admission, and there was no record of AD or CMT being offered to the resident or their responsible party. The Director of Nursing (DON) stated that all residents should have these forms filled out completely upon admission, as they provide directives for care and permission for treatment. Resident 35, who had moderate cognitive impairment and a stage 4 pressure ulcer, also lacked documentation regarding the availability of an AD. The Social Services Assistant (SSA) noted that the resident's responsible party had not been asked about an AD upon admission. The facility's policies on resident rights and advance directives were not followed, leading to the potential for medical treatment and services being provided against the residents' wishes.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to promote the healing of pressure ulcers for three residents with existing stage 4 pressure ulcers. Resident 78, who had severe cognitive impairment and was dependent on assistance for bed mobility, was not repositioned every two hours as required by their care plan. Observations showed that Resident 78 remained in the same position for several hours, and the Certified Nursing Assistant (CNA) stated that repositioning was only done when changing the resident's adult brief, which was not frequent due to the presence of a urinary catheter. Similarly, Resident 241, who had moderately impaired cognitive skills and was dependent on assistance for bed mobility, was not repositioned every two hours as indicated in their care plan. Observations revealed that Resident 241 remained in the same position for extended periods, and the CNA admitted that the resident refused repositioning but failed to inform the licensed nurse to reinforce the need for repositioning. This lack of communication and adherence to the care plan potentially delayed the healing of the resident's pressure ulcers. Additionally, the facility did not ensure the proper use of a Low Air Loss (LAL) mattress for Resident 35, who had moderate cognitive impairment and required maximal assistance with bed mobility. The LAL mattress was observed to be on a static setting, which should only be used for positioning and during patient care. The Director of Staff Development confirmed that the static setting should be off to provide appropriate pressure redistribution. This oversight in mattress settings could have contributed to the delay in healing the resident's pressure ulcer.
Deficiency in Staff Competency for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skills to meet residents' needs safely, specifically in the area of pressure ulcer prevention and management. Two Certified Nursing Assistants (CNAs), identified as CNA 3 and CNA 4, were found to lack training in this critical area. CNA 3, hired in October 2023, did not have pressure ulcer prevention and management included in her Orientation Skills Checklist or Competency Checklist. Similarly, CNA 4, hired in June 2023, also lacked these skills in her Competency Checklist. The Director of Staff Development (DSD) confirmed that the orientation and competency checklists for these CNAs did not cover pressure ulcer prevention and management, and the existing checklist item for 'Proper Positioning' was insufficient as it only referred to proper alignment in chairs or beds. Additionally, the facility did not provide adequate in-service training for direct care staff on pressure ulcer prevention and management, including the use of low air loss mattresses. The facility's training calendar for 2024 and the in-service titled 'Turning and Repositioning, Skin Integrity and Comfort, Skin Management' did not include training on the use of low air loss mattresses. The DSD acknowledged the absence of this training in the calendar and in-service materials. The facility's Policy and Procedure on Competency Assessments, dated May 2023, required employees to demonstrate competency in skills necessary for resident care, but this requirement was not met in the case of pressure ulcer prevention and management.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the transmission of communicable diseases for eight residents. Specifically, the facility did not ensure that Enhanced Standard Precaution (ESP) signage and personal protective equipment (PPE) carts were provided for residents with gastrostomy tubes and Foley catheters, as required by the facility's policy and procedure. This oversight was observed in the cases of Residents 191 and 39, who were at high risk of infection due to their medical conditions. The absence of ESP signage and PPE carts was confirmed during observations and interviews with facility staff, including the Licensed Vocational Nurse (LVN) and the Infection Preventionist Nurse (IPN). Additionally, the facility's Infection Preventionist Nurse failed to change gloves and perform hand hygiene between resident care activities, particularly after handling gastrostomy tube sites for multiple residents. This lapse in infection control practices was observed in a shared room occupied by Residents 38, 32, 30, and 70, all of whom were on ESP due to their susceptibility to infection. The IPN acknowledged the need for proper glove changing and hand hygiene to prevent cross-contamination, as outlined in the facility's Enhanced Standard Precaution policy. Furthermore, a Licensed Vocational Nurse (LVN 1) did not change gloves or perform hand hygiene between providing care to Residents 8 and 2, both of whom were at high risk for infection due to their medical devices. This failure to adhere to infection control protocols was confirmed during an observation and interview with LVN 1, who admitted to not following the necessary procedures. The Director of Nursing (DON) emphasized the importance of hand hygiene and PPE use to prevent the spread of infection, as stated in the facility's Infection Control policy.
Failure to Document Informed Decision on SNF ABN
Penalty
Summary
Resident 33 was readmitted to the facility with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and schizoaffective disorder. The facility issued a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) indicating that Resident 33's Medicare Part A coverage for skilled nursing services would end on February 20, 2024. However, the SNF ABN did not have documented evidence of an informed decision from Resident 33's responsible party regarding financial responsibility for non-covered services. The responsible party did not select one of the three options for care listed on the SNF ABN before signing it on February 16, 2024. During an interview and review of the SNF ABN with the Administrator, it was acknowledged that it was crucial for Resident 33's responsible party to be aware of the financial responsibility for out-of-pocket costs for non-covered services before the Medicare Part A discharge date. The Administrator noted that the Business Office Manager (BOM) failed to ensure that the responsible party had selected a care option for non-coverage before signing the SNF ABN. This oversight placed Resident 33 at risk for incurring out-of-pocket expenses for services not covered by Medicare.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
A certified nurse assistant (CNA) failed to protect a resident's privacy by not closing the privacy curtain while cleaning the resident, resulting in a violation of the resident's right to privacy. The incident involved a resident who was admitted with conditions including hemiplegia, hemiparesis, and cerebrovascular disease, and who had a self-care deficit due to cognitive, communication, and sensory deficits. The resident was dependent on assistance for activities of daily living, including toileting and showering, and was incontinent for bowel and bladder. During an observation, the CNA was seen cleaning the resident while the privacy curtain was left open, exposing the resident to their roommate, who was awake and watching. Interviews with the CNA, a licensed vocational nurse (LVN), and the facility's Director of Nursing (DON) confirmed that privacy curtains should be fully closed to maintain resident dignity and privacy during care. The facility's policy on dignity, revised in February 2021, also indicated that residents should be treated with dignity and respect, with privacy maintained during personal care and treatment procedures.
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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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