Crescent City Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crescent City, California.
- Location
- 1280 Marshall Street, Crescent City, California 95531
- CMS Provider Number
- 056296
- Inspections on file
- 23
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Crescent City Care Center during CMS and state inspections, most recent first.
A physician conducted medical examinations in a group setting in the dining area, rather than in a private location, resulting in a resident with morbid obesity, depression, and epilepsy feeling embarrassed and dissatisfied with the physician’s services. The physician acknowledged performing several examinations among groups of residents due to only visiting monthly and needing to locate residents wherever they were. Anonymous complaints to a resident advocate and resident council minutes reflected concerns about the physician’s practices and interest in a new physician. These actions conflicted with facility policies requiring review of each resident’s total program of care at each visit and guaranteeing residents’ rights to privacy and confidentiality during medical treatment.
A resident with malnutrition, mobility issues, and little to no cognitive impairment repeatedly expressed suicidal ideation, including to a mobile crisis team and at a GACH evaluation, where he stated he would kill himself if he returned to the facility. Despite these statements and an OTA reporting that the resident said, “It’s hospice or suicide,” facility records showed no suicide-focused safety or monitoring care plan was initiated. The DON and ADM acknowledged that a suicidal ideation safety care plan should have been started and that expected interventions, such as enhanced supervision and removal of potential hazards, were not care planned, even though facility policies required assessment, care plan development, immediate reporting, continuous presence, and documentation when suicidal ideation is expressed.
A resident with severe cognitive impairment and a history of elopement attempts exited the facility unsupervised after being left alone in the dining room. Required safety devices, including a Wander Guard and sit-stand alarm, failed to function—one due to an expired battery and the other because it was removed by the resident. Staff did not follow protocols for escorting the resident, and door monitoring was inconsistent, leading to the resident being found outside by neighbors.
An unlicensed staff member admitted to vaping in a resident's room, violating the facility's non-smoking policy, which only permits smoking in designated areas. This was confirmed through staff interviews and review of the staff member's written statement.
Two residents experienced delays in receiving their medications, with one resident's Parkinson's medication and another's scheduled morning medications administered late on multiple occasions. The facility's policy requires medications to be given within one hour of the scheduled time, which was not followed.
The facility failed to provide adequate supervision and effective care plan revisions for residents at risk of falls, resulting in multiple incidents of falls with injuries. A resident with a history of falls experienced numerous falls, including one leading to a major injury requiring surgery, without consistent care plan updates or increased supervision. Another resident suffered a fracture from a fall, and a third resident with severe cognitive impairment experienced falls without appropriate care plan updates, leading to a major injury and subsequent death. Additionally, a fourth resident experienced multiple falls without a fall care plan until after the third fall.
The facility failed to provide adequate nutritional care for residents, leading to significant weight loss and potential health risks. The RD's infrequent visits resulted in minimal assessments, while the unqualified Dietary Manager handled dietary progress notes and care plans, leading to incorrect MDS coding and inadequate monitoring. Residents, including one who was legally blind and Spanish-speaking, did not receive proper meal assistance or fluid intake monitoring, and care plans were not updated despite ongoing weight loss.
The Administrator failed to ensure effective oversight and resources, leading to 134 falls, nutritional issues, and inadequate staffing affecting 81 residents. The QAPI Committee did not implement a fall reduction plan, and the RD's infrequent visits led to dietary errors. Inadequate staffing resulted in unmet care needs and inconsistent charting, compromising residents' well-being.
The facility's kitchen was found in unsanitary conditions, with moldy and spoiled food items, improper labeling, and incomplete documentation of food thermometer calibration. The walk-in refrigerator and freezer were disorganized, and the kitchen had dirty surfaces and equipment. These issues had the potential to cause foodborne illness and spread infections to residents.
The facility failed to uphold the dignity and respect of 15 residents, with incidents including a resident left in a soiled sweater, another moved to a new room without proper notice, and long wait times for assistance. Residents reported discomfort due to untrimmed toenails, cold meals, and lack of dining assistance. Multiple residents expressed dissatisfaction with staff attitudes and long wait times, highlighting a failure to treat residents with dignity and respect.
The facility failed to provide residents with the necessary contact information for the California Department of Public Health, preventing them from filing complaints about potential abuse, neglect, or other violations. During a Resident Council meeting, none of the residents knew how to contact the State, indicating a lack of compliance with regulatory requirements to inform residents of their rights and procedures for reporting grievances.
The facility failed to maintain a clean and homelike environment, with pervasive offensive odors of feces, urine, and body odors noted throughout the building, particularly in the North Hall. Observations revealed stained carpets and soiled linens, with staff and residents confirming the persistent smell. The DON acknowledged the odor, and the facility's policy on cleanliness was not followed.
A facility failed to accurately code the MDS for a resident on a physician-prescribed weight loss plan, marking it incorrectly as not on such a regimen. The resident had a complex medical history, and the error could have affected care planning. The Dietary Manager completed Section K of the MDS, but there was no oversight for accuracy, and the DON's signature only verified completion. Job descriptions lacked clarity on responsibility for accurate MDS completion.
The facility failed to develop individualized care plans for residents, leading to potential health risks. A resident with shortness of breath lacked a care plan for oxygen administration, another resident who choked did not have aspiration precautions, and a resident with respiratory failure and constipation issues lacked appropriate care plans. Additionally, a resident at risk for falls did not have a fall prevention plan after multiple falls.
The facility failed to update care plans for two residents after multiple falls, as required by their policy. One resident experienced numerous falls, including a major injury, without timely updates to their care plan to include necessary interventions like increased supervision. Another resident's care plan was not updated with preventive measures after falls, and no fall risk assessment was conducted after the first fall. This failure to adhere to the facility's policies potentially compromised resident safety.
The facility failed to follow physician orders and its constipation protocol for two residents, resulting in extended periods without bowel movements. Despite having a bowel care program in place, it was not consistently implemented, especially when residents refused oral medications. Staff interviews revealed communication gaps and non-adherence to the protocol, leading to the oversight.
The facility failed to provide adequate ADL assistance, resulting in severe deficiencies. A resident was left in a soiled brief for an extended period, causing severe skin damage and pain. Another resident reported being left in a wet brief and not repositioned frequently, corroborated by ADL flow sheets. Additionally, two residents were not provided with adequate hydration, and three residents did not receive scheduled showers, highlighting a failure to adhere to facility policies.
The facility failed to provide adequate staffing, resulting in significant delays in responding to call lights and providing necessary care. Residents experienced discomfort and neglect due to extended wait times for assistance with ADLs and incontinence care. Insufficient staff during meal times led to delays in feeding, causing meals to become cold and raising concerns about cross-contamination. The lack of prompt incontinence care resulted in severe skin damage for some residents, highlighting the impact of staffing shortages on the quality of care.
A facility failed to provide correct diets to 18 residents, with errors in fortified and mechanical soft diets. Dietary staff did not correct these errors before meal distribution. LPNs checked trays only in the social dining room, while CNAs delivered meals without verifying tray tickets. The DON acknowledged the risk of choking due to incorrect diet consistency.
The facility failed to ensure kitchen staff were knowledgeable about food safety processes, including cooling, thawing, and dishwashing. Interviews revealed that Dietary Aids R, S, T, and U lacked understanding of these processes, despite claims of prior training. The facility's policy on dishwashing was not followed, and a contradiction was found regarding leftover food storage. These deficiencies posed a risk of foodborne illnesses to residents.
The facility failed to provide palatable and appropriately heated meals to most residents, with reports of cold, flavorless food and mismatched entrees. Observations confirmed that meal temperatures were below acceptable levels, and vegetables were overcooked and lacking flavor, contrary to facility policy.
The facility failed to maintain complete and accurate documentation of meal consumption for two residents, leading to significant weight loss. One resident lost over 20% of their weight in six months, with incomplete meal records for May. Another resident experienced a 15.86% weight loss over six months, with inadequate monitoring of meal intake from March to June. The facility's policy required CNAs to document food intake, but this was not consistently followed, impacting the residents' care and healthcare goals.
The facility failed to maintain an effective QAPI program, with the DON responsible for its development but lacking documentation and involvement from leadership. Department heads did not provide necessary reports, leading to untracked interventions for falls and weight loss issues. Despite recording numerous falls, including major injuries, the facility did not have a specific plan to address these issues.
The facility's ineffective QAPI program resulted in several deficiencies, including inadequate monitoring of infection prevention, ADLs, falls, nutrition, and resident dignity. The QAPI meetings lacked consistent attendance and were too brief to address issues. The DON reported that department heads failed to provide necessary data, leaving key areas unaddressed. Despite discussions on falls and weight issues, there was no comprehensive analysis to prevent future incidents, compromising resident safety and care quality.
The facility's QAPI program was compromised due to the Medical Director's inconsistent attendance at meetings, including missing a key quarterly meeting. This absence potentially affected the facility's ability to identify and address resident safety issues. The Administrator noted weather as a possible reason for the absence.
The facility failed to ensure proper hand hygiene practices, as staff did not consistently offer or assist residents with hand washing before meals. Observations showed that multiple residents were served meals without hand sanitation, and staff used the same gloves to assist different residents, increasing the risk of cross-contamination.
A resident was discharged without necessary documentation, including a physician discharge order and a completed Discharge Assessment. The facility's staff could not locate these documents, and the Discharge Assessment was incomplete, lacking a signature from the resident or responsible party. This failure to adhere to the facility's discharge policy could have impacted the resident's continuity of care.
A resident with multiple health issues, including difficulty walking and osteoarthritis, did not receive proper foot and toenail care, resulting in long, thick toenails and severely dry, cracked feet. Despite the resident's complaints of discomfort, the CNA and nurse failed to address the issue or arrange for a podiatrist appointment, as required by facility policy.
A resident on continuous oxygen therapy was found with an empty portable oxygen tank while propelling herself in a wheelchair, risking respiratory distress. Despite the facility's policy and job descriptions indicating that nursing staff are responsible for monitoring oxygen levels, the tank ran out, highlighting a lapse in monitoring and communication among staff.
The facility failed to maintain proper temperatures in two medication refrigerators, storing insulin and COVID-19 vaccines outside the recommended range. Additionally, expired medications were found stored with active ones, contrary to the facility's policy. These deficiencies were confirmed by staff during observations.
A resident with severe cognitive impairment and oral health issues did not receive timely follow-up dental care due to delays in scheduling an appointment with an oral surgeon. The facility's Social Services department failed to make the necessary arrangements in accordance with the facility's policy, resulting in a deficiency.
Failure to Protect Resident Privacy During Physician Examinations
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident’s personal and medical information when the facility physician conducted medical examinations in a group setting in the dining area. Resident 2, who had diagnoses including morbid obesity, depression, and epilepsy and was assessed as having little to no cognitive impairment, reported being examined by the physician in the dining room in front of other residents. During an interview, Resident 2 stated that this examination in the dining room bothered her and made her feel embarrassed, and that the physician barely spent any time with facility residents. Resident council minutes reflected that all participating residents wanted to know if they could see a new physician. In a phone interview, the facility physician acknowledged conducting a few medical examinations among a group of residents in the dining area, explaining that he only came to the facility once a month, had many residents to see, and had to “chase down” residents wherever they were in the building. Electronic correspondence from a resident advocate to the agency included multiple anonymous complaints alleging that the physician conducted group examinations in the dining area where resident privacy and confidentiality were not honored. Facility policies titled “Physician Visits and Physician Delegation” and “Resident Rights” required the physician to review the resident’s total program of care at each visit and affirmed residents’ rights to personal privacy and confidentiality, including privacy during medical treatment, but these requirements were not followed during the group examinations.
Failure to Develop Suicide-Specific Safety Care Plan After Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan focused on safety and monitoring for a resident who expressed suicidal ideation. The resident was admitted with diagnoses including malnutrition, difficulty walking, muscle weakness, and repeated falls, and had little to no cognitive impairment per the MDS dated 2/09/26. On 2/12/26, a mobile crisis team evaluated the resident after he made depressive and suicidal statements, reporting dissatisfaction with facility food, feelings of weakness, hearing problems, and a desire for hospice care. The county mental health note documented that the resident had made suicidal statements and that staff worked with him on meeting some of his needs. On 2/16/26, the resident was found on the floor after a fall and was sent to a general acute care hospital (GACH). The GACH history and physical documented that the resident was passively suicidal and had stated he did not like living at the facility and would kill himself if he returned. The GACH discharge summary later indicated there was no suicidal ideation at discharge and that shared decision making supported his return. The resident was readmitted to the facility on 2/18/26. On 2/19/26, he was found unresponsive and without vital signs on the bathroom commode, with copious amounts of blood on and around him and a toenail cutting tool nearby; his official time of death was documented as 7:20 a.m. Interviews and record review showed that no care plan addressing suicidal ideation or self-harm safety was initiated for the resident after his suicidal statements and evaluations. The DON stated that residents with suicidal ideation were typically transferred to the hospital for psychological screening and that, if they remained in the facility, staff would implement safety measures such as removing call light cords and sharp objects and providing one-to-one supervision, and that she expected social services to initiate a suicidal ideation care plan or coordinate with nursing to do so. The administrator stated that the social service director should have started a suicidal ideation safety care plan when the resident first complained of suicidal thoughts. An occupational therapy assistant reported that the resident had said, “It’s hospice or suicide,” and that she informed social services and a nurse. Facility policies on Behavioral Health Services and Suicide Prevention required comprehensive assessment, care plan development and implementation, immediate reporting of suicidal ideation, not leaving the resident alone, and documentation of mood, behaviors, and actions taken, but these were not reflected in a suicidal ideation or self-harm safety care plan for this resident.
Failure to Prevent Resident Elopement Due to Lapses in Supervision and Device Maintenance
Penalty
Summary
A resident with a history of traumatic brain injury, severe cognitive impairment, psychosis, anxiety, insomnia, bipolar disorder, and schizophrenia was admitted to the facility and had documented elopement attempts since admission. The resident was assessed as high risk for elopement and had medical orders for a Wander Guard device and a sit-stand alarm, with staff instructed to check the Wander Guard placement every shift and to escort the resident to and from meals. Despite these interventions, the resident was left alone in the dining room after dinner while staff were escorting other residents, contrary to the protocol that required the resident to be taken first. During this time, the resident exited the facility through the front doors without staff assistance. Interviews revealed that the Wander Guard device did not alert due to an expired battery, and the sit-stand alarm did not activate because the resident had removed it from his jacket. The receptionist, who usually monitored the doors, was not present on the day of the incident, and there was uncertainty about door monitoring procedures on weekends. The resident was found outside the facility by neighbors, who notified staff. The facility's policy required staff to accompany wandering residents when supervision was necessary, but this was not followed, resulting in the resident's unsupervised exit.
Staff Vaping in Resident Room in Violation of Non-Smoking Policy
Penalty
Summary
A deficiency occurred when an unlicensed staff member was found to have vaped in a resident's room, contrary to the facility's non-smoking policy. The incident was confirmed through interviews with licensed staff, the Director of Staff Development, and a review of the unlicensed staff member's written attestation, in which he admitted to vaping in the resident's room. The facility's policy clearly states that smoking, if allowed, should only occur in designated areas, and employees are required to consult their supervisor regarding designated smoking areas. The failure to adhere to this policy resulted in the deficiency.
Medication Administration Delays
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of its residents, as evidenced by the late administration of medications to two residents. Resident 1, who is prescribed Carbidopa-Levodopa for Parkinson's disease, reported receiving her medication late on multiple occasions, including on the day of the interview. The medication administration history confirmed that the doses were administered more than an hour past the scheduled times on several occasions between December 12 and December 26, 2024. The facility's administrator acknowledged that the medications were given late, which was not in accordance with the physician's orders. Similarly, Resident 2 experienced delays in receiving her scheduled 9 a.m. medications, including Metoclopramide, Vitamin D3, and Metoprolol Tartrate. On November 28, 2024, these medications were administered over two hours late. The administration records showed multiple instances of late administration between November 25 and December 9, 2024. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not adhered to in these cases. The administrator confirmed the delays and recognized that the medications were not administered as scheduled.
Inadequate Supervision and Care Plan Revisions Lead to Multiple Falls
Penalty
Summary
The facility failed to ensure adequate supervision and effective care plan revisions for residents at risk of falls, leading to multiple incidents of falls with injuries. Resident 28, who had a history of falls and required assistance for transfers and walking, experienced numerous falls at the facility. Despite her high fall risk scores, her care plan was not consistently updated with new interventions or increased supervision. This lack of action resulted in several falls, including one that led to a major injury requiring surgery. Resident 15 also suffered from multiple falls, with the facility failing to update her care plan or accurately assess her fall risk. Her care plan lacked new interventions or increased supervision, even after she sustained a fracture from a fall. Similarly, Resident 233, with severe cognitive impairment, experienced falls without appropriate care plan updates or increased supervision. Her fall risk evaluations were inaccurately completed, and she suffered a major injury from a fall, which preceded her death. Additionally, Resident 227 experienced multiple falls without the implementation of a fall care plan until after the third fall. The facility's failure to follow its policies on fall management and supervision contributed to these incidents, highlighting a systemic issue in addressing fall risks and ensuring resident safety.
Inadequate Nutritional Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide adequate nutritional care and services for several residents, leading to significant weight loss and potential health risks. The Registered Dietitian (RD) was only visiting quarterly, resulting in minimal in-person assessments and a lack of tailored nutritional interventions. The Dietary Manager, who lacked a professional scope of practice, was responsible for completing dietary progress notes and initiating nutritional risk care plans, which led to incorrect coding in the Minimum Data Set (MDS) and inadequate monitoring of residents' nutritional status. Resident 29 experienced severe weight loss over several months, with a cumulative loss of 18.8% of body weight. Despite being legally blind and primarily Spanish-speaking, Resident 29 did not receive adequate assistance during meals, and their fluid intake was not properly monitored. The RD did not conduct in-person assessments or revise the care plan despite ongoing weight loss, relying instead on the Dietary Manager and other staff for information. The facility failed to address Resident 29's nutritional needs, including their preference for coffee and concerns about food safety. Resident 12 also faced issues with nutritional care, as their weight loss was not accurately documented in the MDS, and the Dietary Manager, who was not qualified to make clinical recommendations, completed their dietary progress notes. The RD did not adequately oversee the nutritional care plans, and the facility did not reassess or update interventions despite significant weight changes. These deficiencies in nutritional care and monitoring placed residents at risk for further health complications.
Administrator's Oversight Failures Lead to Multiple Deficiencies
Penalty
Summary
The facility's Administrator failed to ensure effective oversight and necessary resources to maintain the quality of care, safety, dignity, and dietary services for all 81 residents. The Quality Assurance and Performance Improvement (QAPI) Committee, which included the Administrator, did not implement an action plan to reduce the number of falls in the facility. This oversight led to 134 falls from January 2024 through May 2024, with three resulting in major injuries. The Administrator was aware of the recurrent falls but did not ensure that interventions for fall prevention were tracked or discussed in meetings. Additionally, the Administrator did not ensure that the Registered Dietician (RD) made frequent visits to oversee kitchen operations, leading to issues such as errors in plating prescribed diets and lack of staff competencies in food handling processes. This lack of oversight compromised the nutritional status of residents and increased the risk of foodborne illness. Furthermore, the RD did not routinely visit residents with significant weight changes to assess their nutritional needs, resulting in multiple residents experiencing nutritional complications. The facility also suffered from inadequate staffing levels, which affected the ability to meet residents' individual care needs. Residents experienced long wait times for call lights to be answered and insufficient assistance with Activities of Daily Living (ADLs), leading to issues such as skin breakdown and compromised dignity. Charting for fluid and meal intake was inconsistent, increasing the risk of dehydration and nutritional concerns. Despite these staffing issues, the facility continued to accept new residents, exacerbating the problem.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to cause foodborne illness and spread infections to 80 of the 81 residents. During an inspection, multiple issues were identified, including the presence of moldy strawberries, undated and unlabeled chopped celery, and spoiled tomatoes in the walk-in refrigerator. Additionally, cooked chicken and chopped onions were improperly labeled, and expired chopped ham was found. The refrigerator floor was dirty, and the freezer was overcrowded, preventing proper air circulation. Further observations revealed unsanitary conditions in the dry storage area, where a moldy onion was found among good ones. The metal container for clean kitchen utensils contained food particles and trash, and the food preparation table and knife storage rack were stained and dusty. Large plastic containers for cereal and flour were grimy, and the exterior of the ice machine was extremely dirty. A mosquito trap with dead mosquitoes was also found in the kitchen. The facility's documentation was incomplete, with missing food thermometer calibration logs for May and June 2024. The emergency food storage room was disorganized, making it impossible to evaluate the food. The facility's policies on kitchen sanitation, labeling and dating of foods, general cleaning, and refrigerator and freezer maintenance were not followed, contributing to the unsanitary conditions observed during the inspection.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of 15 residents, as evidenced by several incidents. Resident 25 was left in a soiled sweater after breakfast, with no staff attending to her needs for a change of clothing. Similarly, Resident 12 was observed wearing a soiled shirt for several hours after lunch, and his disposable brief was not changed for at least five hours. Resident 68 was moved to a new room without timely notice or agreement, causing discomfort due to the lack of a window by his bed, which he preferred. Resident 6 experienced discomfort due to untrimmed toenails, which had not been attended to for months, causing pain while wearing shoes. Resident 55 had to wait 22 minutes to be assisted with dining, resulting in a cold meal that required reheating. Resident 29, who is legally blind and does not speak English, received no assistance during meals, leading her to eat with her fingers without guidance or a washcloth afterward. Resident 40 expressed dissatisfaction with the staff's attitude and the lack of timely assistance, highlighting an incident where a resident was left with vomit on herself by the nurses' station. Multiple residents, including Residents 35, 3, 65, 21, 46, 50, 2, and 58, reported long wait times for assistance, with some waiting in soiled conditions for hours. Resident 65 described being harassed by a staff member who spoke loudly and acted inconsiderately. During a Resident Council meeting, several residents voiced concerns about disrespectful treatment by staff, including refusal to assist with requests and ignoring residents' needs. These incidents collectively demonstrate a failure to treat residents with dignity and respect, as required by facility policy and resident rights.
Failure to Provide Residents with Contact Information for Filing Complaints
Penalty
Summary
The facility failed to provide seven residents with the necessary contact information for the California Department of Public Health, which is essential for filing complaints regarding potential abuse, neglect, exploitation, or other violations of state or federal regulations. This deficiency was identified during a Resident Council meeting where none of the seven residents present were aware of how to contact the State to file a complaint. This lack of knowledge among the residents indicates that the facility did not fulfill its obligation to inform them of their rights and the procedures for reporting grievances. A review of the facility's policy on resident rights, dated October 16, 2021, revealed that it did not include information on the residents' right to contact the Department to formally file complaints about possible violations. The regulatory Health and Safety Code S483.10(g)(4)(i)(C)(D)(ii)(vi) mandates that residents must receive notices in a format and language they understand, including a written description of their legal rights and contact information for relevant state agencies and advocacy groups. The facility's failure to provide this information deprived the residents of their right to formally file complaints about the care they were receiving.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by pervasive offensive odors throughout the building. Observations during the recertification survey revealed a strong smell of feces, urine, and body odors in the hallways and specific rooms, particularly in the North Hall. The carpet in the hallway was stained, and in one instance, a resident's bed linens were found soaked with urine and feces. Interviews with staff and residents confirmed the presence of the odor, with some staff attributing it to residents who eliminate in bed and insufficient staff to change soiled clothing and linens promptly. Residents and staff reported being accustomed to the smell, although it was initially bothersome. The Director of Nursing acknowledged the odor and mentioned using air fresheners in her office. The facility's policy on maintaining a clean and pleasant environment was not adhered to, as the offensive odors persisted despite weekly carpet cleaning. The issue was not reported to the Infection Preventionist, who stated she was unaware of the problem.
Inaccurate MDS Coding for Resident's Weight Loss Plan
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident under Section K, which pertains to Swallowing/Nutritional Status. Specifically, the MDS for a resident, who was on a physician-prescribed weight loss plan, was incorrectly coded as not being on such a regimen. This error was identified during a review of the resident's records, which showed a physician-directed weight loss recommendation and a care plan that included a weight goal. However, the MDS inaccurately reflected that the resident was not on a prescribed weight-loss regimen. The resident in question had a complex medical history, including diagnoses of paranoid schizophrenia, hallucinations, chronic pain, and borderline personality disorder. The resident's weight was within the physician-directed range, but the MDS coding error could have led to inappropriate care planning. Interviews with facility staff revealed that the Dietary Manager was responsible for completing Section K of the MDS, but there was a lack of oversight to ensure accuracy. The MDS Coordinator was involved in checking the completion of Section K but not its accuracy. Further interviews indicated that the Director of Nursing's signature on the MDS was only to verify completion, not accuracy. The facility's job descriptions did not clearly assign responsibility for the accurate completion of Section K to any specific role. This lack of clarity and oversight contributed to the coding error, which had the potential to impact the resident's medical treatment and care planning.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized care plans for several residents, leading to potential health risks. Resident 127, who had a change in condition with shortness of breath and low oxygen saturation, did not have a care plan for oxygen administration despite physician orders. Observations showed inconsistencies in oxygen use, such as the resident being without oxygen while in a wheelchair and the oxygen concentrator running without the resident present. This lack of a care plan could lead to improper monitoring and management of the resident's oxygen needs. Resident 12, who had a choking incident, did not have a care plan for aspiration precautions despite recommendations from a speech therapist. The speech therapist had posted instructions for safe eating, but these were not incorporated into a formal care plan. Observations showed that Resident 12 was not positioned correctly while eating, and staff did not perform frequent spot checks as recommended, increasing the risk of another choking incident. Resident 33, with a diagnosis of acute and chronic respiratory failure, did not have a care plan for oxygen therapy or risk of constipation, despite medical records indicating multiple days without bowel movements. The facility's failure to implement a bowel care protocol and monitor oxygen therapy could lead to significant health issues. Additionally, Resident 227, who was at moderate risk for falls, did not have a care plan for fall prevention after multiple falls, which resulted in injuries and hospital visits. The lack of care plans for these residents indicates a systemic issue in addressing and managing residents' health needs effectively.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans for two residents were reviewed and revised after each fall, as required by their policy. Resident 28 experienced multiple falls, starting from the first documented fall on January 18, 2024, through to a significant fall on June 12, 2024, which resulted in a major injury. Despite these incidents, the care plan for falls was not consistently updated or revised to include new interventions, such as increased supervision, to prevent further falls. The care plan was only revised on April 2, 2024, after the fifth fall, and again on June 16, 2024, after the twelfth fall, but still lacked adequate interventions like increased supervision. Resident 51 also experienced a fall, and it was noted that his care plan was not updated to include necessary interventions such as a fall mat or frequent rounding. His care plan was only developed after he had already experienced falls, and there was no evidence of a fall risk assessment being conducted after his first fall to identify the cause and add preventive measures. The facility's policy required that care plans be reviewed and revised upon the onset of new problems or changes in condition, which was not adhered to in these cases. The facility's failure to follow its own Fall Management Program and Care Planning policies resulted in the residents' care plans not being updated in a timely manner to address the risks of falls. This lack of action potentially compromised the quality of care and safety of the residents, as their care plans did not reflect necessary interventions to mitigate the risk of further falls and injuries.
Failure to Follow Constipation Protocols for Two Residents
Penalty
Summary
The facility failed to monitor and follow physician orders and its own protocol for constipation management for two residents, leading to extended periods without bowel movements. Resident 29, who had multiple diagnoses including stroke sequelae, dementia, and hemiplegia, went several days without a bowel movement on multiple occasions. Despite having orders for a three-step bowel care program and medications like Milk of Magnesia and Dulcolax suppositories, these were not consistently administered, especially when the resident refused oral medications. There was no documentation of alternative bowel care measures being implemented during these periods. Similarly, Resident 33, who was severely cognitively impaired and had conditions such as stroke and morbid obesity, also experienced prolonged periods without bowel movements. The resident's medical record indicated several instances where no bowel care was initiated despite going up to 15 days without a bowel movement. The facility's protocol required bowel care to be started after three days without a bowel movement, but this was not followed. Interviews with facility staff revealed a lack of communication and adherence to the bowel care protocol. Licensed nurses and the Director of Nursing acknowledged that bowel care should have been administered per physician orders if a resident had not had a bowel movement in three days. However, there was a disconnect in communication between Certified Nursing Assistants and nurses, leading to the oversight. The facility's policy emphasized the importance of an effective bowel care program, but it was not effectively implemented for these residents.
Deficiencies in ADL Assistance and Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to significant deficiencies in care. Resident 232 was left in a soiled disposable brief for an extended period after returning from a hospital visit, resulting in severe skin damage and excruciating pain during his final days. Despite being completely dependent on staff for toileting and personal hygiene, Resident 232 did not receive timely incontinence care, as documented in the ADL flow sheets. Interviews with family members and staff confirmed the neglect, and the Director of Nursing acknowledged the prolonged period the brief was left unchanged. Resident 14, who was also dependent on staff for toileting hygiene, reported being left in a wet or soiled brief for more than two hours and not being repositioned frequently. This lack of care was corroborated by ADL flow sheets, which showed that Resident 14 received incontinence care only once per day on several occasions and was often not repositioned at all. The Director of Staff Development confirmed these findings and stated that incontinent residents should be checked every two hours. Additionally, Residents 67 and 4 were not provided with adequate hydration, as they were observed without access to water despite being at risk for dehydration. The facility's policy required that residents be offered drinking water throughout the day, but this was not adhered to. Furthermore, Residents 12, 20, and 29 did not receive their scheduled showers, with documentation showing refusals and a lack of follow-up to ensure personal hygiene needs were met. The facility's failure to adhere to its own policies and procedures for ADL care and documentation contributed to these deficiencies.
Inadequate Staffing Leads to Delayed Care and Resident Discomfort
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in significant delays in responding to call lights and providing necessary care. Several residents reported waiting for extended periods, sometimes up to several hours, for assistance with activities of daily living (ADLs) such as toileting and incontinence care. This lack of timely care led to residents experiencing discomfort, skin irritation, and feelings of neglect. For instance, one resident had to wait two hours for assistance, while another reported waiting four to six hours, resulting in lying in soiled linens. The deficiency also extended to the dining experience, where insufficient staff led to delays in feeding residents, causing their meals to become cold. Observations noted that staff were feeding multiple residents simultaneously without changing gloves, raising concerns about cross-contamination. Additionally, a legally blind resident was left to eat with her fingers due to a lack of assistance, highlighting the inadequate support provided during meal times. Staff interviews confirmed that they were often overwhelmed with the number of residents they were responsible for, which hindered their ability to respond promptly to call lights and provide necessary care. Furthermore, the facility's failure to provide prompt incontinence care resulted in severe consequences for some residents. One resident was left in a soiled brief for over 48 hours, leading to skin damage and excruciating pain. Another resident expressed concerns about the lack of incontinence care, which she believed contributed to her urinary tract infections. The facility's documentation corroborated these claims, showing that residents were often not repositioned or provided incontinence care as frequently as required. Interviews with staff and family members further highlighted the impact of staffing shortages on the quality of care provided to residents.
Dietary Errors and Inadequate Tray Checks in LTC Facility
Penalty
Summary
The facility failed to ensure that 18 out of 81 residents received their prescribed diets without errors. During a tray line observation, it was noted that residents on fortified diets did not receive the necessary butter used to fortify their meals. Additionally, residents on mechanical soft diets were served large chunks of hard melon, which did not meet the required texture for easy chewing. These errors were identified before the trays were distributed, but the dietary staff did not correct them. Furthermore, Licensed Nurses were observed checking trays only for residents eating in the social dining room, neglecting those eating in their rooms. Certified Nursing Assistants delivered meals without verifying that the trays matched the tray tickets. The Director of Nursing acknowledged that incorrect diet consistency could lead to choking. The facility's policies on fortified menu plans and modified diets emphasize the importance of delivering correct diets to ensure residents' quality of life, but these were not adhered to in this instance.
Deficiency in Food Safety Knowledge Among Kitchen Staff
Penalty
Summary
The facility failed to ensure that four kitchen staff members were knowledgeable about essential food safety processes, including the cooling process for leftover food, the thawing process for frozen food, and the 3-step process for manually washing, rinsing, and sanitizing dishware. During interviews, Dietary Aids R, S, T, and U demonstrated a lack of understanding of these processes. Dietary Aid R incorrectly described the 3-step dishwashing process, while Dietary Aids S, T, and U were unable to describe the cooling and thawing processes. This lack of knowledge was observed despite the Dietary Manager's claim of previous training, which was undocumented. The facility's policy on manual dishwashing was not followed, as evidenced by the incorrect description provided by Dietary Aid R. Additionally, the facility's claim of not saving leftovers was contradicted by the discovery of a plastic bag with cooked chicken in the refrigerator, labeled with a date that suggested it was a leftover. The facility failed to provide a policy on the thawing process for meats and food, further indicating a lack of proper food safety protocols. These deficiencies had the potential to result in foodborne illnesses and the spread of infections to all residents, except for one resident who did not eat by mouth.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to provide attractive and palatable meals to 80 out of 81 residents, excluding one resident who was on formula feedings. Observations and interviews revealed that the food served was lacking in flavor, often cold, and not presented in an appetizing manner. Residents reported dissatisfaction with the meals, noting that entrees were mismatched, and the food was frequently served at inappropriate temperatures. Specific complaints included cold food, hard breakfast eggs, and the incorrect type of coffee being served. During a taste tray observation, the Dietary Manager and surveyors confirmed that the food temperatures were below acceptable levels, with pasta and vegetables served at temperatures ranging from 93 to 117 degrees Fahrenheit. The vegetables were noted to be overcooked and lacking flavor, which was confirmed by the Dietary Manager, who stated that the residents preferred them that way. The facility's policy indicated that meals should be nutritious, attractive, and palatable, but the findings showed a failure to adhere to these standards.
Incomplete Documentation of Meal Consumption for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical documentation for two residents, leading to potential issues in tracking their care and meeting healthcare goals. Resident 25 experienced a significant weight loss of over 20% in six months, yet her meal consumption documentation for May 2024 was incomplete. Observations showed that on several days, only one meal was recorded, and on some days, no meals were documented at all. This lack of documentation was confirmed by the Dietary Manager, who acknowledged the issue and stated that it was the responsibility of the care staff to document meal consumption. Resident 29 also suffered from severe weight loss of 15.86% over six months, with inadequate monitoring of meal intake from March to June 2024. The resident's medical history included conditions such as sequelae of cerebral infarction, feeding difficulties, and dementia, which necessitated close supervision and assistance with eating. However, the facility's records showed numerous instances where meal intake was not documented, particularly for breakfast and lunch, which could have contributed to the resident's weight loss. The facility's policy on ADL documentation required CNAs to record residents' food and nourishment intake, but this was not consistently followed for Residents 25 and 29. The lack of proper documentation hindered the interdisciplinary team's ability to track the care provided and assess the residents' ability to meet their healthcare goals, potentially resulting in low quality of care and harm to the residents.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to establish, implement, and maintain an effective Quality Assurance Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) program. The Director of Nursing (DON) was responsible for the QAPI program's development, but there was a lack of documentation and involvement from the governing body and executive leadership. The facility did not maintain QAPI meeting minutes or documentation, which resulted in an inability to address and correct deficiencies related to nutrition issues and falls with injuries. The DON reported that department heads were supposed to bring reports of resident concerns or issues to be entered into the QAPI system, but this was not happening. As a result, the facility failed to track interventions for fall prevention measures, despite recording a significant number of falls, including three major injuries, over the first five months of the year. Additionally, the facility did not have a QAPI project regarding weight loss issues among residents, as the Assistant Director of Nursing had not provided any information to be entered into the QAPI plan. The DON stated that the administrator was aware of the weight loss issues, but no decisions had been made on what to measure in the QAPI plan. Staffing issues were also not being tracked in the QAPI plan. The facility's QAPI policy indicated the use of the Plan-Do-Study-Act (PDSA) cycle for performance improvement projects, but the lack of participation and data tracking by department heads hindered the program's effectiveness.
Ineffective QAPI Program Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program, which led to several deficiencies in resident care and safety. The QAPI meetings lacked the required members, including consistent attendance by the Medical Director, and were often too brief to address significant issues. The facility did not adequately monitor or address key areas such as infection prevention, activities of daily living, falls, meal and fluid intake, resident dignity, call light response times, and nutrition/hydration oversight. These deficiencies were not identified or prioritized, resulting in a lack of corrective action plans and monitoring of outcomes. The Director of Nursing (DON) reported that the Fall Committee was not operational, and interventions for fall prevention were not being tracked despite a high number of falls, including those with major injuries. The DON also noted that department heads were not providing necessary reports for the QAPI system, leading to incomplete data and unaddressed issues such as weight loss among residents. The Assistant Director of Nursing was responsible for tracking weight loss but failed to provide data, leaving the QAPI plan blank in this area. Staffing issues were also not tracked, and the DON expressed that the Administrator was aware of these problems but did not assist in resolving them. Interviews with the facility's physician revealed that while falls and weight issues were discussed, there was no comprehensive analysis or trend identification to prevent future incidents. The physician acknowledged the challenges faced by the facility, including staffing and the resident population, but felt that the residents' needs were being addressed. However, the lack of effective QAPI processes and data analysis hindered the facility's ability to implement necessary safeguards and improvements, potentially compromising resident safety and care quality.
Inconsistent Attendance of Medical Director at QAPI Meetings
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program due to the inconsistent attendance of the Medical Director at QAPI meetings. The review of QAPI committee sign-in sheets revealed that the Medical Director was absent from several meetings, including the quarterly meeting on 11/30/23. The Medical Director attended meetings on 2/28/23, 4/27/23, 7/20/23, 1/24/24, and 4/18/24, but missed the 11/30/23 meeting and did not attend another meeting until 1/24/24, resulting in a six-month gap in attendance. During an interview, the Administrator acknowledged the absence of the Medical Director at the 11/30/23 meeting, suggesting that weather conditions might have been a factor. The facility's QAPI program guidelines emphasize the involvement of all employees, departments, and services, and the Medical Director's job description requires compliance with facility policies and applicable laws. The lack of consistent attendance by the Medical Director at QAPI meetings potentially hindered the facility's ability to identify and address significant resident safety issues effectively.
Inadequate Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices among staff and residents, leading to potential infection risks. Observations revealed that five residents were served lunch without being offered the opportunity to wash or wipe their hands. Interviews with staff indicated a lack of consistent practice in offering hand hygiene before meals, with some staff assuming others had already provided this service. This oversight was consistent across multiple days and involved several residents, including those who were dependent on staff for assistance. In the social dining room, no residents were observed being reminded or offered hand sanitation before meals. The Director of Staff Development, who was present during the dining observation, confirmed that hand sanitation was not provided. Residents reported that hand sanitizer was only offered when surveyors were present, indicating a lack of consistent practice in maintaining hand hygiene standards. In the Total Assisted Dining Room, staff were observed using the same gloves to assist multiple residents, without changing gloves or sanitizing hands between tasks. This practice was confirmed by staff interviews, which highlighted a lack of training and awareness regarding the importance of hand hygiene and glove changes to prevent cross-contamination. The facility's policy on hand hygiene did not specify the need to offer or assist residents with hand washing before and after meals, contributing to the deficiency.
Missing Discharge Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's clinical record included necessary discharge documentation, such as a physician discharge order, a completed signed Discharge Assessment, and a physician Discharge Summary of Care. This deficiency was identified for one of the 23 sampled residents, referred to as Resident 51. The absence of these documents had the potential to disrupt communication between the facility, the physician, and the resident or their responsible party, potentially affecting the continuity of care. The lack of a completed discharge summary could have resulted in insufficient information being provided to the next care provider, impacting the resident's health and wellbeing. Interviews and record reviews revealed that Resident 51 was discharged to home with their son, but the necessary discharge documentation was missing from the medical record. The Business Office Manager and the Administrator were unable to locate the physician discharge order or the Physician Discharge Summary report. Additionally, the Discharge Assessment completed by the nurse was incomplete and lacked a signature from the resident or responsible party, indicating that discharge instructions, including medications, were discussed. The facility's policy on transfer and discharge outlined the responsibilities of social services staff and the interdisciplinary team in preparing discharge documentation, which was not adhered to in this case.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide appropriate foot and toenail care for Resident 6, who was admitted with multiple diagnoses including stroke, difficulty walking, and osteoarthritis. Resident 6's toenails had grown long and thick, causing discomfort when wearing shoes, and her feet appeared severely dry and cracked. Despite Resident 6's intact cognition, as indicated by a BIMS score of 15, she reported that her toenails had not been cut for months. Observations confirmed that her toenails were approximately one-half inch long and required trimming, and her feet needed moisturizing. Licensed staff acknowledged that the CNA responsible for Resident 6's care should have noticed the condition of her feet during routine care and informed the nurse. The nurse should have assessed the situation and arranged for a podiatrist appointment, as the toenails were too thick for the nurse to cut. The facility's policy indicated that only a licensed nurse or physician could cut the toenails of a diabetic resident, and a podiatrist had been retained by the facility. However, the necessary steps to address Resident 6's foot care needs were not taken, leading to the deficiency.
Failure to Monitor Resident's Oxygen Therapy
Penalty
Summary
The facility failed to adequately monitor a resident who was on continuous oxygen therapy, resulting in the resident's portable oxygen tank running out of oxygen. The resident, who had a history of stroke, high blood pressure, emphysema, chronic obstructive pulmonary disease, and shortness of breath, was observed propelling herself in a wheelchair in the hallway when it was discovered that her oxygen tank was empty. This situation could have led to the resident experiencing shortness of breath and potential respiratory distress. The deficiency was identified during an observation where the resident indicated she could not feel any oxygen coming from her nasal cannula. Licensed staff acknowledged the empty tank and stated that while CNAs could inform them if a tank needed refilling, it was ultimately the nurse's responsibility to ensure the tank did not run empty. The facility's policy on oxygen therapy and the charge nurse's job description both emphasize the responsibility of nursing staff to administer oxygen as prescribed and ensure it is done under safe conditions.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to maintain appropriate temperatures in two medication refrigerators, which were used to store resident medications, including insulin and COVID-19 vaccines. During an observation, Refrigerator A was found to be at 52 degrees Fahrenheit, storing Lantus insulin pens and a Prevnar vaccine, while Refrigerator B was at 50 degrees Fahrenheit, storing COVID-19 Pfizer vaccines and an emergency kit. These temperatures were outside the recommended range of 36-46 degrees Fahrenheit, as indicated by a form posted in the medication room. The Maintenance Director confirmed the temperatures and stated he had not been notified of any issues within the last 30 days. Additionally, the facility was found to have expired medications stored with active medications. An expired bottle of fish oil capsules was found in the medication room, and an expired bottle of Glucosamine Chondroitin was found in a medication cart in the east hallway. Both medications had expiration dates of May 2024. The facility's policy on medication storage and expiration, last revised in 2013, requires the destruction or return of expired medications, but this was not adhered to, as confirmed by the staff involved.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who required a follow-up appointment with an oral surgeon. The resident, who was admitted with multiple diagnoses including stroke, hemiplegia, dysphagia, and severe cognitive impairment, had a care plan indicating oral health problems due to poor oral hygiene. A Dental Progress Note dated 3/14/24 indicated the need for a follow-up with an oral surgeon, but the appointment was not made in a timely manner. The Social Services department acknowledged the oversight, citing difficulties in locating resources and insurance authorization issues. The facility's policy on oral healthcare and dental services mandates timely assistance in obtaining routine and emergency dental care, with the Social Services Department responsible for making necessary appointments. However, the resident's follow-up appointment was delayed until the deficiency was brought to the attention of Social Services, three months after the initial visit. This delay in scheduling the follow-up appointment was contrary to the facility's policy and procedure, which emphasizes timely coordination and documentation of dental services.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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