Delta Oaks Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 6940 Pacific Avenue, Stockton, California 95207
- CMS Provider Number
- 055735
- Inspections on file
- 85
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Delta Oaks Post Acute during CMS and state inspections, most recent first.
A resident with osteomyelitis, a PICC line for IV Ertapenem, insulin‑dependent type 2 DM, and on Heparin for DVT prophylaxis signed out for a self‑scheduled medical appointment and did not return at the time staff expected. Nursing notes and interviews show that although staff recognized the resident was overdue and unsuccessfully attempted phone contact with the resident and his family, they delayed notifying the MD and did not contact law enforcement until the following morning, contrary to facility elopement and out‑on‑pass policies. During the approximately 29‑hour absence, the resident missed scheduled IV antibiotic, insulin, and Heparin doses, and later hospital testing showed positive methamphetamine and opiate screens. The facility’s own policies required timely verification of authorized leave, immediate activation of missing resident procedures, and prompt notification of administration, the MD, and police, which were not followed in this case.
A resident with ESRD on dialysis and sequelae of cerebral infarction was identified through an Elopement Evaluation as being at risk for elopement, but no corresponding elopement care plan was developed. During interview and record review, the DON confirmed the absence of an elopement care plan, acknowledged that one should have been in place, and stated that comprehensive care plans guide staff interventions and vigilance when a resident may try to leave. Review of the facility’s wandering and elopement P&P showed it requires residents identified as at risk for wandering or elopement to have care plan strategies and interventions for safety, which were not implemented for this resident.
A resident with polyneuropathy, gout, and a stage 4 sacral pressure injury had physician orders for PRN acetaminophen for mild pain and hydrocodone/acetaminophen via G-tube for pain levels 5–10, assessed using the PAINAD scale. Nursing staff, including an LN who was reluctant to use hydrocodone/acetaminophen, used their own judgment rather than the ordered pain scale parameters, administering acetaminophen when documented pain scores were high and hydrocodone/acetaminophen when pain scores were low or zero. Review of the MAR and confirmation by the DON showed that pain medications were not given according to the physician’s orders or the care plan, resulting in the resident’s pain not being effectively managed.
A resident with a history of agitation was involved in a verbal altercation with another resident and attempted to hit them, prompting an IDT care conference that recommended a psychiatric evaluation and treatment for agitation. The physician entered an order for a psych evaluation, but the ADON and social services staff were unsure whether the referral was completed, and the SSA, who was responsible for sending referrals, had no access to the psychiatrist’s portal and found no psych notes in the EHR. The DON confirmed the order for psychiatric services, the absence of psychiatric documentation in the chart, and acknowledged that without the psychiatrist’s recommendations the facility would not be compliant with psychiatric services and the resident’s psychosocial health would be affected.
A deficiency was found when a garbage dumpster lid was observed left open, as confirmed by multiple staff including the DSD, IP, and DON. Facility policy requires dumpster lids to be closed when not in use to prevent pests and infection, but this was not followed, resulting in non-compliance with established procedures.
Staff failed to maintain resident dignity by standing over two residents while assisting with meals instead of sitting at eye level, as required by policy. Additionally, multiple residents who required incontinence care were left without necessary briefs due to a supply shortage, leading staff to instruct them to urinate or defecate in their beds or use makeshift alternatives. Residents reported feelings of embarrassment and loss of dignity, and staff confirmed the lack of supplies and the actions taken during the shortage.
The facility did not ensure safe water temperatures in resident bathrooms, with some areas exceeding 120°F, and failed to complete a required post-fall mobility assessment for a resident with dementia and diabetes after a bathroom fall. Staff acknowledged the risks of high water temperatures and the importance of post-fall assessments, but facility policies were not followed in these instances.
A nurse left oral medications at a resident's bedside for self-administration, despite facility policy requiring staff to remain with the resident until all medications are taken and to observe ingestion. The resident, who had advanced CKD and was on dialysis, had not been evaluated for self-administration, and the DON confirmed this practice was not permitted.
Surveyors found that drugs and biologicals were not properly stored or labeled, with dirty air-conditioning filters placed on medication refrigerators, soiled Drug Buster bottles in medication carts, and pill cutters with residue. Several medications and sterile supplies were opened without being labeled with the date opened, and opened single-use wound care supplies were available for use, contrary to policy and manufacturer instructions. Staff confirmed these practices did not meet facility standards for cleanliness and safe medication handling.
Surveyors identified several food safety and sanitation deficiencies, including the presence of moldy produce in the refrigerator, uncovered frozen foods in the freezer, worn and unsanitary kitchen equipment, incomplete food cool down logs, and a two-compartment sink lacking an air gap. These issues were confirmed by dietary staff and had the potential to cause cross-contamination and foodborne illness for residents receiving facility-prepared meals.
Staff failed to follow infection control protocols, including improper storage and replacement of urinals for a resident with multiple health conditions, leaving food and drink in another resident's room which attracted pests, and not disinfecting a glucometer according to manufacturer guidelines. These actions did not comply with facility policies and increased the risk of infection.
A resident with multiple chronic conditions was readmitted, but staff did not develop a baseline care plan within 48 hours as required. Both a nurse and the MDS coordinator confirmed the omission, which was not in line with facility policy and left staff without documented instructions for immediate care.
Two residents prescribed blood thinners did not have individualized care plans developed to monitor for side effects or risks associated with their medications. Nursing staff and the DON confirmed that no care plans or monitoring orders were in place, despite facility policy requiring comprehensive, resident-centered care plans for all medical needs.
A resident with hemiplegia, hemiparesis, and functional quadriplegia, who was dependent on staff for ADLs and had documented severe ROM impairments in multiple joints, was not provided with restorative nursing therapy or passive ROM exercises despite facility policy and staff acknowledgment that such services were needed.
A resident with chronic congestive heart failure and on diuretic medication did not have water within reach on multiple occasions, as staff moved the bedside table and failed to return it. Staff interviews confirmed the importance of water access for this resident, and facility policy required regular provision and encouragement of fluids.
A resident with cerebral palsy repeatedly requested transfer to a facility closer to home, but staff failed to proactively pursue alternate placement or document referral efforts as required. The lack of action and documentation led to the resident's emotional distress, including a reported episode of self-harm, and staff confirmed that facility policy was not followed.
Two residents received Midodrine outside of physician-ordered hold parameters, with the medication administered 13 times for each resident when their systolic blood pressure was above the specified threshold. Nursing staff and the DON confirmed that the medication was given in error, despite facility policy and staff awareness of the required parameters.
The facility was found to have a medication error rate of 6.25% after two residents received medications incorrectly: one received insulin after a meal instead of before as ordered, and another received only one drop of prescribed eye medication per eye instead of two. Nursing staff acknowledged the errors, and the DON confirmed expectations for adherence to medication administration protocols.
Two residents were not properly offered or educated about flu and pneumococcal vaccines, and there was no documentation of consent or refusal in their medical records. One resident did not receive the flu vaccine for two years, and another was not offered the pneumococcal vaccine within the required timeframe after admission, despite both being eligible. Facility staff confirmed that the required processes and documentation were not completed.
A resident was not provided the COVID-19 vaccine within 30 days of admission, and there was no documentation of vaccine administration or history in the medical record. Despite a signed consent form, the vaccine was not given, and the immunization record was left blank. Interviews with the IP, SAD, and DON confirmed the lack of documentation and follow-through on facility policy.
Two residents with G-tubes had care plans requiring dressing changes and skin care at the G-tube site, but there were no physician orders specifying the care or frequency. Staff confirmed the absence of these orders, despite facility policy and care plan requirements for such interventions.
A resident with contracture deformity and total dependence on staff did not receive ordered passive range of motion (PROM) therapy to both lower extremities after the service was discontinued without a new therapy referral. Staff confirmed that only upper extremity PROM was provided, and documentation showed the lower extremity PROM had not been given since the discontinuation, despite facility policy and care plan requirements.
Two residents with gastrostomy tubes did not have physician orders in place to direct the care of their G-tube sites. Licensed nursing staff and the Director of Sub-Acute Services confirmed that required treatment orders were missing, and treatment administration records showed a lack of documented care. This was not in accordance with facility policy, which requires daily G-tube site care and clear physician instructions.
A CNA entered the room of two COVID-19 positive residents without wearing the required PPE, including a gown, N-95 respirator, face shield, and gloves, despite clear signage and available supplies. The CNA was aware of the residents' COVID-19 status and the facility's PPE policy but only wore a surgical mask while providing care.
A resident with a history of stroke and diabetes was able to leave the facility undetected after staff failed to verify and document the placement and functioning of a Wanderguard device each shift, as required by physician order and facility policy. The lapse was confirmed by multiple staff and through medical record review, resulting in the resident's unsupervised exit and subsequent return by a family member.
The facility did not submit a required abuse investigation report to the Department within five days after an allegation of abuse involving two residents with dementia. Although the incident was investigated and a summary was prepared, the Administrator confirmed the report was not sent as required by facility policy.
Nursing staff, including CNAs, an LPN, and a restorative nursing assistant, were observed using personal cellphones during work hours in resident care areas, contrary to facility policy. Multiple staff admitted that cellphone use could distract them and delay response to residents' needs. Two residents reported seeing staff on their phones and expressed concern about staff attention and professionalism. Facility leadership confirmed that these actions violated established policies and could result in delayed care.
A resident who was dependent on staff for ADLs, including bathing, did not receive scheduled showers over several weeks, with documentation showing only occasional bed baths and no evidence that showers were offered or refused. Staff interviews and record reviews confirmed that showers were not provided as required, and facility policy for maintaining hygiene and documenting refusals was not followed.
A resident with severe cognitive impairment and a history of domestic abuse was subjected to repeated physical abuse by another resident, including being struck on multiple occasions. Despite facility policies requiring identification and supervision to prevent abuse, staff failed to update care plans with appropriate interventions, did not adequately monitor the residents involved, and did not document necessary actions, resulting in emotional distress and visible injury to the affected resident.
The facility did not provide required written discharge notices to the State LTC Ombudsman for two residents, both of whom had significant medical conditions and received discharge notices. Staff interviews and record reviews confirmed that the Ombudsman was not notified as required by facility policy, removing the opportunity for resident advocacy.
A resident with a history of depression and suicidal ideation was not monitored every 15 minutes as ordered by a physician, despite recent self-harm threats. Staff failed to document required checks, and the resident was able to obtain a razor blade and inflict multiple deep cuts, resulting in hospitalization. Facility policy and care plans requiring close supervision and documentation were not followed, leading to harm.
A resident's prescribed insulin lispro was not continued upon admission to a skilled nursing facility, despite hospital discharge orders. The omission was confirmed by a Licensed Nurse and the Director of Nursing, who acknowledged the failure to transcribe the orders into the Medication Administration Record. The resident's medical doctor confirmed the insulin was to be continued as ordered.
A resident with encephalopathy and hemiplegia was found without access to their call light on two occasions, leading to them screaming for help. The call light was either on the floor or hanging on a pole, out of reach. Licensed nurses and the assistant administrator confirmed the inaccessibility, acknowledging the resident's inability to call for assistance. The resident's care plan noted a history of falls, and the facility's policy required call lights to be accessible.
A resident with encephalopathy and hemiplegia did not receive scheduled twice-weekly showers, leading to discomfort and skin issues. Despite being dependent on staff for personal hygiene, the resident received inconsistent care due to staffing issues and documentation errors. Facility policies required regular bathing, but this standard was not met.
A CNA applied a discontinued prescription cream on a resident with encephalopathy and hemiplegia, following instructions from an LN. The cream, Clotrimazole and Betamethasone, had no active order and was discontinued months earlier. The facility's policy requires only licensed personnel to administer medications, which was not followed in this case.
A resident's shared bathroom contained three soiled and unlabeled bedpans, which were not cleaned or labeled as required by the facility's policy. A CNA confirmed the oversight, acknowledging the risk of infection spread. The resident had purchased the bedpans due to size issues with the facility's bedpans, and staff placed them in the bathroom after use. Both the Assistant Administrator and Infection Preventionist stated that the bedpans should have been cleaned and labeled to prevent infection.
The facility failed to administer medications and monitor blood sugars in a timely manner for three residents, leading to potential negative effects on their health. A resident with diabetes and other conditions experienced late medication and insulin administration, while another resident with hypertension and lupus had medications given hours late. A third resident with diabetes had delayed blood sugar checks and insulin due to staff being unable to locate him. Interviews with staff highlighted the importance of timely administration and the lack of documentation for delays.
A facility failed to follow infection control protocols when a nurse did not wear the required PPE while suctioning a subacute resident with MDROs. The resident, with a history of sepsis, respiratory failure, and ventilator dependence, was on Enhanced Standard Precautions. Despite clear policies and signage, the nurse did not wear a gown, increasing the risk of infection spread. The Infection Preventionist and DON confirmed the expectation for PPE use during such procedures.
The facility was cited for multiple food safety and storage deficiencies, including expired and mislabeled food items, unclean kitchen equipment, and improper food handling by staff. These issues could lead to foodborne illnesses among residents. Additionally, the facility lacked adequate utensils during meal service, and residents reported difficulty chewing improperly cooked vegetables.
The facility failed to accommodate the needs of four residents, resulting in deficiencies in care. A resident with limited arm mobility could not reach her call light, while another with a history of stroke had inaccessible side rails, contrary to physician orders. Two other residents were found without reachable call lights, increasing their risk of unmet needs and falls. These issues were confirmed by staff and highlighted a failure to adhere to care plans and facility policies.
The facility failed to maintain proper respiratory care standards for residents using oxygen. A resident's oxygen tubing was not changed weekly, increasing infection risk. Another resident's room lacked required oxygen use signage, posing safety risks. Additionally, oxygen concentrator filters for three residents were either dirty or missing, potentially leading to respiratory issues.
The facility failed to administer medications correctly for two residents. One resident received medications late and inaccurately documented, while another had medications administered or withheld against physician orders based on blood pressure readings. These actions deviated from the facility's medication administration policies.
A facility failed to protect residents from significant medication errors. A resident was given Methadone without a physician's order, leading to an overdose requiring Naloxone. Another resident's medications, including controlled substances, were left unattended at the bedside, posing a risk of ingestion by others. The facility's medication administration policy was not followed, leading to these errors.
The facility failed to implement its personal food storage policy, lacking microwaves and refrigeration units for residents to store or reheat food brought by family and visitors. Staff interviews revealed that previous administration removed these due to safety concerns, leading to non-compliance with the policy and impacting residents' food safety and enjoyment.
The facility failed to maintain infection control standards, as evidenced by an unlabeled bedpan left on the floor in a shared bathroom and a resident's cluttered room posing an infection risk. Staff confirmed these practices could lead to cross-contamination, and the facility's policies were not adhered to.
A resident in an LTC facility experienced verbal abuse from a CNA, who called her derogatory names, causing distress and a feeling of unsafety. The resident, with intact memory and communication abilities, reported the incident, which was confirmed by her roommate and another CNA. The facility's policies prohibit such abuse, emphasizing respect and dignity for all residents.
A facility failed to follow its abuse policy when a resident alleged verbal abuse by a CNA. The facility did not initiate a timely investigation or report the results to the Department within the required timeframe. The resident, with intact cognitive abilities and a history of depression and anxiety, reported the incident, but the Department had not received an investigative summary 16 days later.
The facility failed to provide dignified care to two residents. One resident did not receive dentures in a timely manner, leading to sadness and reluctance to smile. Another resident, with quadriplegia, was assisted with meals by a CNA standing over them, contrary to facility policy requiring staff to be at eye level with residents during meals.
A resident with Multiple Sclerosis and a history of falls was found to have a cluttered room, with personal items scattered on the floor, increasing her risk of falls. Despite her request for assistance, facility staff were too busy to help organize her belongings. The clutter was confirmed by a CNA and acknowledged by the Activity Director and DON, who emphasized the importance of a clutter-free, homelike environment.
A facility failed to complete the PASRR Level II evaluation for a resident with schizoaffective bipolar disorder and schizophrenia. Despite a positive Level I screening, the evaluation was not conducted due to unresponsiveness to state agency communications. The Social Services Director confirmed the oversight, acknowledging the risk to the resident's mental health needs. The Director of Nursing expected proper evaluation and support, as per facility policy.
Failure to Timely Respond to Resident’s Non-Return From Appointment Resulting in Elopement and Missed Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and timely intervention when a resident did not return from an outing as expected, resulting in an elopement. The resident had been admitted in 2025 with diagnoses including acute osteomyelitis of the right ankle and foot, cellulitis of the right lower limb, a non‑pressure chronic ulcer of the right heel and foot, type 2 diabetes with long‑term insulin use, asthma, difficulty walking, and generalized muscle weakness. The resident also had a right upper arm PICC line for IV Ertapenem to treat osteomyelitis and was receiving Heparin for DVT prevention and insulin for diabetes management. On the day of the incident, the resident left the facility around 12:30 p.m. for a medical appointment that he reported he had independently scheduled, including arranging his own transportation, and he signed out at the nursing station stating he was going out for this appointment. Progress notes and interviews show that the resident did not return at his expected time, which staff understood to be between 6 p.m. and 7 p.m., and he remained out of the facility for approximately 29 hours. A late entry nurse progress note timed at 6 p.m. on the day of departure documented that the charge nurse reported the resident had signed out for his appointment and had not yet returned, and that the resident had also left the previous day with a friend but returned around 6:30 p.m. The note indicated the writer instructed the charge nurse to call the resident’s cell phone and listed contacts, and that the MD and administration were notified. Another progress note the following morning documented that the resident had not returned since leaving for the appointment, that attempts to reach him and his emergency contacts by phone were unsuccessful, and that the DON, Administrator, and MD were notified. The DON later confirmed that the physician was not called until 10 p.m. on the day the resident left and that law enforcement was not contacted until around 7 a.m. the next day, despite the facility’s policy that staff should immediately notify administration, the physician, and then law enforcement when a resident on pass or at an appointment does not return within four hours or by the expected time. Interviews with nursing leadership and staff further described inaction and delays in following the facility’s elopement and out‑on‑pass procedures. The DON stated that based on the facility’s definition, the resident’s absence from the time he failed to return as expected until his arrival the next day constituted an elopement. The DON and ADON both confirmed that the facility did not promptly contact the police the night the resident failed to return, and the ADON stated she was the one who called law enforcement when she came on duty at 7 a.m. the following morning. LN 1 acknowledged that she did not call the police when the resident did not return at his expected time and recognized that not calling could affect the resident’s safety and left staff unaware of his whereabouts or condition. The DON also acknowledged that staff did not follow up with the community medical center to determine whether the resident was there. During the resident’s absence, medication records show missed doses of IV Ertapenem, insulin glargine, and Heparin, with the MAR marked as "AW" (away from center) or "X" (not given) on relevant dates. When the resident eventually returned, he was sent to the hospital, where toxicology screening was positive for methamphetamine and opiates, and social services documented that the resident described his experience outside the facility as frightening. The facility’s written policies outlined specific steps that were not followed in this situation. The "Wandering and Elopements" policy required that if a resident is missing and not on an authorized leave, staff must initiate a search and, if the resident is not located, notify the Administrator, DON, legal representative, attending physician, and law enforcement. The "Out On Pass" policy required that residents have a physician’s order for an out‑on‑pass and that licensed nurses assess the resident’s status and ensure instructions for special needs and medication orders while on pass. Interdisciplinary team notes later clarified that the resident had an MD‑approved one‑day out‑on‑pass order for the previous day only and that he left on the day of the incident believing he did not need a new order. At the time he left, the facility did not have a current out‑on‑pass order for that day, and staff did not promptly implement the missing resident/emergency procedures when he failed to return within the expected timeframe, leading to the identified deficiency in supervision and accident prevention.
Failure to Develop Elopement Care Plan for At-Risk Resident
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive, person-centered care plan addressing elopement risk for one resident. The resident’s admission record showed multiple diagnoses, including End Stage Renal Disease, dependence on renal dialysis, and sequelae of cerebral infarction. An Elopement Evaluation dated 12/24/25 documented that the resident was at risk for elopement. Despite this documented risk, review of the resident’s care plans revealed that no elopement care plan had been created. During a concurrent interview and record review on 2/12/26 at 3:20 PM, the DON confirmed that the resident did not have an elopement care plan and stated there should have been one. The DON acknowledged that not having such a care plan put the resident at risk of elopement and emphasized that a comprehensive care plan is important to guide staff with interventions and to help them be more vigilant if a resident attempts to leave the facility. Review of the facility’s “Wandering and Elopements” policy, revised 3/19, showed that when a resident is identified as at risk for wandering or elopement, the resident’s care plan is required to include strategies and interventions to maintain safety, which was not done in this case.
Failure to Follow Physician-Ordered Pain Management Regimen
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive pain management and to administer pain medication according to physician orders for one resident with significant pain-related conditions. The resident was admitted with diagnoses including polyneuropathy and gout and had a care plan noting acute/chronic pain related to chronic physical disability and a stage 4 pressure wound to the sacrum. Physician orders included acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain, and hydrocodone/acetaminophen 5-325 mg, one tablet via G-tube every six hours as needed for pain levels 5–10. Staff used the PAINAD scale to assess this non-verbal resident’s pain, observing increased respirations and heart rate, open eyes and mouth, and facial grimacing when the resident was in pain. However, the nurse reported using nursing judgment to decide which pain medication to give and expressed reluctance to administer hydrocodone/acetaminophen due to concern that the resident’s body would get used to it. Record review of the Medication Administration Record for the month showed that when the resident had documented pain levels of 8, 5, 6, and 7, staff administered only acetaminophen, despite the physician’s order specifying hydrocodone/acetaminophen for pain levels 5–10. Conversely, hydrocodone/acetaminophen was given when the resident’s documented pain levels were 4 and 0, when acetaminophen should have been used according to the orders. The DON confirmed that the resident sometimes received acetaminophen when pain was above 5 and hydrocodone/acetaminophen when pain was lower, contrary to the physician’s orders and the care plan intervention to administer hydrocodone/acetaminophen as ordered. This failure to follow the prescribed pain management regimen and the facility’s medication administration policy resulted in the resident’s pain not being effectively managed and not being treated per physician orders.
Failure to Complete and Document Psychiatric Evaluation After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received necessary behavioral health services following an altercation. The resident was admitted with diagnoses including muscle weakness and difficulty walking. After a verbal altercation with another resident in which the resident attempted to hit the other party, an IDT care conference was held and documented on 10/27/25. The IDT recommended a psychiatric evaluation and treatment for episodes of agitation. The physician subsequently entered an order on 10/29/25 for a psychiatric evaluation and treatment related to agitation. Despite this, there was no documentation in the resident’s medical record that a psychiatric evaluation occurred or that psychiatric treatment was provided. During interviews and concurrent record reviews, the ADON, SSA, and DON each confirmed key gaps in the referral and documentation process. The ADON acknowledged the IDT recommendation for a psychiatric evaluation and stated she was not sure if the referral had been completed, noting that social services needed to be informed when such referrals were required. The SSA confirmed that social services were responsible for sending psychiatric referrals and that a psychiatrist contracted with the facility typically visited and documented in an external portal, but she did not have access to that portal and was unsure if the resident had been seen; she also confirmed there were no psychiatric notes in the EHR. The DON confirmed the resident’s history of agitation, the altercation details, and the existence of the physician’s psychiatric evaluation order, but stated she did not know if the resident had been seen and also lacked access to the psychiatrist’s portal. The DON verified that no psychiatric notes were present in the resident’s chart and stated it was important for the facility to know the psychiatrist’s recommendations and that without this information the facility would not be compliant with psychiatric services, affecting the resident’s psychosocial health.
Improper Disposal of Garbage Due to Open Dumpster Lid
Penalty
Summary
A deficiency was identified when one of two outside garbage dumpster lids was observed to be left open at the facility, which had a census of 112. During multiple observations and interviews with the Central Supply, Director of Staff Development (DSD), and Infection Preventionist (IP), it was confirmed that the dumpster lid was not adequately closed. The staff members interviewed, including the DSD, IP, and Director of Nursing (DON), all acknowledged that the dumpster lids should have been closed when not in use. The facility's policies and procedures, including those for food-related garbage and refuse disposal and infection prevention and control, require that all garbage containers have tight-fitting lids and remain covered when not in continuous use. The staff confirmed that leaving the dumpster lids open could allow pests and insects to gather and potentially enter the facility, increasing the risk of infection and cross-contamination. The observations and staff statements directly indicated non-compliance with the facility's established procedures for proper garbage disposal.
Failure to Maintain Resident Dignity During Meal Assistance and Incontinence Care
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect in two main areas: meal assistance and incontinence care. Staff were observed standing over two residents while assisting them with their lunch, rather than sitting at eye level as required by facility policy. Both CNAs involved acknowledged that they did not follow the expected procedure due to time constraints and the need to assist other residents. The Director of Nursing and a Licensed Nurse confirmed that staff should be seated next to residents during meal assistance to maintain dignity and ensure safety, as outlined in the facility's policy on dignity and dining experience. A more significant deficiency occurred when the facility ran out of incontinent briefs over a weekend, affecting multiple residents who required these supplies for bladder and bowel incontinence. Several residents reported that staff instructed them to urinate or defecate in their beds due to the lack of available briefs. Some residents described staff taking briefs from their rooms to give to others, and in one case, a resident was told to use a towel. Residents expressed feelings of embarrassment, degradation, and a loss of dignity as a result of these actions. Staff interviews confirmed the shortage, with CNAs and nurses stating that they searched the facility for briefs, asked residents to share, and instructed residents to use their beds when supplies were unavailable. The supply shortage was attributed to the absence of the central supply staff member responsible for ordering and stocking supplies, leading to disorganization and delayed deliveries. Management and nursing staff confirmed awareness of the shortage and described efforts to locate or borrow supplies, but these were insufficient to meet residents' needs. Facility policies reviewed in the report emphasized the importance of treating residents with dignity, respecting their property, and providing necessary care and supplies to avoid neglect and maintain well-being. The events described resulted in residents being left without essential incontinence products, compromising their dignity and comfort.
Failure to Maintain Safe Water Temperatures and Complete Post-Fall Assessment
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment in two key areas: water temperature control in resident-accessible areas and post-fall assessment for a resident. During observations and interviews, it was found that water temperatures in several resident bathrooms exceeded the facility's policy limit of 120°F, with some readings as high as 130°F and 135°F. Staff, including the Maintenance Director, Director of Staff Development, Infection Preventionist, and DON, all acknowledged that water temperatures above 120°F could cause burns or skin damage to residents. A resident also reported that the water would get too hot in the bathroom, but did not report it to staff and simply stopped using it. The facility's policy required water heaters servicing resident areas to be set no higher than 120°F, but this was not consistently followed. In addition, the facility failed to complete a post-fall mobility assessment for a resident who had a fall in the bathroom. The resident, who had dementia and diabetes, was found on the bathroom floor in pain and was subsequently sent to the emergency room. Although the facility's policy required a joint mobility screen after a fall, the DON confirmed that this assessment was not completed after the incident. The last mobility screen for the resident had been done prior to the fall. The DON acknowledged that not completing the assessment meant staff would not have updated information on the resident's mobility status. Facility policies reviewed indicated that water temperatures and fall risk assessments were to be closely monitored and managed to prevent harm. However, the observed failures in both maintaining safe water temperatures and completing required post-fall assessments demonstrated lapses in following these policies, potentially exposing residents to physical harm.
Medications Left Unattended at Bedside Without Supervision
Penalty
Summary
A licensed nurse left a medication cup containing four pills on a resident's bedside table, rather than directly administering the medications and observing ingestion as required by facility policy. The resident, who had chronic kidney disease stage 4 and was dependent on renal dialysis, stated that it was common for the nurse to leave medications at the bedside so she could take them with coffee when delivered by her CNA. The nurse confirmed this practice, acknowledged it was against facility policy, and admitted that the resident had not been evaluated or care planned for self-administration of medications. Facility policies reviewed indicated that medications are to be administered in a safe and timely manner, with staff remaining with the resident until all medications are taken and observing the resident after administration to ensure the dose is ingested. The DON confirmed that medications should not be left unattended at the bedside and that the nurse should be present during administration. The failure to follow these procedures was observed and confirmed through interviews and record review.
Deficient Medication Storage, Labeling, and Cleanliness Practices
Penalty
Summary
Surveyors identified multiple deficiencies related to medication storage and labeling practices in the facility. In two out of three medication rooms and four out of five medication carts, drugs and biologicals were not stored or labeled according to accepted professional standards. Specifically, an external air-conditioning unit with a dirty filter containing grayish dust and debris was placed on top of a medication refrigerator, raising concerns from the Infection Preventionist, Director of Staff Development, and Director of Nursing about potential contamination of medications stored inside the refrigerator. Facility policy required medication storage areas to be kept clean, which was not followed in this instance. Additionally, two bottles of Drug Buster solution, used for medication disposal, were found soiled and in active use in two different medication carts. Licensed nurses confirmed the bottles were dirty and posed a risk of cross-contamination within the carts. The Director of Staff Development and Director of Nursing both acknowledged that the presence of dirty Drug Buster could lead to unwanted drug-to-drug interactions and make the carts difficult to clean. Furthermore, pill cutters in three different medication carts were observed with white and grayish residue, and staff confirmed these devices should have been cleaned to prevent cross-contamination between medications. The survey also found that several medications and sterile supplies were opened but not labeled with the date opened, including a bottle of Miralax, a box of Bisacodyl suppositories, and a bottle of Clobetasol Propionate Topical Solution. Single-use sterile wound care supplies were also found opened and available for use in a treatment cart, contrary to manufacturer instructions and facility policy. Staff interviews confirmed the importance of labeling opened medications and discarding opened sterile supplies, as failure to do so could result in the use of expired or non-sterile products.
Multiple Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with safety standards, as evidenced by multiple observations during a kitchen tour and staff interviews. Surveyors found three moldy tomatoes and a discolored, flattened, and mushy apple in the walk-in refrigerator, which were verified by the Certified Dietary Manager (CDM) and Registered Dietitian (RD) as being unfit for consumption and posing a risk for foodborne illness. Additionally, frozen fish fillets, beef patties, meatballs, and veggie patties were left uncovered in the reach-in meat freezer, exposing them to the environment and potentially affecting their quality and safety, as confirmed by the District Dietary Manager (DDM) and RD. Further deficiencies were observed in the condition of kitchen equipment and adherence to food safety protocols. Three bowls were found to be worn, chipped, and without glaze, and a green cutting board was visibly worn with deep gouges, making them difficult to clean and sanitize. Both CDM and DDM acknowledged that such equipment should have been discarded due to the risk of bacterial growth. Review of facility policy and the FDA Food Code supported the need for clean, sanitary, and properly maintained food service equipment to prevent contamination. The facility also failed to properly document food cooling processes and maintain plumbing standards. The cool down log for egg salad did not indicate when the food reached the required safe temperature, which staff recognized as necessary to ensure food safety and prevent bacterial growth. Additionally, the two-compartment sink used for rinsing and manual dishwashing did not have an air gap, a required feature to prevent backflow of contaminated water, as verified by the DDM and CDM. These combined failures had the potential to lead to cross-contamination and foodborne illness for the 85 residents receiving facility-prepared meals.
Infection Control Failures in Urinal Handling, Room Cleanliness, and Glucometer Disinfection
Penalty
Summary
Staff failed to follow appropriate infection prevention and control measures in several instances. In one case, a resident with multiple diagnoses, including cerebral infarction, heart failure, and chronic kidney disease, had three labeled urinals containing urine placed inside a trash can in their room. The urinals were not replaced with clean ones, and the designated urinal holder at the bedside was left empty. The resident reported that staff were inconsistent in replacing the urinal and that it was not their preference to store it in the trash can. Staff interviews confirmed that this practice did not follow standard procedures and posed an infection control risk. Facility policy required urinals to be cleaned, labeled, and stored in the designated holder, but this was not followed. Another deficiency was observed in a resident's room where multiple flying pests were present. The room contained an uncollected empty fruit cup with used tissue paper and a spoon, a mug with coffee, an empty glass, and another cup with water, all of which had attracted insects. The resident stated that staff were not cleaning the room regularly and that meal trays were not being picked up after meals. Staff confirmed that leaving food and drink at the bedside could attract insects and increase infection risk. There was no care plan documenting any refusal by the resident to have the room cleaned or trays removed, and facility policy required prompt removal of meal trays and maintenance of a pest-free environment. A further issue involved improper cleaning and disinfection of a glucometer by a licensed nurse. The nurse cleaned the device for only 10 seconds with a disinfectant towelette, not following the manufacturer's instructions, which required a two-minute wet contact time using two wipes. Both the infection preventionist and the DON confirmed that the correct procedure was not followed, increasing the risk of cross-contamination. Facility guidelines specified the need for proper cleaning and disinfection of the glucometer after each use, but this protocol was not adhered to.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission or readmission for one resident, as required by both regulation and the facility's own policy. Specifically, a review of the resident's medical record showed that no baseline care plan was created following the resident's readmission in March 2021. This was confirmed during interviews with both a licensed nurse and the MDS coordinator, who acknowledged that the baseline care plan was not completed as required. The facility's policy states that a baseline care plan must be developed within 48 hours of admission to provide effective, person-centered care and to guide staff in meeting the resident's needs. The resident involved had a complex medical history, including chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure, hypertensive heart disease with heart failure, and type 2 diabetes mellitus with diabetic chronic kidney disease. The absence of a baseline care plan meant that there were no documented instructions for staff to follow to address the resident's specific care needs immediately after admission. Both the licensed nurse and the MDS coordinator confirmed that this omission was contrary to facility policy and could negatively affect the resident's health and well-being.
Failure to Develop and Implement Care Plans for Residents on Blood Thinners
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for two residents who were prescribed blood thinner medications. For one resident with diagnoses including deep vein thrombosis (DVT), hypertension, and mobility issues, there was no care plan in place to monitor for potential side effects or risks associated with apixaban, a blood thinner prescribed upon admission. Licensed nursing staff confirmed that there were no orders or documentation for monitoring side effects such as bleeding, and that this monitoring was essential due to the serious complications that could arise from the medication. A review of the facility's policy and procedure for comprehensive care planning indicated that care plans should incorporate identified problem areas, risk factors, and targeted interventions. However, interviews with both nursing staff and the Director of Nursing (DON) confirmed that these procedures were not followed for the resident on apixaban, as no care plan or monitoring orders were present in the medical record. The DON acknowledged that staff were expected to monitor for bleeding each shift and check for signs in the mouth, urine, and stool, but this was not documented or implemented. Similarly, another resident with multiple chronic conditions, including COPD, heart failure, and diabetes with chronic kidney disease, was prescribed both aspirin and Eliquis for DVT prophylaxis. Despite active orders for these blood thinners, there was no corresponding care plan developed. Nursing staff and the DON confirmed the absence of a care plan and recognized the importance of care planning as a guiding tool for providing person-centered care and coordinating services. The facility's policy required comprehensive care plans to address all medical, physical, and psychosocial needs, but this was not done for the residents in question.
Failure to Provide Restorative Nursing Therapy for Resident with Severe ROM Impairment
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, and functional quadriplegia was admitted to the facility and was dependent on nursing staff for activities of daily living. Clinical records, including a comprehensive assessment, indicated the resident had impairments in range of motion (ROM) in both upper and lower extremities. A joint mobility screen documented severe impairment in the resident's right wrist, left hand, and right hand, with approximately 25% or less of full ROM. Despite these findings, the resident was not placed on a restorative nursing therapy program, which would have included passive range of motion (PROM) exercises. Both the Director of Rehab and the Assistant Director of Nursing confirmed that the resident should have been offered restorative nursing therapy services following the decline in ROM. The facility's policy stated that restorative nursing care should be provided as needed to promote optimal safety and independence, but this was not implemented for the resident in question.
Failure to Ensure Water Access for Resident at Risk of Dehydration
Penalty
Summary
A resident with chronic congestive heart failure, who was at risk for dehydration due to the use of diuretic medication, did not have proper access to fluids as required. The resident's care plan identified the risk for dehydration, and the facility's policy stated that adequate hydration should be provided. During multiple observations, the resident's water pitcher was found out of reach, once on a nightstand and another time on a bedside table that had been moved against the wall by staff and not returned to its original position. The resident was unable to reach the water pitcher on both occasions. Staff interviews confirmed that the water pitcher should have been within the resident's reach at all times, especially given the resident's increased risk for dehydration. The certified nursing assistant acknowledged moving the bedside table and forgetting to return it, while both the licensed nurse and the director of nursing confirmed the importance of water access for this resident. The facility's policy also required nursing aides to provide and encourage fluid intake as part of daily routines.
Failure to Provide Medically-Related Social Services for Resident Transfer Requests
Penalty
Summary
The facility failed to provide medically-related social services to a resident with cerebral palsy and paresthesia of the skin by not honoring repeated requests to be transferred to a facility closer to his home. The resident, who had been admitted in 2019, consistently expressed his desire to move closer to his hometown, as documented in care plans, social service assessments, and progress notes. Despite these documented requests, the facility did not proactively pursue alternate placement or maintain documentation of referral efforts as required by facility policy. Interviews with the Social Service Director (SSD), nursing staff, and the Health Information Manager (HIM) confirmed that the resident's requests for transfer were known to staff over several years. The SSD acknowledged that although referrals were reportedly sent to other facilities, there was no documentation to support this, and the HIM confirmed that no such records were received or uploaded into the resident's medical file. The facility's policy required social services to document all referrals in the resident's medical record, which was not followed in this case. The resident's ongoing requests and the lack of action led to emotional distress, as evidenced by multiple progress notes and interviews indicating the resident's frustration and a reported episode of self-harm. Nursing staff and the Director of Nursing (DON) confirmed that the resident's psychosocial well-being was negatively affected by the facility's failure to act on his transfer requests. The DON also confirmed that the facility's policy and expectations regarding documentation and proactive placement efforts were not met.
Failure to Follow Physician-Ordered Hold Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for the administration of Midodrine, a medication used to treat hypotension, were followed for two residents. For both residents, the physician's order specified that Midodrine should be held if the systolic blood pressure (SBP) was greater than 100. Despite these clear instructions, the medication was administered outside of these parameters on 13 separate occasions for each resident, as confirmed by a review of the Medication Administration Records (MAR) and interviews with the Director of Nursing (DON). The DON acknowledged that the medication was given in error and outside of the prescribed parameters on the specified dates. Interviews with nursing staff confirmed their awareness of the hold parameters and the importance of not administering Midodrine when the SBP exceeded 100, as per the physician's orders. The facility's policy on medication administration required that medications be given as prescribed and that vital signs, including blood pressure, be checked and verified prior to administration. Despite these policies and staff knowledge, the medication was repeatedly administered inappropriately, as documented in the MAR and confirmed by the DON.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 6.25%, which exceeds the acceptable threshold of 5%. During medication administration observations, two errors were identified out of 32 opportunities involving two residents. In one instance, a licensed nurse administered 4 units of Insulin Lispro subcutaneously to a resident after the resident had already eaten breakfast, despite the order specifying that the insulin should be given before meals. The nurse confirmed the insulin was given late and acknowledged that the medication should have been administered prior to the meal as ordered. In another case, a licensed nurse administered only one drop of Visine Dry Eye Relief in each eye to a resident, contrary to the physician's order for two drops in each eye twice daily. The nurse admitted to the error, stating unfamiliarity with such an order. The Director of Nursing confirmed that her expectation was for staff to follow the rights of medication administration and to give medications as prescribed, including correct timing and dosage. Facility policy also requires medications to be administered in accordance with prescriber orders and within specified time frames.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer, obtain informed consent, and provide education regarding influenza and pneumococcal vaccinations to two out of five sampled residents. One resident was not offered the flu vaccine for two consecutive years, and there was no documentation of a refusal or education provided to the resident or their responsible party. The resident's medical record did not contain a signed consent or refusal form for the flu vaccine during the relevant flu seasons, despite the facility's policy requiring annual offering and documentation. Another resident was not offered the pneumococcal vaccine within 30 days of admission, as required by facility policy. The resident, who was eligible for the vaccine and had a history of pneumonia requiring antibiotic treatment, had no record of being offered the vaccine, no consent form, and no documentation of education or refusal in the medical record. Interviews with facility staff confirmed that the vaccine should have been offered and documented, but there was no evidence this occurred. Facility policies for both influenza and pneumococcal vaccines require that residents be assessed for eligibility, offered the vaccines, and that informed consent or refusal be documented, along with education about the risks and benefits. In both cases, the required processes were not followed, and the necessary documentation was missing from the residents' medical records.
Failure to Administer and Document COVID-19 Vaccine for a Resident
Penalty
Summary
The facility failed to provide and document the administration of the COVID-19 vaccine for one resident within 30 days of admission, as required. The resident's clinical record did not contain evidence that the COVID-19 vaccine was administered, nor was there documentation of the resident's COVID-19 vaccine history. Interviews with the Infection Preventionist (IP), Sub-acute Director (SAD), and Director of Nursing (DON) confirmed that although the resident signed a consent form for the COVID-19 vaccine on the day of admission, the vaccine had not been given, and there was no documentation of prior vaccination or a valid reason for not administering the vaccine. The medical record also lacked any completed, active, or discontinued orders for the COVID-19 vaccine, and the immunization record was left blank regarding the resident's COVID-19 vaccine status. Facility policy requires that if a resident requests vaccination or missed earlier opportunities, the vaccine should be offered as soon as possible and all efforts, including each dose administered, should be documented in the medical record. In this case, the facility did not follow its own policy, as there was no documentation of the resident's COVID-19 vaccine administration, history, or refusal. The DON acknowledged that the absence of this documentation made it unclear whether the resident had received the vaccine, and the process for obtaining and recording prior vaccination information was not completed.
Failure to Implement Physician-Ordered G-Tube Site Care
Penalty
Summary
The facility failed to ensure that interventions listed on the resident-centered comprehensive care plans were specific to the care and services implemented for two residents with gastrostomy tubes (G-tubes). For both residents, the care plans indicated that dressing changes and skin care at the G-tube site should be provided as ordered, but there were no corresponding physician orders detailing the required care, frequency, or instructions for these interventions. Licensed nurses and the Director of Sub-Acute Services confirmed during interviews and record reviews that the necessary treatment orders were missing from the residents' records, despite facility policy requiring daily treatment to the G-tube site. Both residents were admitted with diagnoses requiring attention to their G-tubes, and their care plans included interventions to monitor and care for the G-tube site. However, the lack of specific physician orders meant that the care plans could not be properly implemented. Staff acknowledged that this omission was inconsistent with facility policy and recognized the importance of having clear, physician-directed instructions for G-tube site care. The facility's policy and procedure for comprehensive care plans also required that interventions reflect professional standards of practice and be tailored to identified problem areas.
Failure to Provide Ordered PROM Therapy to Lower Extremities
Penalty
Summary
A deficiency occurred when a resident with a history of contracture deformity and complete dependence on staff for all activities of daily living did not receive the ordered passive range of motion (PROM) therapy to both lower extremities. The resident's care plan included goals to prevent a decrease in range of motion and worsening of contractures, and physician orders were in place for PROM to both upper and lower extremities. However, the PROM therapy for the resident's lower extremities was discontinued on 2/5/25 without an updated referral from the therapy department, and the resident subsequently only received PROM to the upper extremities. Interviews with facility staff, including the Restorative Nurse Assistant, Director of Nursing, and Physical Therapy Assistant, confirmed that the lower extremity PROM was stopped without proper authorization or a new therapy referral, despite the resident's ongoing risk for contractures due to immobility. Documentation review showed that the last lower extremity PROM was provided on 2/13/25, and facility policy required restorative nursing care as needed to promote optimal safety and independence. This lapse in care resulted in the resident not receiving the necessary services to maintain or improve range of motion as outlined in their care plan and physician orders.
Failure to Obtain Physician Orders for G-Tube Site Care
Penalty
Summary
The facility failed to ensure that physician orders were in place to direct the care of gastrostomy tube (G-tube) sites for two residents who required such care. For both residents, clinical record reviews and interviews with licensed nursing staff confirmed that there were no active physician treatment orders specifying the necessary care for the G-tube sites. Staff acknowledged that facility policy required daily treatment of G-tube sites, and the absence of these orders meant that the prescribed care was not documented or provided as required. Further review of treatment administration records showed no evidence that one resident received any G-tube site care upon readmission, and the other resident lacked orders for dressing changes or site cleaning over a specified period. The Director of Sub-Acute Services confirmed that it was expected for residents with G-tubes to have physician orders detailing treatment instructions. The facility's own policy emphasized the importance of keeping the skin around the G-tube exit site clean, dry, and lubricated, but this standard was not met due to the missing orders.
Failure to Use Required PPE When Entering COVID-19 Isolation Room
Penalty
Summary
A Certified Nursing Assistant (CNA) entered the room of two residents who had tested positive for COVID-19 without wearing the required personal protective equipment (PPE), which included a gown, N-95 respirator, face shield, and gloves. The CNA was observed wearing only a surgical mask despite clear signage posted at the room entrance specifying the necessary PPE for entry. The CNA acknowledged awareness of both the residents' COVID-19 status and the PPE requirements, and confirmed that appropriate PPE was available near the room door. The CNA stated uncertainty as to why the proper PPE was not worn and admitted understanding the risk associated with this action. The two residents involved had significant medical histories, including cerebral infarction, kidney cancer, anxiety disorder, osteoarthritis, and anemia. Both had recently tested positive for COVID-19, as documented in their medical records. The facility's Infection Preventionist confirmed that the expectation was for staff to perform hand hygiene and wear the required PPE when entering isolation rooms for COVID-19 positive residents, in accordance with facility policy. The Infection Preventionist acknowledged that the facility's policy was not followed in this instance.
Failure to Verify Wanderguard Placement Led to Resident Elopement
Penalty
Summary
Staff failed to ensure adequate supervision and monitoring for a resident with a history of cerebral infarction and type 2 diabetes mellitus by not verifying the placement and functioning of the resident's Wanderguard device every shift, as required by physician order and facility policy. The Wanderguard is a monitoring device intended to alert staff if a resident at risk for elopement attempts to leave a designated area. Medical record reviews and staff interviews confirmed that there was no documentation of the required checks, and staff did not follow the established procedures for the Wanderguard system. As a result of this failure, the resident was able to leave the facility without staff knowledge. The incident was discovered only after the resident contacted his mother from outside the facility, prompting the facility to initiate an elopement code and search for the resident. The resident was eventually returned to the facility by his mother. Multiple staff, including the Sub-acute Director, a licensed nurse, the Administrator, and the Director of Nursing, confirmed that the required checks were not performed or documented, placing the resident at risk for elopement.
Failure to Submit Abuse Investigation Report Within Required Timeframe
Penalty
Summary
The facility failed to submit the required investigation report to the Department within five days following an allegation of abuse involving two residents, both of whom had diagnoses including dementia. Record review showed that an incident of alleged abuse between these two residents was investigated, and a '5 Day Summary' was prepared, but the report was never sent to the Department as required by facility policy. During an interview, the Administrator confirmed that the report should have been submitted but was not. The facility's policy states that a written report of the findings must be provided to the appropriate agencies within five working days of the incident, which was not followed in this case.
Staff Use of Personal Cellphones During Work Hours
Penalty
Summary
Several nursing staff, including CNAs, a licensed nurse, and a restorative nursing assistant, were observed using their personal cellphones during work hours while on the floor, in the dining room, and at the nurses' station. Staff members acknowledged during interviews that cellphone use while working could lead to distractions, delayed response times, and failure to meet residents' needs. Facility policy, as outlined in the employee handbook and a specific policy on telephone use, prohibits the use of personal electronic devices during work hours except during meal and break periods. Despite this, staff admitted to using their phones in violation of these policies. Residents reported witnessing nursing staff using cellphones in hallways and expressed concerns about staff not paying full attention to residents who might need help. The Director of Staff Development and the Director of Nursing both confirmed that staff use of personal cellphones during work hours was against facility policy and not in line with professional expectations. The Director of Nursing further confirmed that this behavior could result in delays in care and place residents' health at risk. The deficiency was identified through direct observation, staff and resident interviews, and review of facility policies.
Failure to Provide Scheduled Showers and Document Refusals for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs), including bathing, was not provided showers as scheduled over a period of several weeks. The resident's care plan indicated a need for extensive to total assistance with ADLs, and the facility's shower schedule specified that the resident should receive showers twice weekly. However, documentation revealed that during the months of January, February, and March, the resident did not receive scheduled showers and, in some weeks, received only one bed bath. There was no documented evidence that showers were offered or refused by the resident during this time. Interviews with staff confirmed that the resident was supposed to be offered showers at least twice a week, and if refused, additional attempts should have been made and refusals reported to the charge nurse. The Director of Nursing verified that showers were not provided on the scheduled dates and that documentation did not reflect whether showers were offered or refused. The documentation codes used did not indicate if the resident had refused showers, and there was no evidence that a shower was offered before a bed bath was given. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene, including bathing, and that refusals be documented with attempts to address the underlying cause. The lack of documentation and failure to provide scheduled showers or record refusals constituted a failure to follow the care plan and facility policy for supporting ADLs and maintaining hygiene for a dependent resident.
Failure to Protect Resident from Repeated Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of domestic abuse from physical abuse by another resident. The resident, who had a BIMS score of 1 indicating severe cognitive impairment and a care plan noting a history of an abusive spousal relationship, was involved in two separate incidents where another resident allegedly hit her. The first incident was reported by a roommate who overheard the altercation and by the resident herself, who stated she was hit on the chin and stomach. The second incident was witnessed by another resident and resulted in visible injury, with the resident crying and calling the police after being struck on the face. Following the first incident, the interdisciplinary team met to discuss the situation, but the care plan created for the victimized resident was incomplete, lacking specific goals and interventions to prevent further abuse. Additionally, the staff member responsible for social services was unaware of the resident's history of abuse until after the first altercation, and the care plan had not been updated to reflect this risk. Documentation and monitoring of the alleged perpetrator were also lacking, as confirmed by the ADON, who noted that there was no evidence of increased supervision or monitoring after the initial incident. Facility policies required staff to identify and respond to potential abuse, including providing adequate supervision when resident-to-resident altercations are suspected and updating care plans accordingly. However, these procedures were not followed, as evidenced by the lack of documented interventions, incomplete care planning, and insufficient monitoring of both the victim and the alleged perpetrator. This failure resulted in repeated abuse and emotional distress for the resident involved.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide the required written notice of discharge to the State Long-Term Care Ombudsman's office for two residents who were being discharged. Both residents received a Notice of Discharge with an effective discharge date, but there was no documentation that a copy of this notice was sent to the Ombudsman as required. Interviews with the Business Office Manager, Director of Nursing, and Administrator confirmed that the Ombudsman was not notified, and the Ombudsman’s office also confirmed they did not receive the required notifications. The facility’s own policy and procedure stated that a copy of the discharge notice must be sent to the Ombudsman at the same time it is provided to the resident and their representative, but this was not followed. Resident 1 had a history of necrotizing fasciitis and a below-knee amputation, while Resident 2 had type 2 diabetes with diabetic neuropathy and cellulitis of the left lower limb. Both residents confirmed receipt of their discharge notices. The failure to notify the Ombudsman removed the opportunity for advocacy on behalf of the residents regarding their discharge decisions.
Failure to Supervise and Monitor Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate supervision and follow physician orders for a resident with a history of suicidal ideation, depression, and psychoactive substance abuse. The resident had recently exhibited self-harm behavior by holding scissors to his neck and expressing suicidal thoughts, which led to a physician order for every 15-minute monitoring and the use of plastic utensils. The care plan and facility policy required close monitoring and documentation of the resident's status to prevent self-harm. Despite these orders and interventions, there was no documentation to show that the required 15-minute checks were performed on the day of the incident. Staff interviews confirmed that the monitoring form for the relevant time period was left blank, and the administrator could not provide evidence that the checks were completed or properly discontinued. Staff members, including CNAs and LNs, were either unaware of the resident's risk or could not confirm how the resident obtained a razor blade, which was used in the self-harm incident. As a result of the lack of supervision and failure to follow the monitoring protocol, the resident was able to obtain a razor blade, inflict multiple deep lacerations on his arms and legs, and required emergency medical intervention and hospitalization. The facility's own policy and job descriptions emphasized the importance of monitoring and documentation for residents at risk of self-harm, but these procedures were not followed, directly leading to the resident's injury.
Failure to Continue Prescribed Insulin for Resident
Penalty
Summary
The facility failed to ensure that care provided to a resident met professional standards when the resident's prescribed medication, insulin lispro, was not continued upon admission to the skilled nursing facility. The resident was admitted with a diagnosis of dementia and had been discharged from the hospital with specific orders to continue insulin lispro in two different mixes. However, upon review, it was found that these orders were not transcribed into the Medication Administration Record (MAR) at the facility, and there was no documentation to support the administration of the insulin. Licensed Nurse 1 confirmed that the insulin orders were missing from the MAR and stated that the admitting nurse should have verified all orders with the medical doctor to ensure they were correctly inputted into the system. The Director of Nursing also confirmed the oversight and acknowledged that the facility did not meet its practice standards by failing to carry over the hospital's orders. The resident's medical doctor stated that the insulin was supposed to be continued as ordered upon discharge from the hospital.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring the call light was within reach. The resident, who was admitted with diagnoses including encephalopathy and hemiplegia, was observed on two separate occasions without access to the call light. On the first occasion, the call light was found on the floor, and on the second occasion, it was hanging on a tube feeding pump pole, both times out of the resident's reach. The resident was observed screaming for help during these instances. Licensed nurses confirmed that the call light was not accessible, acknowledging that the resident would be unable to call for assistance, which could lead to potential falls. The assistant administrator also confirmed that residents should have access to their call lights. The resident's care plan indicated a history of an unwitnessed fall, with interventions to remind the resident to use the call light for assistance. The facility's policy on answering call lights emphasized ensuring the call light is accessible to residents when in bed.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to provide a resident with the scheduled twice-weekly bathing, which was necessary for maintaining personal hygiene and preventing infection. The resident, who was admitted with diagnoses including encephalopathy and hemiplegia, was dependent on facility staff for personal hygiene and bathing. Despite being scheduled for showers on Tuesdays and Fridays, the resident reported not receiving these showers consistently for over two months. Instead, the resident received bed baths only three times out of eight scheduled shower days over a four-week period, leading to discomfort, itching, and rashes. Interviews with multiple CNAs revealed that the resident did not refuse personal care and preferred showers over bed baths. However, due to staffing issues, such as the need for multiple CNAs to assist the resident, showers were not consistently provided. Documentation inconsistencies were also noted, with some CNAs mistakenly recording showers when only bed baths were given. The facility's policies required residents to receive showers or bed baths at least twice a week, but the documentation and interviews confirmed that this standard was not met for the resident in question.
Discontinued Medication Applied by CNA
Penalty
Summary
The facility failed to provide services that meet professional standards of quality when a Certified Nursing Assistant (CNA) applied a discontinued prescription cream on a resident. The incident involved a resident with multiple diagnoses, including encephalopathy and hemiplegia. During an observation and interview, the CNA was seen holding a medication cup with white cream, which he stated was given to him by a Licensed Nurse (LN) to apply on the resident's back, arms, and legs. The LN confirmed she provided the cream, identified as Clotrimazole and Betamethasone, to the CNA. However, a review of the resident's Treatment Administration Record (TAR) and Order Summary Report indicated there was no active order for this cream, as it had been discontinued months earlier. Further investigation revealed that the Treatment Nurse confirmed there was no active order for the cream and stated that licensed nurses, not CNAs, should apply prescription ointments. The Assistant Administrator acknowledged that nurses should verify orders before administering medications and that discontinued medications should be removed from the treatment cart. The facility's policy on administering medications specifies that only licensed personnel should administer medications, and they must verify the right resident, medication, dosage, time, and method before administration. The CNA's job description did not include applying prescription creams, highlighting a deviation from established protocols.
Inadequate Infection Control Practices with Bedpans
Penalty
Summary
The facility failed to implement safe infection prevention and control practices for a resident when three soiled and unlabeled bedpans were found in a shared bathroom. During an observation, two grey and one pink used bedpans were seen in a black storage basket on the floor of the bathroom shared by two residents. A Certified Nursing Assistant (CNA) confirmed that the bedpans were used, soiled, and lacked any resident identifiers. The CNA acknowledged that all soiled bedpans should have been cleaned after use and labeled with a resident identifier, and that staff were responsible for cleaning them. The CNA also recognized the risk of infection spread due to the improper handling of the bedpans. Interviews with the resident and facility staff revealed that the resident had purchased the bedpans because the facility's bedpans were too small, and the CNAs placed them in the bathroom after use. The Assistant Administrator and the Infection Preventionist both stated that the bedpans should have been cleaned and labeled to prevent infection. The facility's policy, revised in February 2018, indicated that bedpans should be cleaned, dried, and not left in the bathroom or on the floor, which was not followed in this instance.
Delayed Medication Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents by not monitoring blood sugars before meals and not administering scheduled medications in a timely manner. Resident 1, who has a history of Type 2 diabetes, atrial fibrillation, hypertension, and heart failure, reported that his medications were administered late, and he had to request his insulin. His Medication Administration Record (MAR) showed that medications scheduled for 9 AM were given almost two hours late, and his insulin was administered over two hours after the scheduled time. This delay in insulin administration could potentially lead to unnecessary insulin doses due to inaccurate blood sugar readings. Resident 2, diagnosed with hypertension, systemic lupus erythematosus, and arthritis, also experienced delays in medication administration. Her MAR indicated that medications scheduled for 9 AM were administered several hours late on two consecutive days. An interview with a Licensed Nurse (LN) revealed that she was unaware of her responsibility to pass medications and was delayed by other duties, resulting in the late administration of medications. Resident 3, who has Type 2 diabetes, had his blood sugar checks and insulin administration delayed due to the nurse's inability to locate him in a timely manner. His MAR showed that blood sugar checks and insulin administration scheduled for 11 AM were performed hours later on multiple occasions. Interviews with the nursing staff and the Medical Director confirmed the importance of timely insulin administration and the expectation that medications be given as ordered. The Director of Nurses acknowledged the lack of documentation explaining the delays and emphasized the potential for unnecessary insulin doses if blood sugar readings were taken after meals.
Failure to Follow Infection Control Protocols for Subacute Resident
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures for a subacute resident who required special medical equipment and treatments. The deficiency was observed when a licensed nurse (LN) was seen suctioning the resident without wearing the required personal protective equipment (PPE), specifically a gown, despite the resident being on Enhanced Standard Precautions (EBP) due to multidrug-resistant organisms (MDROs). The nurse acknowledged the requirement for a gown, mask, and gloves during such procedures but did not comply, increasing the risk of infection transmission. The resident involved had a complex medical history, including sepsis, respiratory failure, ventilator dependence, a tracheostomy, and pneumonia. Laboratory results indicated the presence of MDROs, including carbapenem-resistant Klebsiella pneumoniae and Enterococcus faecalis, which were resistant to multiple antibiotics. The resident's room was marked for isolation under EBP, which mandates the use of specific PPE to prevent the spread of these resistant organisms. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed the expectation for staff to wear appropriate PPE during resident care, especially in the subacute unit where residents are considered vulnerable. The facility's policies on infection prevention and control, as well as enhanced barrier precautions, clearly outline the need for gowns and gloves during high-contact activities, such as tracheostomy care, to prevent MDRO transmission. The failure to comply with these protocols was acknowledged by both the IP and the DON, highlighting a lapse in adherence to established infection control measures.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, and service, which could potentially lead to foodborne illnesses among the 94 residents. Observations revealed a dented can of red sweet bell peppers in the dry storage area, which the Registered Dietician (RD) acknowledged could lead to botulism. Expired food items, including graham cracker crumbs, cheese sandwiches, broth concentrates, and frozen bread rolls, were found in various storage areas. The Certified Dietary Manager (CDM) confirmed these items were expired and attributed the errors to new trainees. Additionally, cereal was left uncovered in dry storage, posing a risk of contamination by critters. The kitchen was noted to have several cleanliness issues, including a can opener with metal wearing off, a meat slicer with food residue, and a dirty floor sink. Nonstick pans were found with flaking coating, and the grill was covered in black grease. The CDM acknowledged the need for replacement of the pans and the potential fire hazard posed by unclean equipment. Furthermore, food items were mislabeled or lacked proper labeling, which could lead to confusion and potential allergic reactions among residents. The CDM and RD both emphasized the importance of proper labeling to prevent foodborne illnesses. Additional deficiencies included a coffee machine with an outdated filter, improper handling of food and beverages by nursing staff, and a lack of adequate utensils during meal service. The CDM was unaware of the utensil shortage, which residents confirmed during a council meeting. The facility also failed to properly cool down custard, and staff were unable to articulate the manual dishwashing process. Hot food was not maintained at safe temperatures during meal preparation, as the facility lacked a functioning steamer. Residents reported difficulty chewing vegetables due to improper cooking methods, further highlighting the facility's failure to adhere to food safety standards.
Deficiencies in Resident Care Due to Inaccessible Call Lights and Side Rails
Penalty
Summary
The facility failed to ensure that the needs and preferences of four residents were reasonably accommodated, leading to deficiencies in care. Resident 11, who had diagnoses including respiratory failure, heart failure, and muscle weakness, was unable to reach her call light due to limited range of motion in her right arm. Despite her care plan indicating that the call light should be within reach, it was placed above her head, making it inaccessible. This oversight was confirmed by both a CNA and a licensed nurse, who acknowledged the risk of unmet needs and safety concerns. Resident 37, with a history of muscle weakness and a stroke, required 1/4 upper side rails to assist with repositioning in bed. However, the side rails were incorrectly positioned, making them inaccessible. This was contrary to the physician's order and the resident's care plan, which emphasized the importance of the side rails for maintaining mobility and independence. The Director of Nursing and other staff confirmed the incorrect positioning and acknowledged the potential impact on the resident's ability to participate in his care. Residents 62 and 16 also experienced issues with call light accessibility. Resident 62, who had metabolic encephalopathy and dementia, was found without a call light within reach, as it was on the floor. This was confirmed by a treatment nurse, who noted the risk of falls and unmet needs. Similarly, Resident 16, with diagnoses including dementia and respiratory failure, was observed calling for help because her call light was tied to the back of her siderail, out of reach. A licensed nurse confirmed the inaccessibility and adjusted the bed to provide access. The facility's policy required call lights to be accessible, but this was not adhered to, leading to potential risks for the residents involved.
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to adhere to professional standards of respiratory care for several residents using oxygen. Resident 47's oxygen tubing was not changed weekly as required, with the last change recorded on 7/8/24, despite the facility's standard practice of weekly changes to prevent infection. This oversight was confirmed by both a licensed nurse and the Director of the Subacute Unit, who acknowledged the increased risk of infection for Resident 47, who was on a ventilator. The respiratory therapist and the Director of Nursing also verified that the facility's standard of practice was not followed, placing Resident 47 at risk. Resident 53's room lacked the necessary signage to indicate oxygen was in use, which is a safety requirement to alert personnel and visitors of the presence of a flammable gas. This absence of signage was confirmed by the Assistant Director of Nursing and the Director of Staff Development, who acknowledged the oversight. The Director of Nursing also confirmed that the expected protocol was not followed, as per the facility's policy on ensuring oxygen safety. Additionally, the facility failed to maintain clean oxygen concentrator filters for Residents 84, 106, and 64. Resident 84's and Resident 106's concentrator filters were found with significant dust and debris, while Resident 64's concentrator lacked a filter entirely, with dust and debris present in the air intake. These conditions were confirmed by a licensed nurse and the Director of Nursing, who recognized the potential for respiratory distress and infection due to these deficiencies.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of two residents, Resident 50 and Resident 67. For Resident 50, the medications Midodrine HCL and Gabapentin were signed off as administered before they were actually given, and they were administered late. The MAR indicated that these medications, scheduled for 1 p.m., were documented as given at 2:33 p.m., but were actually administered at 2:52 p.m. This discrepancy was confirmed by LN 4, who acknowledged the error in documentation and timing. The Director of Nursing (DON) stated that this practice did not align with the facility's expectations and policies, which require medications to be administered within an hour of the scheduled time and documented accurately. For Resident 67, the facility failed to administer Midodrine HCL according to physician orders. The medication was either not given when it should have been or administered when it should not have been, based on the resident's blood pressure readings. The MAR for May, June, and July 2024 showed multiple instances where the medication was not administered despite the blood pressure being within the parameters for administration, and instances where it was administered when the blood pressure exceeded the parameters. The Assistant Director of Nursing (ADON) and the DON confirmed these discrepancies, acknowledging that administering or withholding the medication outside of the physician's parameters could lead to adverse events. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and in accordance with good nursing principles. Personnel are required to familiarize themselves with the medication and compare the medication and dosage schedule on the MAR with the medication label before administration. The failures in administering medications to Residents 50 and 67 indicate a deviation from these established guidelines, potentially compromising the residents' health and safety.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to protect residents from significant medication errors, as evidenced by two separate incidents involving Resident 53 and Resident 114. Resident 53 was administered Methadone, a medication not ordered by the physician, which led to a narcotic overdose. The error was identified during a routine check of the Medication Administration Record (MAR) by a nurse. Despite the resident expressing feelings of drowsiness and hunger, the error was not immediately communicated to the resident. The resident required continuous monitoring and administration of Naloxone to reverse the effects of the overdose. The Director of Nursing (DON) was unaware of the details of the medication error. In the second incident, Resident 114's medications, including controlled substances, were left unattended at the bedside by a licensed nurse (LN 4). The nurse administered insulin to Resident 114 but left a cup containing 13 pills on the bedside table without ensuring the resident ingested them. The Infection Preventionist (IP) confirmed the presence of the medications and highlighted the risk of another resident potentially taking them, which could lead to adverse reactions. The DON emphasized the importance of observing residents after medication administration to ensure safety. The facility's policy on medication administration, dated October 2017, was not adhered to in both cases. The policy requires that medications be administered as prescribed, with the resident being observed to ensure the dose is ingested. The failure to follow these guidelines resulted in significant medication errors, posing potential harm to the residents involved.
Deficiency in Personal Food Storage Policy Implementation
Penalty
Summary
The facility failed to implement its policy regarding personal food storage, which required monitoring of food or beverages brought in from outside sources for safety. The deficiency was identified when it was found that there were no microwaves or refrigeration units available for residents to store or reheat food brought by family and visitors. This lack of equipment potentially limited residents' rights and enjoyment of such food and decreased food safety. The facility's policy, dated April 2017, specified that designated staff should monitor food safety for items stored in facility or personal refrigeration units. Interviews with various staff members revealed that the facility previously had two refrigeration units and two microwaves, but these were removed by the previous administration due to safety concerns. The Certified Dietary Manager noted that one refrigerator stopped working, and the other was removed by administration. The Director of Maintenance confirmed that the removal was due to concerns about residents using the microwave unsupervised, which could lead to injury. As a result, the facility was not in compliance with its own policy, impacting residents' ability to safely store and consume food brought from outside.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure safe infection prevention practices for a census of 118 residents. In one instance, a bedpan in a shared bathroom was found unlabeled and left on the floor, posing a risk of cross-contamination. A Certified Nursing Assistant confirmed the bedpan was not labeled and acknowledged the infection risk. The Director of Nursing stated that the bedpan should have been labeled and not placed on the floor, as this could spread infection among residents. In another instance, a resident's room was observed to be cluttered with boxes, bins, trash bags, and clothes, which posed an infection control risk. The resident had a history of stroke and exhibited hoarding behaviors, refusing to allow staff to clean the room. A Licensed Nurse noted an odd smell in the room and confirmed the presence of food that the resident would not discard. The facility's Administrator acknowledged that the room was a mess and that the facility's infection prevention and control policies were not followed.
Verbal Abuse by CNA Leads to Resident Distress
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved CNA 7 calling Resident 30 derogatory names, which was reported by the resident to social services. The resident, who was admitted earlier in the year with diagnoses including diabetes, anxiety, and depression, reported feeling harassed and unsafe due to the verbal abuse. The Minimum Data Set (MDS) assessment indicated that Resident 30 had an intact memory and the ability to understand and be understood by others. The incident occurred when Resident 30 was waiting for a sandwich due to low blood sugar, and CNA 7, who was on break, responded angrily and threw the sandwich on the table. Later, CNA 7 was overheard by Resident 30 and her roommate, Resident 77, making derogatory comments about them. Both residents confirmed the incident, and Resident 30 was visibly upset during interviews, expressing that she did not feel safe in the facility. The facility's policy prohibits abuse, including verbal abuse, and mandates that all residents be treated with respect and dignity. Interviews with other staff members, including CNA 8, confirmed the derogatory remarks made by CNA 7. The Director of Nursing (DON) emphasized that residents should be free from abuse and feel safe in the facility. The facility's policies on abuse prohibition and resident rights were reviewed, highlighting the requirement for staff to treat residents with kindness and respect.
Failure to Timely Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse policy for a resident who alleged verbal abuse by a staff member. The incident occurred when a resident reported to social services that a Certified Nursing Assistant (CNA) was verbally harassing her. Despite the facility's policy requiring an investigation to be initiated within two hours of an abuse allegation and findings to be reported within five working days, the facility did not initiate a timely investigation or report the results to the Department within the required timeframe. The resident involved was admitted in early 2024 with diagnoses including depression and anxiety. An assessment indicated that the resident had intact cognitive abilities. The facility reported the incident to the Department five days after it occurred, but by the time of an on-site visit 16 days later, the Department had not received an investigative summary. During an interview, the Administrator confirmed the failure to report the investigation results within the required period, as outlined in the facility's Abuse Prohibition Policy and Procedure.
Failure to Provide Dignified Care to Residents
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity, resulting in deficiencies in their care. Resident 71, who had diagnoses including mild protein-calorie malnutrition and major depressive disorder, did not receive dentures in a timely manner. Despite a referral for dentures being made approximately ten months prior, and an approved Treatment Assessment Referral (TAR) for full upper and lower dentures, Resident 71 had not received them. This delay led to feelings of sadness and reluctance to smile due to missing teeth, which was acknowledged by the facility staff as a dignity issue. Additionally, Resident 100, who was admitted with quadriplegia and a fracture of the sixth cervical vertebra, was not assisted with meals in a dignified manner. A CNA was observed standing over Resident 100 while assisting with breakfast, rather than sitting at eye level as expected by the facility's policy. This practice was noted to potentially cause discomfort and a loss of dignity for the resident. The facility's policy emphasized treating residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Maintain a Homelike Environment for a Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 43, by not ensuring that her personal belongings were stored according to her preferences. Resident 43, who was admitted in 2020 with diagnoses including Multiple Sclerosis and a history of repeated falls, was observed to have a cluttered room with personal items such as clothes, snacks, water bottles, and other miscellaneous items scattered on the floor. Despite having an intact cognitive status, as indicated by a BIMS score of 15, Resident 43 expressed that she had requested assistance from the Activity Director to organize her belongings, but was informed by facility staff that they were too busy to help. The cluttered state of Resident 43's room was confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the clutter increased the resident's risk for falls. The Activity Director also confirmed awareness of the need to organize the room and mentioned that it was a team effort to arrange residents' rooms. The Director of Nursing (DON) stated that it was her expectation for residents' rooms to be clutter-free to prevent safety hazards and to provide a homelike environment. The facility's policy on providing a homelike environment emphasized maintaining a clean, sanitary, and orderly environment for residents.
Failure to Complete PASRR Level II Evaluation
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident diagnosed with schizoaffective bipolar disorder and schizophrenia. The resident was admitted in early 2024, and the initial PASRR Level I screening indicated a positive result for a history of schizophrenia and the use of psychotropic medication. However, a letter from a state agency dated several months later revealed that the Level II evaluation could not be completed due to the facility's unresponsiveness to multiple communication attempts within 48 hours of the Level I screening. During an interview and record review, the Social Services Director (SSD) confirmed the facility's failure to respond to the state agency's attempts to initiate the PASRR Level II evaluation. The SSD acknowledged being unaware of how the oversight occurred and admitted that the delay placed the resident at risk of not receiving necessary mental health services. The Director of Nursing (DON) expressed expectations for the resident to be adequately evaluated and supported. The facility's policy mandates that the Admissions Director or Social Worker ensure the completion of PASRR evaluations, with a designated backup in case of unavailability.
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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