Desert Springs Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Desert, California.
- Location
- 74-350 Country Club Drive, Palm Desert, California 92260
- CMS Provider Number
- 555339
- Inspections on file
- 80
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Desert Springs Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure appropriate clinical monitoring and timely response to changes in condition for two residents. One resident with diabetes had an elevated HgbA1C and frequent blood glucose readings over 200 mg/dL with repeated sliding-scale Humalog administration, but there was no evidence of repeat HgbA1C testing or physician notification for possible adjustment of insulin therapy, despite facility diabetes protocols requiring periodic A1C monitoring and evaluation when short-acting insulin is used frequently. Another resident with serious medical conditions had multiple documented episodes of diarrhea over several days, yet there was no documentation that these loose stools were addressed or reported to a physician until the resident later developed N/V/D and abdominal tenderness, at which point diagnostic testing confirmed C. diff infection; the DON acknowledged this delay was inconsistent with the facility’s change-in-condition policy.
Surveyors found that staff did not follow the facility’s infection control policies and CDC guidance for residents on isolation precautions. Multiple staff entered rooms of residents with C. diff wearing incomplete PPE, failed to perform hand hygiene with soap and water after exiting, and sometimes relied only on ABHR. In several cases, staff donned PPE without cleaning their hands first. Isolation signage on room doors did not match MD orders: a resident with metapneumovirus on droplet precautions was labeled for contact/C. diff, a resident with influenza on droplet precautions had only Enhanced Barrier Precautions posted, and a resident with confirmed C. diff had signage that directed use of ABHR instead of soap-and-water handwashing. These actions and inaccurate signs resulted in inconsistent implementation of required transmission-based precautions.
A resident with Type 2 DM and severe cognitive impairment had persistent hyperglycemia, an elevated HgbA1C of 10.5%, and was receiving Lantus and Humalog per sliding scale, with a care plan noting poor glycemic control. During a monthly MRR, the consultant pharmacist recommended clarifying with the physician the need for HgbA1C and Vit D 25 OH labs, but this recommendation was not referred to the physician and there was no documentation that the labs were obtained. The DON confirmed the pharmacist’s recommendation was not communicated, contrary to facility policy requiring MRR findings and physician responses to be documented in the medical record.
Staff failed to follow droplet precaution protocols by not wearing required PPE—including gown, gloves, and face shield—when entering the rooms of two residents with influenza, despite clear signage, care plans, and facility policy requiring full PPE use to prevent the spread of infection.
A facility failed to thoroughly investigate and timely report a resident-to-resident physical altercation, involving residents with complex medical and psychiatric histories. The initial report to the state agency was delayed and lacked required witness interviews, and the correct witness was not identified or interviewed until after the state began its investigation. The facility did not follow its own policy for abuse investigation and reporting.
A resident with dementia and cognitive deficits experienced a critically low hemoglobin level, but staff did not promptly notify the physician or send the resident to the ER as required by protocol. The care plan lacked interventions for low hemoglobin, and there was no documented monitoring after hospital readmission or investigation into the cause of the anemia.
A resident with significant mobility impairments did not receive a timely orthotic consultation and device as recommended by PT. Despite documentation and communication attempts by the rehab department, there was no order or referral for the needed AFO, and key staff were unaware of the recommendation. The lack of timely coordination and communication led to a delay in the resident receiving the necessary support.
The facility did not complete required antibiotic surveillance assessments for multiple residents receiving antibiotics, as documentation was missing for several months. The Infection Preventionist confirmed that monitoring of antibiotic appropriateness and related symptoms was not performed according to policy, affecting residents with infections such as UTIs, sepsis, and pneumonia.
Two residents did not have TB testing completed or documented according to facility policy, as confirmed by interviews with LVNs and the Infection Preventionist. Required TB tests were either not performed within the specified timeframe, not read within 72 hours, or not documented in the eMAR and immunization records, resulting in a deficiency in the infection prevention and control program.
A resident reported that a PTA caused a skin tear during a transfer, and multiple staff members were informed of the allegation. Despite facility policy requiring suspension and investigation of accused staff, the DON did not investigate or report the incident, and the PTA was not suspended. The resident's record did not document the abuse allegation.
A resident reported to staff that a PTA roughly handled her, causing a skin tear. The allegation was communicated among therapy staff and to the DON, but the DON did not report the incident to CDPH as required, citing lack of visible injury. The incident was not documented in the resident's record, and the PTA continued working. Facility policy required such allegations to be reported and investigated.
A resident with impaired skin integrity and on anticoagulants developed a skin tear on the right wrist after blood pressure monitoring. The injury was not documented, monitored, or addressed in the medical record, and no physician's order or care plan update was obtained, contrary to facility policy and the resident's care plan.
Black mold was found in a resident's shower, confirmed by both housekeeping staff and the supervisor, despite facility policy requiring regular cleaning of visibly soiled surfaces. The affected resident had COPD and was cognitively intact at the time of the deficiency.
Nursing staff did not follow required procedures for verifying and documenting narcotic counts, including liquid Ativan, by failing to have the narcotics sheet present during verification and not signing the shift-to-shift count sheet. Interviews revealed that some nurses were unaware of the documentation requirement, and review of records showed multiple unsigned count sheets, despite the facility's policy mandating these steps.
A resident with a history of depression repeatedly requested that bleach not be used in her room due to the strong smell causing her discomfort, but staff continued to use bleach products during cleaning. Although some staff were aware of the preference, there was no formal documentation or signage, leading to a CNA unknowingly using a bleach wipe and causing the resident distress.
A resident with mild cognitive impairment was involved in a financial abuse allegation, where a significant sum of money was given to an acquaintance. The facility failed to notify the police and APS within the required two-hour timeframe, as per their policy. The Social Services Director admitted to not notifying the authorities due to confusion and lack of details, which was confirmed by the administrator.
A facility failed to administer HIV medications to a resident as per physician's orders, leading to a 22-day lapse in medication administration. Staff interviews revealed confusion about the policy requiring residents to supply their own medications, and there was no documentation of physician notification about the medication unavailability. The facility's policies were not followed, resulting in a delay in providing the necessary medications.
A resident did not receive ordered Restorative Nursing Services (RNA) due to refusal and staff unavailability, leading to potential risks of decreased mobility. The RNA responsible did not report the missed treatments, and documentation inaccurately reflected the resident's care. Facility staff were expected to report such issues to supervisors for alternative arrangements.
A resident with a history of falls and moderate cognitive impairment experienced multiple unwitnessed falls despite existing interventions like bed alarms and low bed positioning. The facility failed to evaluate and implement new interventions, such as providing a sitter, which could have prevented further falls. The resident's representative temporarily hired a private sitter, which was effective, but the facility did not assume this responsibility.
A resident reported inappropriate touching by an RNA to a family member, who informed the DON. The DON delayed reporting the incident to the state agency, contrary to the facility's policy requiring immediate reporting within two hours. This delay resulted in a postponed investigation by the CDPH.
The facility failed to properly dispose of garbage, with two dumpsters found overflowing and lids not fully closed, leading to trash on the ground. This was observed with the FSD, who acknowledged the issue, and confirmed by an RD who noted the risk of attracting pests and infection control concerns. The facility's policy requires daily inspection to prevent such issues.
Three residents were found with medications at their bedside without proper assessments for self-administration. One resident had an inhaler in her desk drawer, another had multiple medications on her bedside drawer, and a third had inhalers on her overbed table. The facility failed to conduct necessary assessments, leading to potential misuse and lack of monitoring for adverse effects.
Three residents experienced significant delays in call light responses due to understaffing and inadequate adherence to facility policies. A resident with cerebral infarction and moderate cognitive impairment reported that staff often ignored his call light. Another resident with paraplegia was left in soiled conditions due to insufficient night shift staffing. A third resident, cognitively intact, also faced long wait times, with staff confirming reliance on registry workers. Facility policy mandates a five-minute response time, which was not met.
The facility failed to offer and document the formulation of Advance Directives (ADs) for several residents, and did not maintain copies of existing ADs in medical records. Residents who were cognitively intact or had the capacity to make decisions were not provided with necessary education or resources about ADs, nor was there documentation of such offers. Additionally, a resident with an existing AD did not have a copy in their medical record, and no follow-up was conducted to obtain it.
The facility failed to maintain a homelike environment for five residents due to peeling wallpaper in their rooms. Residents expressed discomfort, and staff confirmed the issue, noting a lack of a system to regularly check room conditions. The Administrator acknowledged the need for maintenance to address the damage, aligning with the facility's policy for a comfortable setting.
The facility failed to submit Quarterly MDS assessments to CMS within the required timeframe for several residents, with delays ranging from 40 to 43 days after the ARD. The MDS coordinator and DON acknowledged the backlog in submissions, which had been ongoing since October 2024, and efforts were being made to address it. Despite these efforts, the facility remained out of compliance with federal regulations.
The facility failed to provide resident-centered activities for three residents, leading to inactivity and disengagement. A former beautician, a bartender, and a teacher were not offered activities aligned with their past interests, despite care plans indicating the need for personalized engagement. The Activity Assistant and Director acknowledged the oversight, which contradicted facility policies.
The facility failed to provide sufficient staffing, leading to delayed assistance with ADLs and call lights not being answered promptly. Residents reported long waits for help, particularly at night, and issues with registry staff unfamiliar with their needs. Staffing records showed DHPPD below state minimums, and staff interviews confirmed heavy workloads and challenges in providing adequate care.
The facility failed to manage pharmacy services properly, leading to two deficiencies. An inspection revealed missing Norco tablets from a Controlled II Emergency Kit without documentation. Additionally, a resident received blood pressure medications despite their SBP being below the holding parameters specified in the physician's orders. The DON confirmed these deviations from the facility's policies.
The facility failed to properly store and label medications, resulting in expired medications being found in various locations, medications without open dates, and a discontinued order stored in active stock. The DON and staff confirmed these deficiencies, acknowledging the need for adherence to medication labeling and storage policies.
The facility failed to ensure safe and effective food service operations, with staff not following recipes for pureed foods, leading to improper textures. Additionally, improper sanitization practices were observed, with staff using water instead of properly concentrated sanitizer and not adhering to recommended sanitization times, risking cross-contamination and bacterial growth.
The facility failed to follow recipes for preparing pureed foods and seasoning broccoli, leading to potential nutritional deficiencies for residents. Observations revealed that pureed bread, chicken, and vegetables were not prepared according to recipes, resulting in improper textures. Additionally, broccoli was served without seasoning, affecting its taste. The facility's policies require standardized recipes to meet residents' nutritional needs, but these were not adhered to during food preparation.
The facility failed to provide appetizing and palatable food at appropriate temperatures, as reported by several residents. Complaints included cold, bland, and unappetizing meals, with some residents stating that their feedback to dietary staff did not lead to improvements. A test tray evaluation confirmed the lack of seasoning in the food, and the Registered Dietitian highlighted the importance of following recipes to ensure nutritional adequacy.
The facility failed to prepare pureed bread according to the prescribed recipe for residents on a pureed diet. A cook was observed using incorrect methods, resulting in a lumpy texture. The Food Service Director and Registered Dietitian confirmed the texture was not smooth, as required by facility policy, potentially affecting residents' intake.
The facility did not offer evening snacks to most residents, affecting their nutritional wellbeing. Residents reported not receiving snacks unless requested, and staff confirmed that snacks were only provided if pre-labeled or specifically requested. The Food Service Director acknowledged the lack of extra snacks, and the Registered Dietitian stressed the importance of offering snacks to all residents to maintain a home-like environment.
The facility was found to have multiple deficiencies in food storage and sanitation practices, including storing thawed meat past use-by dates, improper placement of a coffee cart near a trash bin, and the presence of moldy produce. Additionally, worn-out cutting boards, dust accumulation, and food residue on equipment were observed, posing potential health risks to residents.
The facility failed to provide a sanitary and comfortable environment for two residents. One resident did not receive appropriate window coverings to block sunlight, leading to discomfort. Another resident's bathroom had black stained patches on the floor, which were caused by a cleaning solution and deemed unacceptable by the resident. Both the Maintenance Supervisor and Administrator acknowledged the need for improvements.
A resident's dignity was compromised when their urinary bag was left uncovered, as observed by an LVN. The DON confirmed that the bag should have been covered, aligning with the facility's policy on dignity. The resident, with a urinary tract infection, had an order for the catheter to be in a privacy bag at all times.
The facility failed to provide necessary care for two residents. A resident with a blister on the heel did not receive timely treatment, and another resident did not receive prescribed medications due to a power failure affecting the electronic system. The facility's procedures for medication administration and wound care were not followed, leading to these deficiencies.
A resident with impaired vision due to cataracts did not receive a scheduled eye appointment, despite expressing the need for new eyeglasses. The resident's care plan and order summary indicated the necessity for an eye-health consult, but the facility failed to list the resident for an eye checkup when the doctor visited. This oversight was contrary to the facility's policy on assisting visually impaired residents.
A resident experienced severe weight loss due to the facility's failure to provide adequate nutrition and monitor interventions. The resident, with a vegetarian diet preference, was not consistently given appropriate food items, and their protein shake supplement was not monitored or offered as recommended. The facility did not address the resident's refusal to be weighed or implement additional interventions for poor food intake, leading to a 25% weight loss over 11 months.
A resident with multiple fractures did not receive prescribed Norco for severe pain due to computer issues and lack of a paper MAR. LVN 7, unfamiliar with the facility's protocol during system outages, administered Tylenol instead. The DON confirmed the resident did not receive Norco from admission until the next morning, resulting in inadequate pain relief.
A facility failed to ensure timely action on a consultant pharmacist's recommendation for a resident on furosemide, a diuretic. The resident's medical records lacked recent BMP tests to monitor electrolytes and kidney function, despite the pharmacist's request. The facility's policies did not specify time frames for physician action, and no follow-up was documented, leading to inadequate monitoring and potential health risks.
A resident was inappropriately prescribed quetiapine (Seroquel) for psychosis without a valid diagnosis or psychiatric evaluation. The medication, initially used for sleep during a hospital stay, was continued at the facility with a new indication of psychosis. Facility staff, including the DON and physicians, acknowledged the lack of a valid diagnosis, and the Consultant Pharmacist did not recommend the continuation of the medication. Facility policies on psychotropic medication use were not followed.
A facility was found to have a 7.14% medication error rate due to two incidents involving incorrect administration of Lidocaine patches. One resident received a 4% patch instead of the prescribed 5% due to an unclear order, while another resident had the patch applied to the wrong side of the back due to an unupdated order. The errors were acknowledged by the DON.
A resident with missing teeth was not referred to a dentist despite a standing order for dental consultation and treatment. The resident expressed difficulty in speaking and chewing, and staff interviews confirmed that the dental issues were not addressed, contrary to facility policy requiring dental assessments and assistance with appointments.
The facility failed to ensure the Food Service Director met the required educational qualifications, as he was still in the process of obtaining his Certified Dietary Manager certification. The facility lacked a qualified dietetic services supervisor, and the Registered Dietitian's role did not include day-to-day operational supervision. This non-compliance with Federal and State regulations resulted in a deficiency.
A resident did not receive their preferred beverages and appropriate protein substitutions, leading to nutritional deficiencies. The facility failed to follow dietary preferences and ensure nutritional adequacy, as confirmed by staff interviews and policy reviews.
The facility failed to ensure infection control practices when CNAs did not wear PPE while caring for a resident under Enhanced Barrier Precautions (EBP) due to wounds. Despite being aware of the EBP requirement, the CNAs admitted to forgetting to use PPE, which is crucial to prevent the spread of multi-drug resistant organisms (MDROs). The facility's policy requires gowns and gloves for residents with wounds, and staff were informed of EBP protocols through various means.
Two residents in the facility had bed controls with exposed and damaged wiring, compromising their safety. One resident reported the issue long ago, but it was never repaired, causing her anxiety. The Maintenance Supervisor and Assistant acknowledged the damage and the need for repair, which was not done, violating the facility's maintenance policy.
Failure to Monitor Diabetes Control and Timely Address Recurrent Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and the residents’ clinical needs for two residents. For one resident with type 2 diabetes mellitus and severe cognitive impairment, the record showed an elevated HgbA1C of 10.5% from a lab drawn in mid-February 2025, with a care plan problem of hyperglycemia and poor glycemic control. Physician orders included Lantus at bedtime and Humalog per sliding scale before meals and at bedtime. The MAR from early January through early February 2026 showed multiple blood glucose readings above 200 mg/dL with Humalog administered per sliding scale on multiple occasions. However, there was no evidence that the resident’s blood sugar control was evaluated through repeat HgbA1C testing after February 2025, nor that the frequent elevated blood sugars and repeated use of short-acting insulin were reported to the physician for possible adjustment of diabetic medications. During interview and concurrent record review, the DON confirmed that the last HgbA1C for this resident was in February 2025 and that the resident did not have a standing order for routine HgbA1C monitoring, despite the facility’s diabetes clinical protocol stating that A1C should be monitored on admission (if no recent result is available) and every six months thereafter for residents receiving insulin who are well controlled, with frequency adjusted based on glucose control. The protocol also stated that if short-acting insulin must be administered frequently, the provider should consider initiating or adjusting intermediate- or long-acting insulin, and that providers will order desired glucose targets, monitoring regimens, and parameters for reporting information related to blood sugar management. The DON stated that the resident’s blood sugar should have been evaluated and referred to the physician if there was a need to adjust diabetic medications, but this was not done. For another resident admitted with diagnoses including metabolic encephalopathy and sepsis, bowel continence documentation from mid- to late January 2026 showed multiple episodes of diarrhea recorded on numerous days and at various times. Despite these repeated episodes of loose stools beginning on January 17, 2026, there was no documented evidence that the episodes were addressed or that the physician was notified until a progress note on January 26, 2026, when the resident was documented as having nausea, vomiting, and diarrhea, multiple episodes of vomiting and diarrhea, fatigue, and mild abdominal tenderness. At that time, the physician ordered contact isolation and stool sample collection to rule out norovirus and C. difficile, and subsequent lab results on January 28, 2026, were positive for C. diff toxin. In interview, the DON acknowledged that the resident’s multiple episodes of loose stools starting January 17, 2026, were not addressed or referred to the physician within 72 hours, contrary to the facility’s “Change in a Resident’s Condition or Status” policy, which requires prompt notification of the physician for significant changes in a resident’s condition that will not normally resolve without intervention.
Failure to Implement Correct Isolation Precautions and Hand Hygiene for C. diff and Respiratory Infections
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies and CDC guidance for residents on isolation precautions for C. diff and respiratory infections. During an unannounced visit related to gastrointestinal and respiratory outbreaks, surveyors observed that staff did not consistently use appropriate PPE or perform required hand hygiene when entering and exiting rooms of residents on contact enteric precautions for C. diff. For one resident with C. diff, the Administrator and Social Services Director entered the room wearing only surgical masks, without donning the required gown and gloves indicated on the contact enteric signage posted at the door. Both staff members left the room without washing their hands, despite the sign instructing everyone to wash or gel hands when entering and wash on leaving the room. For another resident with C. diff, a staff member serving meals and coffee donned a mask, gown, and gloves before entering the room but removed the PPE and used only alcohol-based hand rub (ABHR) after exiting, without washing hands with soap and water as required by the facility’s C. diff and norovirus policies. The staff member also did not perform hand hygiene before donning PPE on re-entry. The Infection Preventionist confirmed that residents with C. diff are placed on contact enteric precautions and that staff should wear gown and gloves before entering and wash their hands after leaving the room, and that handwashing with soap and water is superior to ABHR for removal of C. diff spores. A physical therapist entering the room of a resident with C. diff wore appropriate PPE but, after removing it and exiting, used only ABHR and did not wash hands with soap and water before proceeding to another area. Additional deficiencies were identified in the accuracy of isolation signage for residents on transmission-based precautions. One resident with a diagnosis of human metapneumovirus had a physician’s order for strict single-room isolation with droplet precautions, but the door signage incorrectly indicated contact precautions for C. diff. Another resident with a positive C. diff laboratory result and an order for contact precautions had a sign that indicated contact precautions for C. diff/norovirus but instructed staff to use ABHR before entering and when leaving the room, rather than specifying handwashing with soap and water after leaving as required for contact enteric precautions. A further resident with a physician’s order for isolation with droplet precautions due to influenza had a door sign indicating Enhanced Barrier Precautions instead of droplet precautions. The Director of Nursing and Infection Preventionist acknowledged that the signage for these residents did not reflect the ordered type of isolation precautions. A certified nursing assistant assigned to the resident with metapneumovirus reported redirecting the resident from the hallway back into the room while wearing only an N95 mask and no gown or gloves, then donning PPE inside the room without performing hand hygiene beforehand. The CNA stated the resident was on contact precautions for C. diff based on the posted sign, even though the physician’s order and the Infection Preventionist’s review confirmed the resident was actually on droplet precautions for metapneumovirus. Review of facility policies on isolation, C. diff, norovirus, and influenza showed that the facility required appropriate signage at room entrances specifying the type of CDC precautions and PPE instructions, and required soap-and-water handwashing after care of residents with C. diff or norovirus. The observed practices and incorrect signage did not conform to these written policies and CDC guidance. These failures had the potential for the spread of communicable disease among residents, staff, and visitors.
Failure to Communicate Pharmacist Lab Recommendations to Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a consultant pharmacist’s medication regimen review (MRR) recommendation was communicated to the physician for one resident. During an unannounced visit, surveyors reviewed the record of Resident A, who had diabetes mellitus and severe cognitive impairment with a BIMS score of 3. Resident A’s orders included Lantus 25 units at bedtime and Humalog insulin before meals and at bedtime per sliding scale, with a prior HgbA1C order and result of 10.5%. The Medication Administration Record from early January through early February showed blood glucose levels above 200 mg/dl with Humalog administered per sliding scale. The resident’s care plan documented hyperglycemia and poor glycemic control related to Type 2 diabetes mellitus, evidenced by the elevated HgbA1C and use of sliding scale insulin, with instructions to reassess nutritional status and glycemic control routinely. A review of the consultant pharmacist’s MRR dated December 22, 2025, showed a recommendation to clarify with the physician the need for HgbA1C and Vitamin D 25 OH lab tests. Further review of the resident’s record revealed no documented evidence that this recommendation was implemented or referred to the physician after it was made. In an interview, the DON confirmed that the pharmacy consultant’s recommendation for lab tests for this resident was not communicated to the physician and acknowledged that it should have been discussed. The facility’s Medication Regimen Review policy stated that the consultant pharmacist is to review each resident’s medication regimen monthly, identify and report medication-related problems and irregularities, and provide written reports to attending physicians, the DON, and the Medical Director, with copies and physician responses maintained in the permanent medical record. This process was not followed for Resident A’s recommended lab monitoring.
Failure to Follow Droplet Precaution PPE Protocols for Residents with Influenza
Penalty
Summary
Facility staff failed to implement infection control precautions in accordance with established policies and procedures for two residents who required droplet precautions due to influenza. Certified Nurse Assistants (CNAs) were observed at the bedsides of both residents wearing only face masks, without donning the required gown, gloves, and face shield, despite clear signage and available personal protective equipment (PPE) outside the rooms. Both CNAs acknowledged during interviews that they were aware of the requirement to wear full PPE when entering rooms under droplet precautions, and admitted they should have been wearing all required PPE while interacting with the residents. Resident 4 had a diagnosis of immunodeficiency and influenza, with care plans and physician orders specifying the need for contact and droplet isolation precautions. Signage outside the resident's room detailed the sequence for donning PPE, including gown, mask or respirator, goggles or face shield, and gloves. Despite these instructions, CNA 1 was observed at the bedside wearing only a face mask. The Infection Preventionist (IP) confirmed that all staff, visitors, and contractors were required to wear full PPE when entering rooms with droplet precautions, regardless of the nature of the interaction. Similarly, Resident 3, who had bronchitis and was also on contact and droplet precautions due to influenza, was observed in her room when CNA 2 entered wearing only a face mask. Resident 3 reported that staff did not always wear a gown and face shield when providing care. The care plan and physician orders for Resident 3 also specified the need for isolation precautions and in-room care. The IP reiterated that full PPE was required for anyone entering the room, as indicated by the posted signage and facility policy. Facility policies reviewed confirmed the necessity of transmission-based precautions, including the use of gloves, gown, and goggles or face shield when there is a risk of exposure to respiratory secretions.
Failure to Timely Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse between two residents and did not report the results of the investigation to the state survey agency within the required five-day timeframe, as outlined in the facility's policy. The incident involved two residents, who were married but roomed separately, and escalated from a verbal argument to a physical altercation over a television. Both residents reported being struck by the other, and law enforcement was notified, resulting in one resident being detained and escorted out of the facility by sheriffs. Medical records and progress notes indicated that both residents had significant medical and psychiatric histories, including schizoaffective disorder, psychosis, bipolar disorder, cerebral infarction, and COPD. Documentation showed that the altercation was reported to the DON and law enforcement, and that the residents were separated following the incident. However, the facility's initial five-day report was submitted 15 days after the incident and lacked witness interviews, contrary to policy requirements. Subsequent investigation revealed that the wrong resident was initially identified as a witness, and the actual witness was not interviewed until after the state agency began its investigation. The DON was unaware of the revised report and the correct witness information prior to its submission to the state. The facility's policy required timely and thorough investigation, including interviews with all witnesses and documentation of findings, which was not followed in this case.
Failure to Provide Timely Care and Care Planning for Critically Low Hemoglobin
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with critically low hemoglobin levels. The resident, who had diagnoses including dementia and cognitive communication deficit, was admitted with low hemoglobin and had physician orders for biweekly CBC labs. On October 6, a lab result showed a critically low hemoglobin of 6.8 g/dl, which was reported to the facility multiple times by the laboratory, but staff were not reached until later. The licensed nurse documented notifying the physician the following afternoon and was awaiting a response, but there was no documentation that the physician addressed the critical result or that the resident was sent to the emergency room as per facility protocol for hemoglobin levels below 7 g/dl. Additionally, after the resident was readmitted from the hospital following a blood transfusion, there was no evidence of the required 72-hour monitoring. The resident's care plan did not include interventions for low hemoglobin at any point since admission, and there was no documented review to determine the cause of the low hemoglobin for further physician orders. The facility's policy required prompt physician notification and care plan revision for significant changes in condition, but these steps were not documented or implemented for this resident.
Delay in Ordering Orthotic Consultation and Device
Penalty
Summary
The facility failed to ensure that an orthotic consultation, as recommended by physical therapy, was ordered in a timely manner for a resident with significant mobility impairments. The resident, who had diagnoses including paraplegia, hemiplegia, and hemiparesis, was identified as being at risk for decline in activities of daily living and mobility. Physical therapy documented the need for an orthotist consult for a left ankle-foot orthosis (AFO) and communicated this need to the interdisciplinary team. However, there was no corresponding order for the orthotic device or referral for consultation found in the resident's medical record. Interviews revealed that the social services director was unaware of the recommendation and had not received communication from rehabilitation regarding the need for the brace. Further review indicated that the process for obtaining orthotic devices involved assessment and recommendation by the rehab department, followed by communication to social services and nursing to obtain an order and schedule an appointment with the vendor. Despite the physical therapist's and director of rehabilitation's efforts to communicate the need for an AFO, including emails to the social services assistant and the DON, no action was taken for nearly a month. The DON acknowledged that this delay was excessive and that there was no policy in place for orthotic consults. This lack of timely coordination and communication resulted in a delay in the resident receiving the necessary orthotic device.
Failure to Conduct Effective Antibiotic Surveillance Program
Penalty
Summary
The facility failed to ensure an effective antibiotic surveillance program was conducted for 11 out of 12 residents who were prescribed antibiotics, as required by the facility's policy and procedure. During an unannounced visit, the Infection Preventionist (IP) reported that antibiotic use was monitored by printing a daily list of residents on antibiotics and following up with licensed nurses to confirm administration and check for adverse effects. However, upon review of documentation, it was found that antibiotic surveillance assessments, which should include a review of the resident's symptoms and appropriateness of antibiotic use, were not completed for residents on antibiotics from August 2024 to January 2025. The IP was unable to provide surveillance documentation for this period, confirming that the required monitoring was not performed. The facility's policy outlined that surveillance tools, culture reports, sensitivity data, and antibiotic usage reviews should be included in infection prevention and control activities. Despite this, the lack of documented surveillance meant that the appropriateness of antibiotic use for residents with various infections, including UTIs, sepsis, pneumonia, and infections at other sites, was not evaluated according to policy. This lapse was acknowledged by the IP, who stated that the absence of infection surveillance and antibiotic stewardship placed residents at risk for improper antibiotic use and ineffective infection control.
Failure to Complete and Document TB Testing per Facility Policy
Penalty
Summary
The facility failed to ensure tuberculosis (TB) testing was completed according to its own policy and procedure for two of three residents reviewed. Interviews with multiple licensed vocational nurses (LVNs) revealed that TB tests were required to be completed within 24 hours of admission and documented in the electronic Medication Administration Record (eMAR). However, record reviews showed that for one resident, there was no documentation that a TB test was completed within 24 hours of admission, and for another resident, there was no documentation that the first step of the TB test was conducted. Additionally, for the second resident, although the first step TB test was administered, there was no documentation that the test was read within the required 72-hour window, nor was there documentation that the second step TB test was completed. The Infection Preventionist confirmed that newly admitted residents should receive TB testing within 24 hours, with results read within 72 hours, and that documentation should be consistent across the immunization record and eMAR. Review of the facility's policy indicated that a two-step Mantoux Tuberculin Skin Test (TST) should be performed and documented for residents not previously admitted. The lack of documentation and failure to follow the established TB testing protocol for these residents constituted a deficiency in the facility's infection prevention and control program.
Failure to Investigate and Suspend Staff After Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure regarding the investigation of an abuse allegation for one resident. A resident reported that a Physical Therapy Assistant (PTA) had roughly squeezed her while assisting her into a wheelchair, resulting in a skin tear on her right arm. The resident, who was cognitively intact according to her most recent assessment, informed the Director of Rehabilitation (DOR) and requested a different PTA. The Occupational Therapist (OT) and Physical Therapist (PT) were also made aware of the allegation, and the OT reported it to the DOR. The DOR was believed to have reported the incident to the Director of Nursing (DON). Despite the facility's policy requiring all abuse allegations to be thoroughly investigated and for the accused employee to be suspended pending investigation, the DON did not conduct an investigation or report the allegation because she did not observe a bruise on the resident. The PTA was not suspended and continued to have resident contact. The resident's medical record did not contain documentation of the abuse allegation. The facility's policy, revised in September 2022, specifies that any employee accused of abuse is to be placed on leave with no resident contact until the investigation is complete, and that a follow-up investigation report is to be provided within five business days.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required timeframe after a resident reported being roughly handled by a Physical Therapy Assistant (PTA), resulting in a skin tear. The resident, who was cognitively intact with a BIMS score of 15 and had a history of gait and mobility abnormalities, stated that the Director of Rehabilitation (DOR) was made aware of the incident when she requested a different PTA. The Occupational Therapist (OT) reported the allegation to the Physical Therapist (PT) and then to the DOR, believing the DOR would inform the Director of Nursing (DON). The PTA was aware of the allegation but was not suspended from duties following the report. The DON confirmed that she and the DOR checked on the resident after learning of the allegation but did not report the incident to CDPH, citing the absence of visible bruising as the reason. The resident's records did not document the abuse allegation, and facility policy required all reports of abuse to be reported to appropriate agencies and thoroughly investigated. The failure to report the allegation as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Provide Timely Care and Treatment for Skin Tear
Penalty
Summary
A resident with a history of impaired skin integrity, including a tendency to bruise easily and use of anticoagulant medication, sustained a skin tear on the right wrist after a blood pressure cuff was applied. The resident was observed with a wound dressing on the wrist and reported the injury during an interview. Review of the resident's care plan indicated that staff were to check skin during daily care and notify the physician of abnormal findings. However, there was no documented evidence that the skin tear was identified, monitored, or addressed for care and treatment in the resident's medical record. Further review and interviews with facility staff, including an LVN and the DON, confirmed that there were no change in condition notes, physician's orders, or care plan updates related to the skin tear. The facility's wound care policy required a physician's order for wound care procedures, but this was not obtained. The lack of documentation and physician notification resulted in the skin tear not being properly assessed or treated according to facility policy and the resident's care plan.
Black Mold Observed in Resident Shower
Penalty
Summary
A deficiency was identified when black mold was observed in the shower area of one resident's bathroom. The resident reported the presence of black mold, and both the housekeeper and housekeeping supervisor confirmed the observation during interviews and inspections. The housekeeping supervisor acknowledged that the substance appeared to be black mold and stated it should not be present in the resident's shower or anywhere in the facility. The administrator also confirmed that black mold should not be present in the facility. The facility's policy on cleaning and disinfection requires that housekeeping surfaces be cleaned regularly, when spills occur, and when surfaces are visibly soiled. The affected resident had a diagnosis of chronic obstructive pulmonary disease (COPD) and was cognitively intact, as indicated by a BIMS score of 14. The presence of black mold in the resident's shower indicated a failure to maintain a sanitary environment as required by facility policy, particularly for a resident with a chronic lung disease. The deficiency was based on direct observation, staff interviews, and review of the resident's medical record and facility policies.
Failure to Follow Narcotic Count and Documentation Procedures
Penalty
Summary
The facility failed to follow its policy and procedure for accounting for narcotic controlled substances, specifically regarding the verification and documentation of liquid Ativan for a resident with an anxiety disorder. During an end-of-shift narcotic count, two LPNs did not have the narcotic count sheet present while verifying the amount of liquid Ativan stored in the medication room refrigerator. Instead, one nurse relied on memory and prior knowledge of the count, and both nurses acknowledged that the narcotics book should have been with them to accurately verify the medication, resident, and remaining amount. The Director of Nursing confirmed that the expectation was for nurses to have the narcotics sheets present during the count to ensure accuracy. Additionally, a review of the facility's Narcotic and Controlled Substance Shift-to-Shift Count Sheet for a specific month revealed multiple instances where either the off-going or on-coming nurse did not sign the sheet after completing the shift-to-shift narcotic count. Interviews with registry nurses indicated that they were unaware of the requirement to sign the count sheet, and in some cases, the sheet was not available for signature. Both nurses confirmed that the medication count was performed, but the required documentation was not completed. The facility's policy requires that controlled substances be counted at the end of each shift by both the off-going and on-coming nurses, with both individuals signing the designated record. The policy also states that any discrepancies should be reported to the Director of Nursing. The observed failures included not having the narcotics sheet present during the count and not signing the shift-to-shift count sheet, which were confirmed by staff interviews and record review.
Failure to Honor Resident's Preference Regarding Use of Bleach in Room
Penalty
Summary
The facility failed to honor a resident's expressed preference to not use bleach or bleach-containing products when cleaning her room. Despite the resident's repeated requests over several months to avoid bleach due to its strong smell and the fact that it caused her to cough, staff continued to use bleach products in her room. Housekeeping and environmental services staff were aware of the resident's request and had communicated it to their supervisors, but the information was not consistently relayed to all staff members responsible for cleaning the resident's room. On one occasion, a CNA, unaware of the resident's preference, used a bleach wipe to clean the resident's bedside table, which caused the resident to become upset due to the strong smell. The CNA attempted to mitigate the situation by wiping the area with a wet towel, but the resident remained distressed. Interviews with other staff, including the LVN and DON, revealed that while some staff were aware of the resident's request, there was no formal documentation in the resident's medical record, no physician's order, and no signage in the room to alert all staff to the resident's preference. The resident's medical record indicated a diagnosis of depression and modified independence in decision-making. The lack of consistent communication and documentation regarding the resident's preference led to repeated use of bleach products in her room, resulting in her preference not being honored and causing her distress.
Failure to Report Financial Abuse Allegation
Penalty
Summary
The facility failed to notify the police and Adult Protective Services (APS) of an allegation of financial abuse involving a resident, as required by their policy and procedure. The incident involved a resident with mild cognitive impairment, who was reportedly involved in a financial transaction where a significant sum of money was given to an acquaintance. The Social Services Director (SSD) was informed of the situation but did not notify the police or APS within the required two-hour timeframe, citing a lack of details and confusion about jurisdictional responsibilities. The facility's policy mandates immediate reporting of suspected abuse to the administrator and relevant authorities, including APS and law enforcement, within two hours. However, the SSD failed to document the notifications on the SOC 341 form, and during interviews, admitted to not notifying the police and APS due to confusion and lack of awareness. The administrator confirmed that all suspicions of abuse should be reported to all relevant agencies within the specified timeframe, which was not adhered to in this case.
Failure to Administer HIV Medications as Ordered
Penalty
Summary
The facility failed to administer HIV medications to Resident 2 according to the physician's orders, which were crucial for managing the resident's HIV condition. Resident 2 was admitted with a diagnosis of HIV and had physician's orders for Dolutegravir Sodium and Rilpivirine Hydrochloric acid to be administered daily. However, the Medication Administration Record indicated that these medications were not given from January 8 to 29, 2025, despite the care plan specifying that HIV medications should be administered as ordered. Interviews with facility staff revealed a lack of clarity and adherence to the facility's policy regarding the provision of HIV medications. LVN 1 and LVN 2 indicated that it was the facility's policy for newly admitted residents to supply their own HIV medications due to their high cost. RN 1 explained that if residents could not provide their medications, the facility's Social Service or Case Manager should be notified to seek assistance from local organizations, and if medications were not obtained promptly, the facility's pharmacy should supply them. However, there was no documentation of physician notification about the unavailability of the medications, and the facility did not provide the medications until January 30, 2025. The Administrator acknowledged that the facility did not provide the HIV medications in a timely manner and expressed disappointment in the delay. The facility's policies required contacting the prescriber if medication delivery was delayed and ensuring documentation and communication with the pharmacy. Despite these policies, the facility failed to ensure Resident 2 received the necessary HIV medications, potentially compromising the resident's health by increasing the risk of a higher viral load and opportunistic infections.
Failure to Provide Restorative Nursing Services as Ordered
Penalty
Summary
The facility failed to provide Restorative Nursing Services (RNA) as ordered by the physician for a resident, identified as Resident 2, which could potentially lead to muscle contractures and decreased range of motion (ROM) and mobility. The deficiency was identified during an unannounced visit to investigate a complaint regarding quality of care. RNA 1, responsible for providing RNA treatments, confirmed that treatments were not administered to Resident 2 during the week of February 2 through 8, 2025, due to the resident's refusal on one day and RNA 1 being unavailable on the other scheduled days. Resident 2, who was admitted with diagnoses including abnormalities of gait and muscle weakness, had a care plan that required RNA treatments three times a week. However, RNA 1 did not report the missed treatments to a supervisor, which was against the facility's expectations. The RNA Weekly Summary inaccurately documented that Resident 2 was seen three times, which RNA 1 clarified as a misunderstanding, thinking it referred to visual checks rather than actual treatment sessions. Interviews with the facility's staff, including the Registered Nurse (RN) and the Administrator, revealed that there was an expectation for RNA staff to report any inability to provide treatments so that alternative arrangements could be made. The facility's policy emphasized the importance of individualized and resident-centered restorative goals, but the lack of proper documentation and communication led to a failure in executing the care plan for Resident 2.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure the effectiveness of interventions to address multiple falls for a resident, leading to repeated unwitnessed falls. The resident, who was under hospice care with a history of falls and moderate cognitive impairment, experienced several falls in January 2025. Despite having interventions such as a bed alarm, low bed position, and padded floor mats, the resident continued to fall, indicating that these measures were ineffective. The Director of Nursing (DON) acknowledged that the interventions in place were not preventing the falls and that additional measures, such as a sitter, were not evaluated or implemented. The resident's care plan included interventions like keeping the call light within reach and using a bed alarm, but these were not sufficient given the resident's confusion and non-compliance with using the call light. The facility's policy required re-evaluation and implementation of new interventions if falls continued, but this was not adequately done. The report highlights that the facility did not provide a sitter, which was identified as a potentially effective intervention. The resident's representative had temporarily hired a private sitter, which prevented falls during that period, but the facility did not take over this responsibility. The DON admitted that the facility should have provided a sitter to ensure the resident's safety, as the existing interventions were not effective in preventing further falls.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a Restorative Nursing Assistant (RNA) and a resident to the California Department of Health (CDPH) within the required timeframe. The incident involved a resident who reported that the RNA had inappropriately touched him. The resident, who had a history of cerebral infarction, chronic kidney disease, depressive disorder, anxiety disorder, type 2 diabetes mellitus, legal blindness, and congestive heart failure, informed his family member about the incident. The family member then reported the allegation to the Director of Nursing (DON) on December 3, 2024. Despite being informed of the allegation, the DON did not initiate an investigation or report the incident to the state agency until December 7, 2024, which was four days after the initial report. This delay was contrary to the facility's policy, which requires allegations of abuse to be reported immediately, defined as within two hours. The failure to report the incident promptly resulted in a delayed investigation by the CDPH and had the potential to expose the resident to further abuse.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. On January 6, 2025, at 4:50 p.m., two of five dumpsters at the loading dock were found overflowing with boxes, with lids not fully closed, and trash scattered on the ground beneath them. This observation was made in the presence of the Food Service Director (FSD), who acknowledged that the lids should be properly closed and trash should not be on the ground to prevent attracting pests and rodents. Further, on January 9, 2025, during an interview with a Registered Dietitian (RD), it was confirmed that improperly closed dumpster lids could attract pests and flies, posing a risk of them entering the kitchen when the door is open, thus creating an infection control issue. The facility's policy, dated 2023, mandates daily inspection of garbage and trashcans to ensure no debris is on the ground and lids are closed, emphasizing the need to keep the area clean to prevent it from becoming a feeding ground for vermin and rodents.
Failure to Assess Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure proper assessment for safe self-administration of medication for three residents, leading to medications being improperly stored and potentially misused. Resident 101 was found with an opened Ventolin HFA inhaler in her desk drawer, despite having fluctuating capacity to understand and make decisions. The resident's family members were aware of the inhaler and would remind nurses to administer it, as Resident 101 could not effectively self-administer. The facility's records indicated that Resident 101 did not want to self-administer medications, and no further assessments were conducted, yet the medication was documented as unsupervised self-administration. Resident 265 had three opened medications on her bedside drawer, including Trelegy Ellipta, Combivent Respimat, and MAX STRENGTH Aspercreme. The resident stated she self-administered the medications, particularly Trelegy, when experiencing shortness of breath. However, there were no physician orders for Combivent and Aspercreme, and the facility's records showed that Resident 265 did not want to self-administer medications at the time of assessment, with no further assessments conducted. Resident 19 was found with two opened respiratory inhalers, Symbicort Aerosol and Combivent Respimat, on her overbed table. The resident self-administered the medications for shortness of breath without informing the nurses each time. The facility's policy required an assessment for self-administration, which was not conducted for Resident 19. The DON acknowledged that the facility's policy and procedure regarding self-administration assessment and medication administration were not followed, posing a risk of residents not receiving medications according to physician orders and not being monitored for adverse effects.
Delayed Call Light Response Leads to Care Deficiency
Penalty
Summary
The facility failed to ensure that call lights were answered within a reasonable time for three residents, leading to delays in care. Resident 95 expressed frustration over the call light system, stating that staff would either not respond or turn off the light without addressing his needs. This issue had persisted for over two months. Resident 95, who has a history of cerebral infarction and muscle weakness, was found to have moderate cognitive impairment. A Certified Nursing Assistant (CNA) confirmed the resident's complaints and noted that some staff members were not conducting hourly rounds as required. Resident 5, who suffers from paraplegia and polyneuropathy, reported that during the night shift, the facility was understaffed, with only two CNAs for the entire unit. She stated that her call light often went unanswered for hours, resulting in her lying in her own waste for extended periods. Her care plan indicated a need for assistance with activities of daily living due to her condition. The resident also noted that the issue was exacerbated when registry agency staff were on duty. Resident 464, who is cognitively intact and self-responsible, also experienced long wait times for call light responses, citing facility understaffing as a contributing factor. Interviews with staff, including a CNA and an LVN, revealed that the facility had been relying heavily on registry staff during night shifts, leading to delays in care. The facility's policy requires call lights to be answered within five minutes, but this standard was not being met, as confirmed by the Director of Nursing.
Failure to Offer and Document Advance Directives
Penalty
Summary
The facility failed to uphold residents' rights by not offering the formulation of an Advance Directive (AD) to several residents or their representatives. Specifically, seven out of thirteen residents reviewed did not receive education or resources about ADs, nor was there documentation of such offers in their medical records. For instance, Resident 514, who was cognitively intact, did not have an AD, and there was no evidence that the Social Service Assistant (SSA) provided the necessary information or documented any efforts to do so. Similarly, Resident 116, who had the capacity to make decisions, also lacked documentation of being offered AD education. In another case, Resident 123, who was cognitively intact, did not have an AD in their record, and there was no documented evidence that the formulation of an AD was offered. The Registered Nurse (RN) and SSA both acknowledged the absence of an AD and the lack of documentation regarding the offer. The Social Services Director (SSD) confirmed that ADs should be offered upon admission and reviewed quarterly, but this process was not followed for Resident 123. Additionally, Resident 263, who had moderate cognitive impairment but the capacity to make healthcare decisions, also did not have an AD or documentation of an offer to formulate one. Furthermore, the facility failed to maintain copies of existing ADs in the medical records. For Resident 13, who had an AD, there was no copy available in the medical record, and no follow-up was conducted to obtain it. The SSA admitted to not following up with Resident 13 to secure a copy of the AD. The facility's policy required that information about ADs be prominently displayed and retrievable in the medical record, but this was not adhered to, leading to potential non-compliance with residents' wishes regarding medical treatment.
Failure to Maintain Homelike Environment Due to Peeling Wallpaper
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for five residents, as observed through the presence of peeled and damaged wallpaper in their rooms. Specifically, the wallpaper was found to be peeling behind the headboards in rooms 808, 212, 213, 113, and 609. Resident 63 expressed discomfort with the peeling wallpaper above her headboard, and the Maintenance Supervisor acknowledged that the damage was caused by the bed scraping against the wall. Resident 265 noted that the wallpaper had been peeling since her admission, and Licensed Vocational Nurse 3 confirmed the issue, stating that maintenance should have been notified. The Maintenance Supervisor admitted that there was no system in place under prior management to regularly check and maintain the condition of the rooms. Further observations revealed that the wallpaper behind Resident 27's headboard had been peeling since her transfer to the room months prior, and similar issues were noted in the rooms of Residents 73 and 28. The Administrator acknowledged that the maintenance staff should have addressed the damaged wallpaper to ensure a homelike environment. The facility's policy on providing a homelike environment, dated February 2021, emphasized the importance of maintaining a safe, clean, and comfortable setting for residents, which was not upheld in these instances.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Quarterly Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for five out of ten residents reviewed. The Resident Assessment Instrument Manual specifies that Quarterly Assessments should be transmitted no later than 28 days from the Assessment Reference Date (ARD). However, the assessments for the residents were transmitted between 40 to 43 days after the ARD, which is beyond the required timeframe. Interviews with the MDS coordinator and the Director of Nursing (DON) revealed that the facility was aware of the backlog in MDS submissions, which had been an issue since October 2024. The MDS coordinator acknowledged the delay and mentioned that efforts were being made to address the backlog. The DON confirmed that she was aware of the late submissions and had sought assistance from the corporate office to manage the backlog. Despite these efforts, the facility remained out of compliance with federal regulations due to the delayed transmission of MDS assessments.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to consistently provide activities that met the individual preferences of three residents, leading to a deficiency in resident engagement and activity. Resident 10, who was a former beautician, expressed a desire to engage in hair services and styling, yet was observed spending her time watching TV and sleeping, with no activities related to her past interests being provided. Her care plan indicated a need for independent leisure activities, but this was not reflected in her daily routine. Resident 48, a former bartender, reported a lack of engaging activities and expressed interest in socializing and serving drinks, which aligned with his past occupation. However, he was left with minimal interaction and activities that did not cater to his interests, leading to feelings of boredom and isolation. The Activity Assistant was unaware of his background and did not provide activities that matched his preferences, despite his care plan indicating a need for enjoyable and meaningful activities. Resident 128, a former teacher who taught sign language, was observed with limited access to reading materials and music, despite her care plan indicating a need for such resources. She was often found sleeping or inactive, with no activities provided that aligned with her interests. The Director of Nursing and Activity Director acknowledged the lack of personalized activities and the need for activities that reflect residents' past occupations and interests, as outlined in the facility's policies.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple complaints from residents and their families about delayed assistance with activities of daily living (ADLs) and call lights not being answered in a timely manner. Residents reported waiting for over an hour for assistance, particularly during night shifts, and having to call the front desk for help. The facility's reliance on registry staff, who were often unfamiliar with the residents' needs, contributed to the inconsistency in care. This was further exacerbated by high staff turnover and the use of temporary staff who were not adequately integrated into the facility's operations. Interviews with residents revealed that the lack of consistent staffing led to delays in receiving pain medication and assistance with personal care. Some residents reported having to wait for hours for help, and others noted that their personal belongings were frequently lost. The facility's staffing records indicated that the Direct Care Service Hours Per Patient Day (DHPPD) were below the state-required minimum on several occasions, highlighting the chronic understaffing issue. The facility's policy on staffing and use of registry staff was not effectively implemented, resulting in inadequate care for the residents. Staff interviews corroborated the residents' complaints, with CNAs and LVNs acknowledging the heavy workload and the challenges of providing adequate care with insufficient staff. The facility's Director of Nursing (DON) admitted to the staffing shortages and the ongoing efforts to hire more permanent staff. However, the continued reliance on registry staff and the high turnover rate among new hires contributed to the ongoing deficiencies in care. The facility's failure to maintain adequate staffing levels and ensure timely response to residents' needs negatively impacted the quality of care provided.
Pharmacy Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to ensure the provision of pharmacy services met the needs of the residents in two significant instances. Firstly, during an inspection of the Controlled II Emergency Kit, it was discovered that a plastic box for Norco, a potent narcotic pain medication, had its seal broken, and four tablets were missing without any documentation. The Director of Nursing (DON) confirmed the absence of the tablets and could not account for them, which was a deviation from the facility's policy requiring documentation of any medication removed from the emergency kit. Secondly, the facility administered three different blood pressure medications to a resident despite their Systolic Blood Pressure (SBP) being below the holding parameters specified in the physician's orders. The resident, who had a history of cerebral infarction, hypertensive heart disease, and atrial fibrillation, received Carvedilol, Hydralazine, and Losartan Potassium on multiple occasions when their SBP was below 110, contrary to the orders. The DON acknowledged that the medications were administered outside the prescribed parameters, which was against the facility's policy on administering medications in accordance with prescriber orders.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications in accordance with the manufacturer's instructions and facility policies, leading to several deficiencies. During inspections, three expired medications were found in various locations, including the medication refrigerator, IV/IM E-kit, and oral E-kit. The expired medications included an IV bag of compounded Daptomycin, a vial of Zofran, and unit-dose warfarin tablets. The Director of Nursing (DON) confirmed the presence of these expired medications and acknowledged that the facility's staff could not verify the contents of unopened E-kits until they were opened for emergency use. Additionally, six different medications were found without open dates in the medication room, refrigerator, and carts. These included IV bags of D5 1/2NS and Lactated Ringer's, D5W bags, Lorazepam oral concentrate, Latanoprost eye drops, and a Lantus Solostar insulin pen. The lack of open dates and proper labeling could lead to potential medication errors and compromised medication potency. The DON and other staff members confirmed the absence of open dates and acknowledged the need for proper labeling and storage. Furthermore, a discontinued order of Lorazepam was found stored in the active stock of a medication cart, and a box of Santyl Collagenase ointment was stored without pharmacy-applied labels. The facility's policies require that discontinued medications be removed from active stock and stored securely until disposed of, and that all medications be properly labeled. The DON and nursing staff verified these deficiencies and recognized the need for adherence to the facility's medication labeling and storage policies.
Deficiencies in Food Preparation and Sanitation Practices
Penalty
Summary
The facility failed to ensure that the food service staff were able to carry out the functions of food and nutrition services safely and effectively. During the preparation of pureed foods, the cook did not follow recipes, resulting in improperly textured food items. The cook used a whisk instead of a blender for pureeing bread, leading to a lumpy end product. Similarly, the pureed vegetables and chicken were watery, requiring additional thickener to achieve the correct consistency. The Food Service Director confirmed that the proper method was not followed, and the Registered Dietitian emphasized the importance of smooth pureed foods to prevent aspiration and ensure adequate nutrient intake. The facility also failed to maintain proper sanitation practices. The cook and diet aides used water instead of a properly concentrated sanitizer to clean kitchen equipment, as indicated by the orange color on the test strips. The Food Service Director explained that the sanitizer dispenser required time for the solution to mix properly, which the staff were unaware of. The Registered Dietitian highlighted the risk of cross-contamination and bacterial growth due to improper sanitization. Additionally, the staff did not adhere to the manufacturer's guidelines for sanitizing kitchenware. The cook and diet aides submerged washed kitchenware in the sanitizer sink for significantly less time than the recommended one minute. This failure to follow proper sanitization procedures could lead to cross-contamination and bacterial growth. The facility's policy required a three-step process of washing, rinsing, and sanitizing, which was not consistently followed by the staff.
Failure to Follow Recipes for Pureed and Seasoned Foods
Penalty
Summary
The facility failed to ensure that recipes were followed for preparing pureed food items, including bread, chicken, and vegetables, during a dinner meal. On January 6, 2025, observations revealed that the pureed bread was prepared without following a recipe, resulting in a lumpy texture. Similarly, the pureed vegetables and chicken were prepared without adhering to the recipes, leading to watery consistencies. The Food Service Director noted that the pureed bread was grainy and not smooth, which could cause residents to choke or lose interest in eating. The Registered Dietitian emphasized the importance of following recipes to ensure smooth textures and adequate nutritional value. Additionally, the facility did not follow the recipe for seasoning broccoli during a lunch meal on January 7, 2025. The broccoli was steamed without any seasoning, contrary to the facility's recipe, which called for margarine and salt to be added. The Food Service Director confirmed that the broccoli lacked salt, and the Registered Dietitian highlighted that not following recipes affects the taste of food, potentially leading to poor oral intake and inadequate nutrient intake among residents. The facility's policies and procedures, including those for food preparation and menu planning, require the use of standardized recipes to meet residents' nutritional needs. However, the failure to adhere to these recipes during food preparation had the potential to impact the nutritional intake of residents on pureed and regular diets, as observed in the facility's Diet Type Report dated January 6, 2025.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to adhere to its policy and procedure to provide appetizing and palatable food at appropriate temperatures according to residents' preferences. This deficiency was observed in nine residents, who reported issues such as food being served cold, lacking flavor, and being unappetizing. Specific complaints included egg salad without real egg pieces, hard and brittle cheese enchiladas, and bland food. Residents expressed dissatisfaction with the taste and temperature of their meals, and some reported that their feedback to the dietary staff did not result in any changes. During a test tray evaluation, the Food Service Director confirmed that the broccoli lacked seasoning, supporting the residents' complaints about the food's lack of flavor. The Registered Dietitian emphasized the importance of following recipes to ensure meals are tasty and meet nutritional needs, as failure to do so could lead to inadequate nutrient intake and weight loss. The facility's policies on meal service and food preparation were reviewed, indicating that meals should be served at appropriate temperatures and with satisfactory flavor and consistency, which was not achieved in this instance.
Improper Preparation of Pureed Bread for Residents on Pureed Diet
Penalty
Summary
The facility failed to ensure that pureed bread was prepared according to the prescribed recipe for 12 residents who were on a physician-prescribed pureed diet. During an observation, a cook was seen preparing pureed bread using a half loaf of wheat bread, 240 milliliters of 2% milk, and two tablespoons of butter, which was then cooked in a steamer and whisked, resulting in a lumpy texture. The cook did not follow any recipe during the preparation process. Further evaluation by the Food Service Director revealed that the pureed bread had a grainy texture, which was not smooth as required. The Registered Dietitian confirmed that pureed food should be smooth to prevent aspiration or spitting out, which could lead to insufficient calorie intake and weight loss. The facility's policy and procedure documents indicated that pureed diets should be smooth and moist, prepared using a food processor or blender, and the recipe for pureed bread specified that it should be smooth and free of lumps.
Failure to Offer Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that evening snacks were offered to eight out of nine residents, which could potentially affect their nutritional status and wellbeing. During a resident council meeting, several residents reported not being offered evening snacks, and one resident mentioned that it took a long time for nursing staff to provide a snack upon request. Observations revealed that the evening snacks delivered to the nurse station were pre-labeled with residents' names and room numbers, with no extra snacks available for other residents. Interviews with Certified Nurse Aides (CNAs) confirmed that they only distributed snacks with residents' names and did not offer additional snacks unless specifically requested by residents, which required them to go to the kitchen to obtain more. The Food Service Director (FSD) acknowledged that the dietary staff prepared snacks only for those with physician orders or who requested them, and confirmed the lack of extra snacks for general distribution. The Registered Dietitian (RD) emphasized that evening snacks should be offered to all residents to create a home-like environment and maintain their wellbeing. The facility's policy on snacks, revised in September 2010, aimed to provide residents with adequate nutrition, but the current practice did not align with this policy, as residents were not routinely offered evening snacks.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, as evidenced by multiple observations of improper handling and storage of food items. Thawed, uncooked meat, including chicken and bacon, was stored in the walk-in refrigerator past their use-by dates, contrary to the facility's policy which mandates that chicken should be used within two days after thawing and bacon within five days. This oversight was confirmed by the Food Service Director (FSD) and Registered Dietitian (RD) 1, who acknowledged the potential risk of foodborne illnesses to residents. Additionally, the facility's kitchen was found to have several unsanitary conditions that could lead to cross-contamination. A coffee cart was improperly stored next to an uncovered trash bin, and trash was observed on the kitchen floor in multiple areas. Worn-out cutting boards with rough surfaces were still in use, and there was a buildup of food residue and dust on various kitchen equipment and surfaces. These conditions were acknowledged by the FSD and RD 1, who recognized the risk of contamination and the need for proper cleaning and maintenance. Further issues included the presence of moldy, bruised, and wilted produce in the walk-in refrigerator, a rolling cart with chipping paint used for storing soup bowls and dessert cups, and an opened cheese enchilada exposed to air in the walk-in freezer. An expired cranberry cocktail was also found in the nourishment room refrigerator. These findings indicate a lack of adherence to the facility's policies and procedures for food storage and sanitation, posing a potential health risk to the residents who rely on the facility for safe and nutritious meals.
Failure to Provide Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide a sanitary and comfortable environment for two residents. For Resident 22, the facility did not provide appropriate window coverings to block sunlight according to the resident's preference. Instead, a bath towel was used to cover the window, which was insufficient in blocking the light, causing discomfort to the resident. The Maintenance Supervisor acknowledged that the towel was not an appropriate solution and that the blinds should have been replaced with darker shades. The Administrator also agreed that the blinds should have been replaced to ensure the resident's comfort. For Resident 63, multiple black stained patches were observed on the bathroom floor, which the resident found unacceptable and uncomfortable to use. The Maintenance Supervisor explained that the stains were caused by a bleach cleaning solution and agreed that the stained floor should be replaced. The Administrator expected maintenance staff to regularly check the rooms and agreed that the bathroom floor should have been changed to provide a sanitary and comfortable environment for the resident.
Failure to Cover Urinary Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident by not covering their urinary bag, as observed during a survey. On January 6, 2025, a Licensed Vocational Nurse (LVN) was seen with a resident whose urinary bag was uncovered and visible to others, containing 110 ml of yellow liquid. The LVN acknowledged that the urinary bag should have been covered with a privacy bag and expressed that it would be embarrassing if it were their own bag left uncovered. Further interviews and record reviews revealed that the Director of Nursing (DON) confirmed the importance of treating residents with respect and dignity, stating that the urinary bag should have been covered. The resident, admitted with a diagnosis including a urinary tract infection, had an order summary indicating the need for the urinary catheter to be in a privacy bag at all times. The facility's policy on dignity, dated February 2021, emphasized the importance of promoting residents' well-being and self-esteem, explicitly stating that urinary catheter bags should be covered.
Failure to Administer Medications and Initiate Treatment
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to deficiencies in their treatment. For Resident 515, a blister on the right heel was identified, but the treatment orders were not initiated until three days later. Despite the presence of a treatment order to clean the blister with normal saline and apply a honey-based gel, there was no documentation of the treatment being administered from January 4 to January 6, 2025. The Treatment Nurse confirmed that the treatment was not documented and therefore not performed, which was against the facility's wound care policy. For Resident 414, medications were not administered as ordered due to a power failure that affected the electronic medication administration system. The resident's family member reported that medications, including Eliquis, Atorvastatin, and Gabapentin, were not given during the night shift. The Licensed Vocational Nurse on duty explained that the medications could not be verified or administered until the computers were back online. However, the facility had a procedure to print paper Medication Administration Records (MARs) during such outages, which was not followed. The Director of Nursing confirmed that the medications were not administered as the blister packs for the medications were still intact for the date in question. The facility's failure to administer medications and initiate treatment as ordered by physicians resulted in potential harm to the residents. The Director of Nursing acknowledged the lapses in following standard procedures for medication administration and wound care. The facility's policies on administering medications and wound care were not adhered to, leading to these deficiencies.
Failure to Follow Up on Eye Appointment for Resident
Penalty
Summary
The facility failed to ensure a scheduled eye appointment was followed up for a resident with impaired vision due to age-related cataracts. The resident, who was cognitively intact and capable of making decisions, expressed the need for an eye checkup to replace her damaged eyeglasses, which were held together with adhesive tape. Despite the resident's request and the urgency of the situation, as noted by a Licensed Vocational Nurse, the facility did not provide a schedule for an eye appointment, potentially delaying necessary treatment to maintain effective vision. The resident's care plan indicated impaired visual acuity, and the order summary called for an eye-health and vision consult exam with follow-up treatment. However, the resident was not listed for an eye checkup when the eye doctor visited the facility. The Social Service Assistant confirmed that the resident should have been referred to an optometrist. The facility's policy on visually impaired residents emphasized the responsibility to assist residents in obtaining necessary services, including scheduling appointments and arranging transportation, which was not adhered to in this case.
Failure to Provide Adequate Nutrition and Monitor Interventions
Penalty
Summary
The facility failed to provide sufficient nutrition and monitor the effectiveness of nutritional interventions for a resident, leading to severe weight loss. The resident, who had a vegetarian diet preference, was not consistently provided with the appropriate food items according to their dietary needs and preferences. On multiple occasions, the resident did not receive the requested juices or a protein substitute on their meal tray, which were essential for maintaining their nutritional status. Additionally, the facility lacked a menu spreadsheet for a vegetarian diet, and there was no consultation with the Food Service Director or Registered Dietitian for meal substitutions. The facility also failed to monitor the resident's consumption of a prescribed protein shake supplement, which was recommended to be given five times a day. Despite the Registered Dietitian's recommendation, the supplement was not consistently offered or monitored, and there was no system in place to track the resident's intake. Furthermore, the resident's refusal to be weighed was not addressed with alternative measures, and there was no documentation of the resident's nutritional status being reassessed after August 2024. The resident experienced an unplanned and undesired severe weight loss of 30 pounds, or 25%, over 11 months, placing them at risk for further health decline. The facility's interdisciplinary team did not implement additional interventions to address the resident's poor food intake, such as recommending an appetite stimulant or providing snacks. The Director of Nursing acknowledged the resident's weight loss was due to insufficient oral intake and that the facility did not provide sufficient calories and nutrition, particularly in the absence of a protein food item at breakfast.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 267, who was admitted with multiple fractures and required Norco for moderate to severe pain. On the morning of January 10, 2025, Resident 267 reported a pain level of 11/10, indicating severe pain, and stated she had not received her prescribed Norco for 14 hours. The resident had been asking for her pain medication since the previous evening but did not receive it due to computer issues at the facility. Licensed Vocational Nurse (LVN) 7, a registry staff member, administered Tylenol instead of Norco, despite the resident's pain level being 5/10, which warranted Norco according to the physician's order. LVN 7 was unaware of the facility's protocol for medication administration during computer outages and did not utilize the paper Medication Administration Records (MARs) provided by the Case Manager. The paper MAR for Resident 267 was not generated due to her admission coinciding with the computer system's downtime, leaving LVN 7 without the necessary documentation to administer Norco. The Director of Nursing (DON) confirmed that Resident 267 did not receive Norco from the time of her admission until the morning of January 10, 2025. The facility's policy on pain management emphasizes the importance of implementing medication regimens as ordered and monitoring the effectiveness of interventions. However, due to the lack of access to electronic records and the absence of a paper MAR for Resident 267, the facility failed to adhere to these guidelines, resulting in inadequate pain relief for the resident.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's (CP) Medication Regimen Review (MRR) recommendation for a resident was carried out in a timely manner. The resident, who was readmitted to the facility with a diagnosis of hypertensive heart disease with heart failure, was prescribed furosemide to manage fluid retention. However, the CP's recommendation for a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) to monitor the resident's electrolytes and kidney function was not acted upon by the physician. This lack of action was confirmed during an interview with the Director of Nursing (DON), who acknowledged that no BMP laboratory testing had been ordered. The facility's policies did not specify time frames for physicians to act on CP's recommendations, contributing to the delay. The absence of recent BMP tests in the resident's clinical records indicated inadequate monitoring of blood electrolytes and kidney function, which is critical when administering diuretics like furosemide, especially in older adults. The facility's policy required the CP to contact the Medical Director or Administrator if the physician did not respond timely, but there was no evidence of such follow-up. This deficiency resulted in inadequate monitoring and had the potential to compromise the resident's health.
Inappropriate Use of Antipsychotic Medication for a Resident
Penalty
Summary
The facility failed to ensure that antipsychotic medications were ordered and used appropriately for a resident, identified as Resident 157, who was reviewed for unnecessary medications. Resident 157 was admitted to the facility with diagnoses including anxiety disorder and unspecified psychotic disorder with hallucinations due to a known physiological condition. However, there was no prior history of psychotic disorders or a thorough psychiatric evaluation conducted by a qualified medical professional to justify the use of antipsychotic medication. Resident 157 was prescribed quetiapine (Seroquel) 25 mg to be administered at bedtime for psychosis manifested by physical aggression, despite the absence of a valid diagnosis of psychosis. The medication was initially prescribed during a hospital stay for sleep, and upon transfer to the facility, it was continued with a new indication of psychosis. The facility's Director of Nursing (DON) and physicians acknowledged that the diagnosis of psychosis was not valid, and there was no psychiatric evaluation conducted by the facility psychiatrist due to restrictions related to the resident's medical group. The facility's policies and procedures regarding psychotropic medication use and non-controlled medication orders were not followed, as there was no comprehensive review or verification of the appropriateness of the medication order. The Consultant Pharmacist also indicated that the continuation of Seroquel for psychosis was not recommended without a valid diagnosis. This oversight had the potential for Resident 157 to receive unnecessary medication with serious long-term adverse effects.
Medication Administration Errors Lead to 7.14% Error Rate
Penalty
Summary
The facility was found to have a medication error rate of 7.14% during a medication administration observation. Two medication errors were identified involving two residents. For the first resident, a Licensed Vocational Nurse (LVN) administered a Lidocaine 4% patch instead of the prescribed Lidoderm 5% patch due to a lack of specified strength in the physician's order. The LVN mistakenly believed that Lidocaine 4% and Lidoderm were the same strength, leading to the administration error. The second error involved another resident who was supposed to receive a Lidocaine 4% patch on the right side of the back as per a recent physician's order. However, the LVN applied the patch to the left side of the back, as the order had not been updated in the resident's medical record. The facility's medication administration record (MAR) also failed to specify the side of the back for the patch application, contributing to the error. The Director of Nursing acknowledged that medications should be administered according to the physician's order.
Failure to Address Dental Needs of a Resident
Penalty
Summary
The facility failed to identify, refer, and follow up on the dental needs of Resident 22, who was observed with missing upper and lower teeth and expressed difficulty in speaking and chewing food. Despite the resident's request to see a dentist for dentures, she had not been seen by a dentist since her admission. The resident's Minimum Data Set indicated she was edentulous, and there was a standing order for dental consultation and treatment, yet no appointment was made. Interviews with facility staff, including an LVN, the Social Service Director, the Facility Dentist, and the Director of Nursing, revealed that the dental issues of Resident 22 were not addressed. The staff acknowledged the importance of dental care for nutrition and psychosocial well-being and admitted that the resident should have been referred to a dentist. The facility's policy required dental assessments within 90 days of admission and assistance with dental appointments, which were not followed in this case.
Non-compliance with Dietary Supervisor Qualifications
Penalty
Summary
The facility failed to ensure that the Food Service Director (FSD) met the educational requirements as outlined in the facility's policy, Federal Regulation, and California Health and Safety Code. The FSD, who had been working at the facility for seven years and was promoted to the position three years ago, did not possess the necessary certification for his role. He was in his first semester of obtaining his Certified Dietary Manager certification, which did not meet the qualifications required for the position responsible for the day-to-day management of the dietary department. The California Code of Regulations and the Health and Safety Code specify that if the position responsible for the day-to-day management of the dietary department is not a registered dietitian, there must be a full-time person who meets specific training requirements to act as the dietetic services supervisor. The facility did not have a qualified dietetic services supervisor, nor did the contract for the Registered Dietitian (RD) or the RD position description include the responsibility for the day-to-day operational or staff supervision of the dietetic services. The RD worked limited hours and focused primarily on residents' clinical nutrition, spending only a small portion of her time overseeing dietetic services. The facility's job description for the Dietary Supervisor and its policy on Personnel Management both indicated that a qualified Dietary Service Supervisor should be responsible for the total operation of the Dietary Department. However, the FSD did not meet the educational or certification requirements outlined in these documents. This lack of compliance with both Federal and State regulations led to the deficiency identified during the survey.
Failure to Honor Dietary Preferences and Provide Nutritional Adequacy
Penalty
Summary
The facility failed to honor a resident's beverage preferences and provide appropriate protein substitutions, leading to nutritional deficiencies. On January 6, 2025, Resident 116, who is a vegetarian, did not receive the apple juice and cranberry juice specified on his meal ticket during lunch. This omission was confirmed by LVN 17, who acknowledged that the absence of these juices resulted in the resident not receiving sufficient calories as recommended by the registered dietitian. On January 9, 2025, during breakfast, Resident 116 was not provided with a protein-based substitution for the bacon egg scramble, which he could not consume due to his dietary preferences. CK 2, responsible for serving the meal, admitted to not consulting the food service director or registered dietitian for an appropriate substitution and was unable to locate a vegetarian menu or guidance documents. The registered dietitian confirmed that the lack of protein substitution and missing juices contributed to a deficiency in calories and protein intake for Resident 116. The facility's policies on food preferences and therapeutic diets emphasize the importance of adhering to residents' dietary preferences and ensuring nutritional adequacy. However, the failure to follow these policies resulted in Resident 116 not receiving the necessary nutrition, potentially contributing to unplanned weight loss. The director of nursing acknowledged these deficiencies and the potential impact on the resident's nutritional status.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices when Certified Nursing Assistants (CNAs) did not wear personal protective equipment (PPE) while providing care to a resident under Enhanced Barrier Precautions (EBP). On January 7, 2025, CNAs 8 and 9 entered the room of Resident 463, who had a sign indicating EBP due to wounds, and provided care without wearing PPE. Both CNAs acknowledged their awareness of the EBP requirement and admitted to forgetting to use PPE, which is essential to prevent the spread of multi-drug resistant organisms (MDROs). Resident 463 was admitted with diagnoses including hemiplegia and had multiple wounds requiring EBP during high-contact care activities. The facility's policy mandates the use of gowns and gloves for residents with wounds, even if not infected with MDROs. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that staff were informed of EBP requirements through various means, including morning huddles and signage. However, the CNAs' failure to adhere to these protocols during care activities for Resident 463 led to the deficiency.
Exposed Wiring on Bed Controls Compromises Resident Safety
Penalty
Summary
The facility failed to maintain bed equipment in a safe operating condition for two residents, leading to exposed and damaged wiring on bed controls. Resident 8 reported that the bed control next to her bed was damaged with exposed inner wires, which made her nervous every time she used it. Despite reporting the issue a long time ago, the bed control was never repaired. The Maintenance Supervisor acknowledged the damage and stated that the bed control cord should have been fixed or replaced to prevent further damage and malfunction. Similarly, Resident 318's bed control was found to be damaged with exposed wiring through the protective covering. Resident 318 expressed concern about the exposed wiring and kept the control at the end of the bed to avoid using it. The Maintenance Assistant confirmed that the wiring should not be visible through the covering. The facility's policy on maintenance service, dated December 2009, requires the maintenance department to keep all equipment in a safe and operable manner, which was not adhered to in these instances.
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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