Downey Community Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Downey, California.
- Location
- 8425 Iowa Street, Downey, California 90241
- CMS Provider Number
- 555128
- Inspections on file
- 37
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Downey Community Health Center during CMS and state inspections, most recent first.
Nursing staff were not aware of the meaning of visual identifiers, such as a 5-fingers sign indicating the need for more than two-person assistance during transfers, despite having attended relevant in-service training. This lack of awareness was confirmed through interviews and review of facility policies and training records.
A Restorative Nurse Aide documented that restorative care services, including PROM exercises and PRAFO application, were provided to a resident with severe cognitive impairment and mobility limitations, when these services were not actually performed due to staffing shortages. The RNA later confirmed the documentation was inaccurate, and facility policy requires all medical record entries to be complete and accurate.
A resident with cognitive impairment and total dependence for transfers was moved from a wheelchair to a bed using a Hoyer Lift by a CNA without the required second staff member. Staff interviews and documentation confirmed that a two-person assist was necessary per care plan, facility policy, and manufacturer guidelines, but this protocol was not followed during the transfer.
Surveyors found that the Infection Preventionist Nurse did not complete the required ten hours of annual continuing education in Infection Prevention and Control after certification, as confirmed by both interview and record review. This failure was contrary to state guidance and the facility's job description, which require ongoing education for the role.
Staff training on abuse reporting did not align with federal guidelines, as the lesson plan instructed staff to report abuse allegations within 24 hours instead of the federally required two-hour timeframe. The DON and DSD confirmed the lesson plan was based on state guidance and facility policy, but neither was certain of the federal requirements. Facility policies referenced compliance with both state and federal regulations, but the actual training provided to staff was inconsistent with federal mandates.
Kitchen staff did not consistently wear required hair coverings in food service and preparation areas, as observed when a dishwasher worked without proper hair netting. Additionally, a large container of powdered nutritional supplement in the dry storage room was found unlabeled and undated, contrary to facility policy requiring all food items to be labeled and dated.
A resident with dementia and a primary language of Spanish was provided an English-only Arbitration Agreement, which she could not understand or remember signing. The facility did not have a Spanish version available, despite policy requiring explanation in a language the resident understands.
A resident with severe cognitive impairment, muscle weakness, and a history of falls was observed twice with her call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. Both a CNA and an LVN confirmed the call light was not within reach and acknowledged the importance of its placement for resident safety.
A resident with severe cognitive impairment and multiple medical conditions developed skin tears and bleeding on both forearms after striking bed siderails during care. The CNA who discovered and dressed the wounds did not report the incident to licensed staff, resulting in delayed notification to the physician and the resident's representative. The deficiency was identified when the resident's representative noticed the injuries and questioned staff, revealing a lack of timely communication and documentation.
A resident with a history of psychosis, dementia, schizophrenia, and major depressive disorder was prescribed an antidepressant for depression, but the MDS assessment failed to include depression as an active diagnosis. The MDS Coordinator confirmed this omission was an error, despite facility policy requiring accurate and comprehensive assessments.
A resident admitted with multiple diagnoses, including neuropathic pain, was prescribed Pregabalin, but staff failed to develop and implement a care plan for this medication. Both an LVN and the DON confirmed the absence of a care plan, despite facility policy requiring one for proper monitoring and intervention.
A resident with a history of stroke and hemiplegia was on dual antiplatelet therapy with aspirin and clopidogrel, as ordered by the physician. However, the care plan included an intervention to avoid aspirin, which conflicted with the resident's prescribed treatment. The care plan was not revised to reflect the concurrent use of both medications, leading to potential confusion among licensed nurses regarding the resident's antiplatelet therapy.
Two residents with severe cognitive impairment and multiple medical conditions were observed with long, dirty fingernails, despite care plans and facility policies requiring staff to assist with daily grooming and nail care. CNAs acknowledged responsibility for nail hygiene but did not ensure the residents' fingernails were kept clean and trimmed.
Two residents receiving controlled medications for pain management did not have their medication administrations properly documented on the Controlled Drug Record by nursing staff, resulting in discrepancies between the recorded and actual counts of medication doses. Nurses acknowledged the omissions and confirmed that facility policy required accurate documentation of each dose removed.
A resident receiving Pregabalin for neuropathic pain was not monitored for sedation as required by physician orders and facility policy. Despite repeated observations of the resident lying in bed with eyes closed, there was no documentation on the MAR of monitoring for sedation or holding the medication, and staff interviews confirmed the lack of required monitoring.
A resident with diabetes did not receive glipizide as ordered, with the medication being administered significantly earlier than 30 minutes before breakfast. Despite the resident's requests and physician instructions, nursing staff gave the medication at a set time rather than in relation to mealtime, and did not offer alternatives such as a snack or adjusting the administration time. Staff interviews confirmed a lack of adherence to physician orders and facility policy, resulting in a significant medication error.
A resident with severe cognitive impairment was observed with outside food left at the bedside for approximately four hours, contrary to facility policy requiring removal or refrigeration of perishable items after two hours. Staff did not check, remove, or properly store the food, and interviews confirmed that this practice did not align with established procedures for food safety.
A resident's Advance Directives Acknowledgement form was found incomplete, missing required initials, despite facility policy requiring complete and accurate medical records. The Admission Coordinator confirmed responsibility for the oversight, and the resident had multiple medical conditions and was dependent on staff for daily care.
A resident with hemiplegia and impaired cognitive skills was unable to use the standard call light system due to limited hand function. Staff were aware of the issue but did not report it or provide an alternative, such as a touch pad call light, as required by facility policy. The deficiency was identified through observation, interviews, and record review.
Facility staff did not report an allegation of resident-to-resident physical abuse to the State Agency within the required two-hour timeframe. Two residents with mental health diagnoses were involved in an altercation, but the incident was only reported after a surveyor's inquiry, resulting in delayed notification to authorities.
A resident with intact cognition and multiple medical conditions alleged that a CNA physically abused her during care. Despite the report, the CNA was not immediately removed from duty and continued to care for the resident's roommates. Facility staff did not investigate the allegation promptly, contrary to policy requiring immediate action when abuse is reported.
A resident with multiple medical conditions reported being hit by a CNA and expressed a preference not to have that CNA assigned. The incident and the resident's concerns were not documented in the medical record or progress notes, and a change of condition following an abuse allegation was also not recorded per shift as required. The DON confirmed that documentation was incomplete and did not meet facility policy or standard practice.
A resident with diabetes was not monitored for blood sugar levels as ordered by the physician over a three-day period following readmission from a hospital. Despite clear orders for insulin administration based on a sliding scale and regular blood sugar checks, nursing staff did not perform or document these checks. The omission was confirmed by staff interviews and facility records, and the resident ultimately experienced a significant hyperglycemic episode, requiring transfer to a hospital.
A resident was denied readmission to a facility after hospitalization, despite being medically cleared and having available beds. The facility cited a lack of isolation beds due to the resident's history of MDRO, although the MDRO was not active. The facility's policy prioritizing readmission was not followed, leading to the resident staying at the hospital longer than necessary.
The facility failed to post required signage for two residents on Enhanced Barrier Precautions (EBP), which necessitates the use of gowns and gloves to prevent the spread of multidrug-resistant organisms. Both residents required EBP due to medical conditions involving a jejunostomy tube and a Foley catheter, respectively. Observations revealed the absence of signage at their room entrances, a deficiency confirmed by the Infection Prevention Nurse and Director of Nursing, contrary to the facility's policy.
The facility failed to implement the care plan intervention of bilateral floor mats for a resident identified as high risk for falls. Despite a doctor's order and the facility's policy, the fall mats were not properly placed, potentially putting the resident at risk of injury.
The facility failed to implement infection control practices, including Enhanced Barrier Precautions and proper use of PPE during wound care for two residents. Additionally, staff did not follow hand hygiene policies during a medication pass for another resident.
The facility failed to ensure home medications were reviewed by a pharmacist before administration and did not accurately document the administration of Lorazepam, a controlled medication, for two residents. This led to potential medication errors and increased health risks.
The facility failed to ensure proper documentation and monitoring of lorazepam use for a resident with paranoid schizophrenia, leading to potential medication errors and an unwitnessed fall. The LVN admitted to not documenting the administration and effectiveness of the medication, and non-pharmacological interventions were not attempted prior to administration.
The facility failed to maintain a medication error rate of less than 5% during medication pass for four of five sampled residents. Errors included crushing non-crushable medications, late administration of Metformin, incorrect dosing of docusate sodium, improper resident identification, and not shaking liquid medications before administration.
The facility failed to prepare pureed food with the required smooth texture for 23 residents, resulting in lumpy and chunky lasagna that required chewing. This was confirmed by the Dietary Supervisor and Registered Dietitian, posing a choking risk for residents with swallowing difficulties.
The facility failed to ensure safe and sanitary food storage and preparation practices, including storing expired and undated food items, maintaining an unclean dry storage area, and using previously cooked ground beef without proper documentation and monitoring. The Dietary Supervisor acknowledged these issues and stated that the items should be discarded and that all food should be labeled, dated, and covered during storage to prevent cross-contamination and ensure food safety.
The facility failed to inform a resident of the medications being administered prior to administration, violating the resident's right to be informed and to participate in their care. An LVN was observed giving a resident a medicine cup containing pills without explanation, and the resident expressed a desire to know what medications he was taking. Interviews with staff confirmed this was against facility policy.
A resident with intact cognitive skills and multiple diagnoses was served meals with plastic utensils without being informed of the reason, leading to feelings of distress. Staff were unaware of the reason for the use of plastic utensils, and there was no documentation to support this intervention, violating the facility's dignity policy.
A resident's right to privacy was violated when the case manager repeatedly opened the resident's mail without permission, despite the resident's intact cognitive skills and capacity to make decisions. The case manager admitted to the actions, which were against the facility's policy and procedure on mail handling.
The facility failed to develop and implement a care plan for a resident with suicidal ideations, despite the resident expressing a desire to harm herself due to feeling anxious and sad. The resident's records and staff interviews confirmed the absence of a care plan addressing her mental health needs, which was a significant oversight.
The facility failed to maintain appropriate grooming and personal hygiene for two residents, leading to dirty and untrimmed nails. Despite staff acknowledging the issue and the facility's policy requiring daily nail care assessment, the residents' nails were not cleaned or trimmed, posing a risk of infection and negatively impacting their quality of life.
A facility failed to conduct a Post-Fall Assessment and IDT meeting after a resident with severe cognitive impairment and mobility issues experienced an unwitnessed fall. The necessary assessments and meetings were not completed, increasing the risk of future falls and injury for the resident.
A resident received Potassium Chloride ER in a crushed form mixed with other medications, contrary to the manufacturer's specifications and the facility's policy. The error was observed during a survey, and the resident's medical records showed multiple instances of this improper administration. LVNs admitted to the mistake, and the DON confirmed the facility's guidelines against crushing certain medications.
A resident with missing teeth and on a mechanical soft diet was repeatedly served tortillas that were too hard to chew, leading her to only eat the filling and leaving the tortillas uneaten. Interviews with staff confirmed that this placed the resident at risk of choking and aspiration.
A resident with severe cognitive and physical impairments was provided with a standard call light system they were unable to use. Despite the resident's inability to activate the call light due to weakness in their hands and fingers, no action was taken to provide a more suitable system, such as a touch pad call light. Interviews with staff confirmed the need for a more appropriate call light system, as per the facility's policy.
Staff Unaware of Visual Identifier Meanings for Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff, specifically Certified Nurse Assistants (CNAs), were aware of the meaning of visual identifiers posted in resident rooms, which are intended to communicate special needs or accommodations for residents. During interviews, a CNA was unable to identify the significance of a 5-fingers visual identifier, which, according to facility policy, indicates that a resident requires more than two persons for assistance during transfers. Despite having attended an in-service training on visual identifiers, the CNA did not recall the meaning of the sign when questioned. A review of the facility's lesson plan and policy confirmed that staff are expected to check for visual identifiers before providing care and to follow any associated precautions. The Director of Staff Development stated that staff are expected to apply what they learn in training to their daily practice to ensure resident and staff safety. However, the lack of staff awareness regarding the visual identifier demonstrates a failure to ensure that staff have the necessary competencies to provide appropriate care for residents as outlined in facility policy.
Inaccurate Documentation of Restorative Care Services
Penalty
Summary
A deficiency occurred when a Restorative Nurse Aide (RNA) documented that restorative care services, specifically passive range of motion (PROM) exercises and the application of a Pressure Relief Ankle Foot Orthosis (PRAFO), were provided to a resident, when in fact these services were not performed. The resident in question had significant cognitive impairment, was unable to make or understand decisions, and had diagnoses including osteoporosis and rheumatoid arthritis, with documented limitations in range of motion. The resident's care plan included physician orders for PROM and PRAFO application five times per week. However, on the date in question, the RNA signed off in the RNA Program Administration Report as if the tasks were completed, despite not having seen the resident or performed the ordered interventions due to insufficient staffing. During interviews, the RNA admitted to signing off on the tasks without performing them and acknowledged that the documentation should have reflected the missed care and the reason for it. The Director of Staff Development confirmed that documentation should always be accurate and never indicate that care was provided when it was not. The facility's policy and procedures also required that documentation in the medical record be objective, complete, and accurate. This inaccurate documentation practice was identified through record review and staff interviews.
Failure to Use Two-Person Assist During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a required two-person assist during a Hoyer Lift transfer for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including metabolic encephalopathy, vascular dementia, and cerebral infarction, was dependent on staff for all transfers and unable to make decisions or support himself. Despite care plan interventions and physical therapy recommendations indicating the need for full assistance, a certified nursing assistant (CNA) transferred the resident from a wheelchair to a bed using the Hoyer Lift without a second staff member present. Multiple interviews confirmed that facility policy, the resident's care plan, and the manufacturer's guidelines all required two staff members for Hoyer Lift transfers to ensure safety. The CNA, as well as other staff including an LVN, RN, DON, and Director of Rehab, acknowledged that a two-person assist was necessary for this resident due to his cognitive and physical limitations. The incident was directly observed and reported by the responsible party, and documentation supported that the resident was fully dependent and at risk during transfers.
Plan Of Correction
Corrective Action: Res1 is currently in the hospital. RN will assess Res 1 regarding transfer assistance needs upon return. On 7/31/25, the DON/DSD provided CNA1 1:1 service/disciplinary action regarding the need to exercise clinical judgement when operating a Hoyer lift with another staff. How to Identify Potentially Affected: On 7/29/25, the charge nurses checked other residents requiring Hoyer lifts for transfers to ensure the staff is operating it safely, with another staff assisting as needed. No similar issues identified. Systematic Change: On 7/30-31, 2025, the DSD/Designee (Director of Staff Developer) in-serviced the licensed nurses and licensed nurses on the facility's policy on operating Hoyer lifts with additional staff based on staff's clinical judgment, to ensure resident's safety. The facility will continue to have visual identifiers for the use of Hoyer lifts to alert CNAs and Licensed nurses. The DSD will complete the CNAs' skills competency on how to safely operate the Hoyer lift upon hire, annually, and as needed. MONITORING: The DON/Supervisors/Charge Nurses will monitor compliance with proper use of Hoyer lifts through routine rounds. The facility will conduct a QA study on staff compliance to the use of Hoyer lifts in the next 30 days or until acceptable compliance is achieved. If lack of compliance is identified, revisions will be made as needed. Trends and findings will be reported to the QA committee for further recommendations. Completion date: 8/10/25
Infection Preventionist Lacked Required Continuing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist Nurse (IPN) completed the required ten hours of continuing education in Infection Prevention and Control within a year of certification. During an interview and record review, the IPN confirmed that after completing the Nursing Home Infection Preventionist Training Course certification, no further documented continuing education in the field had been completed. The IPN acknowledged responsibility for maintaining at least ten hours of annual continuing education to stay current with guidelines and protocols, and admitted that this requirement had not been met. A review of the California Department of Public Health's All Facilities Letter and the facility's Infection Control Coordinator Job Description both indicated the necessity for ongoing education in infection prevention and control. The job description specifically stated that the Infection Control Coordinator is responsible for promoting professional growth and development through educational activities and participation in trainings. The lack of documented continuing education for the IPN was directly observed and confirmed during the survey process.
Inconsistent Staff Training on Abuse Reporting Timelines
Penalty
Summary
The facility failed to ensure that staff training on abuse reporting was consistent with federal reporting guidelines. During interviews and record reviews, it was found that the lesson plan used for staff education indicated that allegations of abuse were to be reported to the State Agency within 24 hours unless the allegation involved injury. Both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the lesson plan was based on state guidance and facility policy, but neither was certain of the specific federal requirements. The DON stated that the lesson plan was reviewed and approved for staff education, and the DSD acknowledged the importance of timely reporting to ensure resident safety. Further review of facility policies and the All Facilities Letter (AFL) 21-26 revealed that federal guidelines require all allegations of abuse to be reported to the State Agency within two hours, not 24 hours as taught in the lesson plan. The Administrator (ADM) also stated that the facility's policy was to report resident-to-resident altercations within two hours, and the facility's policy and procedure documents referenced compliance with both state and federal regulations. However, the training provided to staff did not align with these federal requirements, creating a risk of delayed reporting and investigation of abuse allegations.
Failure to Ensure Proper Hair Covering and Food Labeling in Dietary Services
Penalty
Summary
Kitchen staff failed to consistently wear hair coverings while working in food service and preparation areas. During an observation, a dishwasher was seen without the required hair covering in the dishwashing area near the food preparation station. The staff member stated he was unaware that his hair netting had fallen and believed his hair was still covered. The dietary supervisor confirmed that a hair covering not properly secured could result in hair falling into food, clean dishes, or food preparation areas, which increases the risk of food contamination. Additionally, in the dry food storage room, a large plastic container filled with a powdered substance was found to be unlabeled and undated. The dietary supervisor identified the substance as a powdered nutritional supplement and acknowledged that it should have been labeled and dated according to facility protocol. Facility policies reviewed indicated that all food items in the storeroom should be labeled and dated, and that food delivered to the facility should be marked with a received date.
Failure to Provide Arbitration Agreement in Resident's Preferred Language
Penalty
Summary
The facility failed to ensure that a resident with a primary language of Spanish fully understood the binding Arbitration Agreement at the time of admission. The resident, who had diagnoses including major depressive disorder and dementia with moderately impaired cognition, required an interpreter to communicate with healthcare staff and preferred to receive information in Spanish. Despite this, the Arbitration Agreement was only provided in English, and the resident signed the agreement without a Spanish version being available. During interviews, the resident stated she did not remember the arbitration agreement, could not read English, and would have preferred the agreement in Spanish for better understanding. The Admission Coordinator confirmed that the Arbitration Agreement was only available in English and acknowledged that the facility should have provided it in Spanish for residents whose primary language was Spanish. Facility policy required that agreements be explained in a language the resident understands, but this was not followed in this instance.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident's call light was not within reach on two separate occasions. During observations, the call light cord was found hanging from the left-upper side rail with the touch pad touching the floor, making it inaccessible to the resident. The resident was awake and lying in bed during both observations. The resident's care plan specifically indicated that the call light should be within reach due to her high risk for falls. The facility's policy also required staff to check call light placement during rounds to ensure it was accessible. The resident involved had diagnoses of generalized muscle weakness, dementia with severely impaired cognition, and a history of falls. She was dependent on staff for all self-care and mobility needs and lacked the capacity to make decisions. Interviews with a CNA and an LVN confirmed that the call light was not within reach and acknowledged that it should have been accessible for the resident's safety. Both staff members stated that checking call light placement was part of their routine responsibilities.
Failure to Promptly Notify Physician and Representative of Resident's Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician and the resident's representative of a significant change in condition involving a resident who developed skin tears and bleeding on both forearms. The resident, who had diagnoses including dementia, cerebrovascular accident, major depression, diabetes mellitus, and hypertension, was assessed as severely cognitively impaired and unable to make decisions. The care plan required monitoring for skin breakdown and reporting injuries to the physician. Despite this, the resident was found with dressings on both forearms, and neither the physician nor the resident's representative was informed in a timely manner. Interviews and record reviews revealed that the skin tears and bleeding occurred after the resident struck her arms on the bed siderails during personal care. The CNA who discovered and dressed the wounds did not report the incident to licensed nursing staff out of fear of suspension. The incident was only brought to the attention of the treatment nurse and subsequently the director of nursing after the resident's representative noticed the dressings and inquired about them. Documentation in the electronic medical record did not indicate how the injuries occurred or who applied the dressings, and there was no evidence of timely notification to the physician or the resident's representative, contrary to facility policy.
Inaccurate MDS Assessment for Depression Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's diagnosis of depression. The resident, who had a history of psychosis, dementia, and schizophrenia, was readmitted to the facility with documented diagnoses that included major depressive disorder. Medical records, including a psychiatric evaluation and physician orders, indicated the resident was prescribed bupropion, an antidepressant, specifically for depression. Despite this, the MDS assessment did not include depression as an active diagnosis. During an interview and record review, the MDS Coordinator confirmed that the omission of the depression diagnosis from the MDS was an error, acknowledging that the resident's use of antidepressant medication and documented diagnosis warranted its inclusion. The facility's policy requires comprehensive and accurate assessments to guide care planning, but this was not followed in this instance, resulting in an incomplete assessment for the resident.
Failure to Develop and Implement Care Plan for Prescribed Medication
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan for a resident who had been prescribed Pregabalin to treat neuropathic pain. The resident was admitted with multiple diagnoses, including arthritis, muscle weakness, polyneuropathy, and acute pulmonary edema. Documentation showed that the resident had intact cognition and required maximal assistance with activities of daily living. Despite a physician's order for Pregabalin, there was no corresponding care plan outlining the medication's use, monitoring parameters, potential side effects, or necessary interventions. During interviews, both a Licensed Vocational Nurse and the Director of Nursing confirmed that a care plan for Pregabalin was not present in the resident's records. The facility's policy required care plans to be initiated upon admission and revised as needed to ensure proper delivery of care. The absence of a care plan for this medication was acknowledged by staff and was not in accordance with facility policy.
Failure to Revise Care Plan for Dual Antiplatelet Therapy
Penalty
Summary
The facility failed to revise the person-centered care plan for a resident who was on dual antiplatelet therapy with aspirin and clopidogrel. The resident had a history of stroke, hemiplegia, and hemiparesis, and was receiving both medications for stroke prophylaxis as ordered by the physician. The care plan, however, included a standardized intervention to avoid the use of aspirin, which conflicted with the resident's current medication orders. The Minimum Data Set Coordinator confirmed that the care plan should have been revised to reflect the concurrent use of both antiplatelet medications, as the resident had been on this therapy since admission. This discrepancy in the care plan had the potential to cause confusion among licensed nurses regarding the appropriate administration of the resident's antiplatelet therapy. The facility's policy required care plans to be updated with new interventions as necessary, but the care plan for this resident was not revised to accurately reflect the physician's orders and the resident's current treatment regimen.
Failure to Maintain Resident Nail Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for two residents who were unable to perform these tasks independently. Observations revealed that both residents had long fingernails with visible dirt or black substance underneath. One resident, who had diagnoses including diabetes mellitus, hypertension, and dysphagia, was noted to have severely impaired cognitive skills and required maximal assistance with activities of daily living (ADLs). Despite a care plan indicating daily assistance with ADLs, the resident's fingernails remained untrimmed and unclean. Certified Nursing Assistants (CNAs) acknowledged responsibility for daily nail care and recognized the importance of keeping fingernails clean to prevent infection. Another resident, with diagnoses including schizoaffective disorder, dementia, bipolar disorder, and diabetes mellitus, also had severely impaired cognitive skills and required supervision or touching assistance for ADLs. This resident was observed with long, dirty fingernails, and staff confirmed the condition and the associated risks. The care plan for this resident also specified daily assistance with ADLs and nail care as needed. Facility policy and CNA job descriptions required assistance with personal grooming, including nail care, but these standards were not met for the two residents identified.
Failure to Accurately Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the Controlled Drug Record for two residents who were receiving controlled medications for pain management. In the first instance, a resident with diagnoses including radiculopathy, cervicalgia, and low back pain was prescribed pregabalin 25mg three times daily. After administration of the morning dose, the nurse did not document the removal of the medication on the Controlled Drug Record, resulting in a discrepancy between the number of doses recorded and the actual number left in the bubble pack. The nurse acknowledged the omission and confirmed that facility procedure required documentation of each dose removed. In the second instance, another resident with a history of surgical amputation and a stage three pressure ulcer was prescribed tapentadol 100mg twice daily. The nurse administered the medication but failed to document it on the Controlled Drug Record, leading to an inaccurate count of remaining doses. Both nurses involved stated they were responsible for documenting each administration on the Controlled Drug Record as per facility policy, which was not followed in these cases. The facility's policy required licensed nurses to record administered controlled medications on both the MAR and the narcotic count sheet.
Failure to Monitor for Sedation with Pregabalin Administration
Penalty
Summary
The facility failed to monitor a resident for signs of overmedication while the resident was prescribed Pregabalin for neuropathic pain. Multiple observations over several days showed the resident lying in bed with eyes closed, suggesting possible sedation. The resident's physician order included parameters to hold Pregabalin if sedation occurred, but there was no documentation on the medication administration record (MAR) indicating that monitoring for sedation was performed or that the medication was held as directed. The resident had a history of arthritis, muscle weakness, polyneuropathy, and acute pulmonary edema, and was assessed as having intact cognition but requiring maximal assistance with activities of daily living. Interviews with nursing staff and the DON confirmed the importance of monitoring for sedation and following physician orders, but also revealed that no documentation of such monitoring was present. The facility's policy required monitoring and documentation of medication side effects, which was not followed in this case.
Failure to Administer Glipizide According to Physician's Orders
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus and a history of long-term insulin use did not receive glipizide as ordered by the physician. The physician's order specified that glipizide should be administered 30 minutes before breakfast and dinner. However, the Medication Administration Record and audit reports showed that the medication was consistently given at 6:30 a.m., while the earliest breakfast was served at 8:00 a.m., resulting in the medication being administered up to one and a half hours before the resident ate. The resident expressed concerns to staff about the timing of the medication, stating that she was instructed by her physician to take glipizide within 30 minutes before breakfast and that taking it earlier could jeopardize her health. Despite her requests, nurses insisted on administering the medication at the scheduled time and did not offer it closer to breakfast or provide a snack. The resident did not refuse the medication but asked for it to be given at the appropriate time, and when this was not accommodated, she considered refusing it for her safety. Interviews with nursing staff revealed a lack of awareness regarding the resident's concerns and the physician's specific timing instructions. Staff acknowledged that medications intended to be given before meals should be administered closer to mealtime or with a snack if necessary, but this was not done. Facility policies required nurses to follow physician orders and to re-offer medications if initially refused, but these procedures were not followed in this case, resulting in a significant medication error.
Failure to Remove Perishable Outside Food from Resident Bedside
Penalty
Summary
The facility failed to follow its policy regarding the removal and storage of outside food brought in for a resident. Specifically, a resident with severe cognitive impairment and a regular diet order was observed receiving outside food, which remained at the bedside for approximately four hours. Staff did not check or remove the food within the required timeframe, as outlined in the facility's policy, which states that potentially hazardous foods left out for more than two hours without refrigeration or a heat source must be discarded. Interviews with staff, including an LVN and the Dietary Supervisor, confirmed that outside food should not be left at the bedside for more than one to two hours due to the risk of spoilage. The Dietary Supervisor also noted that perishable items, such as chili with cheese, should be refrigerated, labeled, and monitored. Despite these procedures, the food was left at the resident's bedside well beyond the allowed period, and staff did not intervene to remove or properly store the food.
Incomplete Advance Directives Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, the Advance Directives Acknowledgement (ADA) form for a resident was found to be incomplete, missing the resident's initials. The Admission Coordinator, who was responsible for completing the ADA form upon admission, confirmed during an interview and record review that the form was not properly filled out. The ADA form is a legal document included in the resident's medical record and is intended to reflect the resident's medical needs and wishes. The resident involved had a history of major depressive disorder, gastrostomy, and anemia, and was dependent on staff for activities of daily living, though their cognitive skills were intact. The facility's policy required that medical records be complete and accurate, but this was not followed in this instance, resulting in an incomplete legal document within the resident's file.
Failure to Provide Accessible Call Light System for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with left body hemiplegia and right-sided weakness was unable to use the standard call light system in their room. Observations showed the call light was placed near the resident's left hand, but the resident was unable to press the button due to limited finger movement. The resident was dependent on staff for most activities of daily living and had impaired cognitive skills, as documented in their medical records and assessments. Despite these limitations, the call light system provided was not accessible to the resident. Interviews with staff revealed that the certified nursing assistant (CNA) was aware the resident could not use the call light but did not notify the charge nurse or maintenance to obtain an alternative system, such as a touch pad call light. The facility's policy required staff to assess residents' ability to use the call system and to provide alternatives if needed, but this was not followed. The director of staff development and a registered nurse both confirmed the importance of ensuring residents can use their call lights, but in this case, the necessary accommodations were not made.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
Facility staff failed to report an allegation of resident-to-resident physical abuse to the State Agency within the required two-hour timeframe for two residents. One resident, with a history of schizoaffective disorder, paranoid schizophrenia, and psychosis, reported that her previous roommate threw a chair at her. The incident was not reported to the State Agency until the surveyor brought it to the attention of the facility's social worker and program director. The facility's policy and process require that such allegations be reported within two hours, but the mandated reporting form (SOC-341) was not sent until several hours after the allegation was made known to staff. The records reviewed indicated that both residents involved had significant mental health diagnoses but were assessed as not having cognitive impairments. The incident was only discovered after a resident disclosed the altercation during an interview with the surveyor, and the facility's documentation showed the resident had been moved to another room due to incompatibility, without any prior report of abuse. The delay in reporting was confirmed by interviews with facility staff, including the program director and administrator, who acknowledged the requirement for timely reporting and the failure to meet it in this case.
Failure to Remove CNA After Abuse Allegation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was immediately removed from access to a resident after an allegation of physical abuse was made. A resident, who was alert, oriented, and had intact cognition, reported to the Social Service Designee that the CNA hit her on the back, pressed on her back while in bed, and pushed her during a transfer, resulting in her hitting her head on the side rail. The resident also reported that the CNA told her to be quiet and not to scream. The incident was reported to a nurse, but the CNA continued to work the remainder of the shift and was still assigned to care for the resident's roommates after the allegation was made. Interviews and record reviews revealed that the nurse did not investigate the allegation or ask the resident about the incident, attributing the request for a different CNA to the resident's baseline behavior of having preferred caregivers. The facility's policy required immediate investigation and reassignment or suspension of employees accused of abuse, but this was not followed. As a result, the CNA remained on duty and continued to provide care to other residents in the same room as the alleged victim after the abuse allegation was reported.
Failure to Document Resident Concerns and Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate documentation for a resident who reported concerns regarding care provided by a CNA. The resident, who had diagnoses including low back pain, muscle weakness, and diabetes mellitus, and was cognitively intact, reported to a social service designee that a CNA hit her on the back and pressed on her back while in bed. The resident stated she informed a nurse about the incident, but there was no documentation in the resident's progress notes regarding her concerns or the incident. The Director of Nursing confirmed that such concerns should have been documented as a grievance and in the progress notes to ensure appropriate follow-up and staff education, but this was not done. The only documentation found was in the 24-hour communication log, noting the resident's request not to have the CNA assigned, which the DON attributed to the resident's baseline behavior rather than a specific concern. Additionally, the facility did not document a change of condition after the resident alleged abuse by the CNA. Although a Change of Condition assessment was completed, there was no corresponding documentation in the nursing progress notes for the relevant shift. The DON acknowledged that nurses are required to document per shift and as needed when there is a change of condition, and that this documentation is essential for resident safety and continuity of care. The facility's policies and the LVN job description both require complete and timely documentation, which was not met in this instance.
Failure to Monitor Blood Sugar as Ordered for Diabetic Resident
Penalty
Summary
The facility failed to follow professional standards of practice by not implementing a physician's order to monitor a resident's blood sugar (BS) levels on three consecutive days. The resident, who had a history of diabetes mellitus type 2, hypertension, and anxiety disorder, was readmitted to the facility with orders from a general acute care hospital to continue insulin administration based on a sliding scale, with BS checks before meals and at bedtime. Despite these clear orders, the Medication Administration Record (MAR) and blood sugar summary showed that the resident's BS levels were not checked as ordered on 2/28/2025, 3/1/2025, and 3/2/2025. The omission was confirmed through interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), all of whom acknowledged that the resident's BS was not monitored during the specified period. The LVN explained that the absence of documentation in the MAR indicated that the checks were not performed, and the DON confirmed that the failure to monitor BS could result in unrecognized hypoglycemia or hyperglycemia. The resident reported that after returning from the hospital, BS checks stopped for two days, and only resumed after the resident requested it due to feeling unwell. On 3/2/2025, the resident experienced a change of condition, with a recorded BS level of 491 mg/dl, and subsequently requested transfer to a hospital. Facility policy and procedures reviewed indicated that care should be provided in accordance with physician orders, and that the frequency of BS monitoring is determined by the physician and must be documented by licensed nurses. The failure to follow these standards resulted in the resident experiencing a hyperglycemic episode and requiring hospital transfer.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite having available beds and the resident being medically cleared for discharge. The resident, who had a history of right hemiplegia and chronic kidney disease, was transferred to a General Acute Care Hospital (GACH) for symptoms of wheezing and shortness of breath. After treatment, the resident was deemed appropriate for discharge back to the facility. However, the facility denied readmission, citing a lack of isolation beds due to the resident's history of multidrug-resistant organisms (MDRO), even though the MDRO was not active. Interviews with facility staff revealed that the Admission Coordinator informed the Director of Nursing (DON) that the resident did not require isolation, but the DON insisted on an isolation bed. The facility's census showed available beds, yet the DON did not allow the resident to return. The facility's policy stated that residents discharged to the hospital should be given priority for readmission, but this was not followed, resulting in the resident remaining at the hospital for two additional days.
Failure to Implement Enhanced Barrier Precautions Signage
Penalty
Summary
The facility failed to implement its infection prevention and control measures by not ensuring clear signage was posted for two residents who were on Enhanced Barrier Precautions (EBP). These precautions require the use of gowns and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs). The absence of signage at the entrance of the residents' rooms meant that staff and visitors might enter without the necessary personal protective equipment (PPE), increasing the risk of transmitting disease-causing organisms. Resident 4 was admitted with a malfunctioning enterostomy and was dependent on staff for activities of daily living (ADLs). A physician's order indicated that Resident 4 required EBP due to the presence of a jejunostomy tube. However, during an observation, it was noted that there was no signage at the entrance of Resident 4's room to indicate the need for EBP. Similarly, Resident 5, who had severe cognitive impairment and was dependent on staff for ADLs, was ordered to be on EBP due to the presence of a Foley catheter. Again, there was no signage at the entrance of Resident 5's room. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) confirmed that signage should have been present to inform staff, visitors, and vendors of the necessary precautions before entering the rooms. The facility's policy and procedure documents also indicated that clear signage was required to communicate the type of precautions and required PPE. The lack of signage was identified as a deficiency in the facility's infection prevention and control program, as it failed to provide the necessary communication to prevent the spread of infections.
Failure to Implement Care Plan Intervention of Bilateral Floor Mats
Penalty
Summary
The facility failed to implement the care plan intervention of bilateral floor mats for Resident 3, who was identified as high risk for falls. During an observation, it was noted that there was no fall mat on the right side of the bed, and the fall mat on the left side was positioned closest to the roommate's bed. Interviews with RN1 and LVN1 confirmed that fall mats are intended to minimize injury by providing a cushion and that Resident 3 had a doctor's order for fall mats on both sides of the bed. The care plan dated 4/15/2024 also indicated the need for bilateral floor mats for safety precautions. Resident 3 was admitted with diagnoses of muscle weakness, hemiplegia, and dementia, and was dependent on staff for transfers and mobility. A change of condition assessment indicated that Resident 3 was found half dangling from the bed, leading to the doctor's order for bilateral floor mats. The facility's policy, titled Falling Star Program, also required floor mats for residents identified as high risk for falls. Despite these directives, the facility did not ensure the proper placement of the fall mats, potentially putting Resident 3 at risk of injury.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement infection prevention and control practices as outlined in their infection control program. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) as mandated, which required the use of gowns and gloves for specific care activities to limit the spread of infections. Despite being in-serviced on EBP, the facility staff did not adhere to these guidelines, as evidenced by the lack of EBP implementation for residents requiring such precautions. The Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) acknowledged the potential for increased infections due to this failure. The facility also failed to ensure that the Treatment Nurse wore proper personal protective equipment (PPE) during wound treatment for Resident 88. The Treatment Nurse did not wear a disposable gown while performing wound care, despite the resident having an infected left lower leg wound. This was observed during a wound treatment session where the nurse only used gloves and did not follow the facility's infection control policies. Additionally, the facility did not ensure that certified staff used PPE when providing wound treatment for Resident 129. The staff did not wear PPE gowns during high-contact resident care activities, such as wound care, which is required by the facility's Enhanced Barrier Precaution policy. Furthermore, the facility did not follow its own hand hygiene policy, as observed during a medication pass for Resident 16, where the licensed nurse did not wash or sanitize hands before and after taking the resident's blood pressure and measuring oxygen saturation.
Failure to Review Home Medications and Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that medications brought from home were reviewed by the pharmacist before being administered to residents. Specifically, for two residents, medications stored in two medication carts were not reviewed by the facility's pharmacist. This discrepancy was observed during an inspection and interview with LVNs, who confirmed that the home medications were not sent to the facility's pharmacy for review. The prescription labels on these medications did not match the current physician's orders, leading to potential medication errors and adverse reactions for the residents involved. Additionally, the facility failed to accurately account for and document the administration of Lorazepam, a controlled medication, for another resident. The Controlled Drug Record (CDR) and Medication Administration Record (MAR) showed discrepancies in the number of doses administered versus documented. The LVN responsible admitted to administering doses without proper documentation, which could lead to double dosing and increased risk of side effects. Interviews with the Director of Nursing (DON) and a review of the facility's policies confirmed that home medications must be verified by the facility's pharmacy and that controlled medications require accurate documentation. The lack of adherence to these policies resulted in unsafe medication administration practices, increasing the risk of serious health complications for the residents involved.
Failure to Properly Document and Monitor Lorazepam Use
Penalty
Summary
The facility failed to ensure that lorazepam was used for a medical condition as diagnosed and documented in the resident's clinical record for one resident. The resident was admitted with diagnoses including paranoid schizophrenia, difficulty in walking, muscle weakness, and chronic obstructive pulmonary disease. The facility did not define resident-specific target behaviors regarding the use of lorazepam and failed to monitor the medication for adverse effects and effectiveness. Additionally, the facility did not quantify episodes of constant fidgeting as per the physician's order related to the use of lorazepam. The resident's Medication Administration Record (MAR) indicated zero documented behaviors of constant fidgeting every shift between specific dates. The MAR was also left blank for non-pharmacological interventions for the use of lorazepam. The Licensed Vocational Nurse (LVN) admitted to sometimes forgetting to document the administration of lorazepam immediately after administration and did not document the behavior or reason for administering the PRN medication in the nursing progress notes. The LVN also stated that non-pharmacological interventions were not tried prior to administering lorazepam. The Director of Nursing (DON) confirmed that the resident's Controlled Drug Record (CDR) indicated the resident was administered 12 doses of lorazepam, but only 4 doses were documented on the MAR. The DON stated this discrepancy could result in a medication error and negatively affect the resident. The facility's policy and procedure for psychotropic use and medication administration were not followed, leading to the failure to document specific behaviors, adverse reactions, and the effectiveness of the medication, which could have contributed to the resident's fall.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication pass for four of five sampled residents. For Resident 621, the facility did not administer hydroxychloroquine and potassium chloride extended release (ER) in accordance with the manufacturer's specifications and the facility's policy. Additionally, Resident 621's physician order for aspirin was not administered as prescribed. The Licensed Vocational Nurse (LVN) 6 crushed medications that should not be crushed and administered them to Resident 621, which was against the facility's policy and the medication's instructions. This error was repeated multiple times, and the nurse did not realize the mistake until it was pointed out by the surveyor. The nurse admitted to not checking the medication cards properly and acknowledged the potential health risks involved in crushing non-crushable medications. Other staff members also confirmed the importance of not crushing certain medications and the proper procedures to follow, which were not adhered to in this case. Resident 10 was not administered Metformin within the scheduled time frame as per the facility's policy. The medication was given almost two hours late without any documentation or notification to the physician. The nurse responsible admitted to the delay and acknowledged that there was no valid reason for the late administration. The Director of Nursing (DON) confirmed that Metformin should be administered with food and that any significant delay should be reported to the physician. Resident 16 was administered a lower dose of docusate sodium than prescribed and was not identified using at least two identifiers before medication administration. The nurse responsible admitted to the mistake and acknowledged that the resident was not wearing an identification band. The DON confirmed that proper identification procedures were not followed. Additionally, Resident 53's medications, which required shaking before administration, were not shaken, leading to potential underdosing. The nurse responsible admitted to not following the manufacturer's instructions, and the DON confirmed the importance of shaking medications to ensure proper dosing.
Deficient Pureed Food Preparation
Penalty
Summary
The facility failed to prepare food by methods that conserved texture and appearance for 23 residents receiving a pureed diet. During an initial facility tour, complaints about the flavor of the food were identified. Observations during lunch service revealed that the pureed lasagna was dry, lumpy, and contained large pieces of pasta, which required chewing before swallowing. This was confirmed by Cook 1, who stated that the lasagna was pureed using a blender with some broth, but the resulting texture was not smooth. A test tray further confirmed the presence of chunky pieces that required chewing. The Dietary Supervisor and Registered Dietitian both acknowledged that the pureed lasagna did not meet the required smooth consistency and posed a choking risk for residents with swallowing difficulties. The facility's menu and policy indicated that pureed food should be smooth and moist, able to hold its shape, and not require chewing. The Registered Dietitian also verified with the facility's speech therapist that pureed products should not require chewing before swallowing. The facility's policies and procedures were reviewed, confirming that the pureed diet should be of a smooth and moist consistency, in compliance with national guidelines and physicians' orders.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Six plastic bags of packed lunch with meat sandwiches for residents were stored in the refrigerator with use-by dates exceeding the storage period for previously prepared sandwiches. Additionally, a medium-sized container of tomato sauce and cooked green beans were stored past their use-by dates. There were also four ham and cheese sandwiches stored without any date, and a liquid egg carton with an open date exceeding the manufacturer's use-by date. A large bowl of previously prepared whipped cream was stored uncovered, and ready-to-eat deli meats were stored in a dirty container with juices and small pieces from the deli meats. The Dietary Supervisor acknowledged these issues and stated that the items should be discarded and that all food should be labeled, dated, and covered during storage to prevent cross-contamination and ensure food safety. The dry storage area was not maintained in a clean manner, with food debris on top of bulk food containers and a torn bin liner inside the bin holding flour, causing flour to spill inside the bin. Rusted metal parts were also observed inside the bin. The Dietary Supervisor stated that the dry food storage area should always be clean to prevent pests and that the liners storing bulk food should be intact. The facility's policy and procedure indicated that storerooms should always be clean and that dry bulk food should be stored in seamless metal or plastic containers with tight covers or in bins that are easily sanitized. Previously cooked ground beef with a preparation date of 3/27/2024 and a use-by date of 3/29/2024 was used to prepare lunch on 4/1/2024. The ground beef was not monitored for a safe cool-down process, and the cooking and cooling of the ground beef were not documented. The Dietary Aide and Cook were unaware of who cooked the ground beef and did not check the dates, leading to the use of potentially unsafe food. The facility's policy and procedure indicated that hot foods to be refrigerated should be placed in shallow pans to permit rapid cooling. The Dietary Supervisor acknowledged the mistake and stated that the ground beef cooked on 3/27/2024 was not safe because it was not known if it was cooled and stored in a safe way.
Failure to Inform Resident of Medication Administration
Penalty
Summary
The facility failed to keep a resident informed and did not ensure a resident exercised his right to choose by not informing Resident 74 of the medications being administered prior to administration. During an observation, an LVN was seen giving Resident 74 a medicine cup containing pills without explaining what medications were in the cup. Resident 74, who had fluctuating capacity to understand and make decisions, stated he did not know what medication he had just swallowed and expressed a desire to be informed about the medications he was taking. The LVN admitted to not following the facility's policy of informing residents about their medications, acknowledging it was a violation of the resident's rights. Interviews with the Director of Staff Development and the Director of Nursing confirmed that it was the facility's policy and expectation for licensed nurses to explain the medications to residents prior to administration. The facility's Policy and Procedure on Medication Administration also indicated that licensed nurses must explain to residents the type of medication being administered and the procedure. The failure to inform Resident 74 of his medications violated his right to be informed and to participate in his care, as outlined in the facility's policies and procedures.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure respect and dignity for Resident 134 by serving meals with disposable plastic utensils without informing the resident of the reason. Resident 134, who had diagnoses including fibromyalgia, depression, and paraplegia, had intact cognitive skills and was capable of making decisions. Despite this, there were no physician orders or care plans addressing the need for plastic utensils, and the resident was not informed why she was receiving them, leading to feelings of distress and indignity. During observations and interviews, it was revealed that Resident 134 had been receiving plastic utensils since January 2024 due to previously verbalized suicidal ideations. However, there was no documentation in the care plans, physician orders, or nursing notes to support this intervention. Staff members, including CNAs, LVNs, and the Dietary Supervisor, were unaware of the reason for the use of plastic utensils and did not communicate this to the resident. The Director of Nursing confirmed that plastic utensils were used as an intervention for residents with suicidal ideations but acknowledged that once the resident was no longer in danger, the use of plastic utensils should have ceased. The facility's policy on dignity emphasized the importance of promoting quality of life, respect, and individuality, and prohibited demeaning practices. The failure to discontinue the use of plastic utensils and inform the resident of the reason violated this policy and compromised the resident's dignity and well-being.
Violation of Resident's Right to Privacy
Penalty
Summary
The facility failed to respect a resident's right to personal privacy by allowing the case manager to open Resident 90's mail without permission. Resident 90, who had intact cognitive skills and the capacity to make decisions, reported that her mail was opened multiple times by the case manager despite her requests for it to remain unopened. The case manager admitted to opening the mail to verify medical appointments and acknowledged that she did not have permission to do so. This action made Resident 90 feel violated and upset, as she had to repeatedly ask the case manager to stop opening her mail. The Director of Nursing confirmed that the facility's policy requires all mail to be delivered unopened unless otherwise indicated by the attending physician and documented in the resident's medical record. The facility's policy and procedure on mail, dated January 2024, also stated that staff members should not open mail unless requested by the resident. The case manager's actions were in direct violation of this policy, as well as the resident's right to privacy, as outlined in the facility's guidelines.
Failure to Develop Care Plan for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident with suicidal ideations. The resident, who had diagnoses including fibromyalgia, depression, and paraplegia, expressed suicidal thoughts due to feeling anxious and sad when her family did not visit her during the holidays. Despite these expressions, there was no care plan addressing her suicidal ideations, which was confirmed during interviews with staff and a review of the resident's records. The resident's Minimum Data Set (MDS) indicated that her cognitive skills for daily decision-making were intact, and she required assistance with personal hygiene, toileting, and eating. The resident's History and Physical (H&P) also confirmed her capacity to understand and make decisions. However, a Change of Condition (COC) assessment noted that the resident verbalized wanting to kill herself, and she was monitored every 15 minutes for a few days. Despite these measures, the care plan did not reflect her suicidal ideations. Interviews with various staff members, including the Dietary Supervisor, Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), revealed that the lack of a care plan for the resident's suicidal ideations was a significant oversight. The DON emphasized the importance of having a care plan to provide proper interventions and prevent residents from hurting themselves. The facility's Policy and Procedure (P&P) also indicated that care plans should include measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to maintain appropriate grooming and personal hygiene for two residents, leading to dirty and untrimmed nails. Resident 88, who has diagnoses including cellulitis, type 2 diabetes, and cerebral infarction, was observed multiple times with a black substance under his fingernails. Despite being able to understand and make decisions, Resident 88 stated that no one had assisted him with nail care. Staff members, including a Psychiatric Assistant, Licensed Vocational Nurse, and Registered Nurse, acknowledged the issue and highlighted the potential risks of infection and cross-contamination due to the dirty fingernails. The Director of Nursing confirmed that nail care should be assessed daily and that Resident 88's nails should have been cleaned and trimmed by the staff if he was unable to do so himself. Similarly, Resident 222, who has diagnoses including COPD, schizophrenia, depression, dementia, and muscle weakness, was found with long toenails and a brown substance underneath them. Resident 222 expressed that he could not remember the last time his toenails were cleaned or cut and stated that he would like staff assistance for this. A Certified Nursing Assistant confirmed the condition of Resident 222's toenails and acknowledged that it was their responsibility to clean and trim the nails. However, there was no documentation to show that the toenails' status was reported to the charge nurse or that a podiatrist visit was scheduled. The Licensed Vocational Nurse and Social Services staff also confirmed that the toenails should have been assessed and reported for further care. The facility's policy and procedure on Activities of Daily Living (ADLs) indicated that assistance should be provided to residents for personal hygiene, including nail care. However, the observations and interviews revealed that the staff failed to adhere to these guidelines, resulting in the residents having dirty and untrimmed nails, which posed a risk of infection and negatively impacted their quality of life and self-esteem.
Failure to Conduct Post-Fall Assessment and IDT Meeting
Penalty
Summary
The facility failed to assess and identify the potential hazard and resident's risk factors for falls for one of three sampled residents by not completing a Post-Fall Assessment and conducting an Interdisciplinary Team (IDT) meeting after the resident had an unwitnessed fall. The resident, who had a history of cerebral infarction, metabolic encephalopathy, and schizophrenia, was found on his knees on the floor of his room. Despite the resident's severe cognitive impairment and use of a wheelchair for mobility, the necessary post-fall assessments were not conducted, and the IDT meeting was not held to determine the cause of the fall and implement preventive measures. This failure increased the potential for future falls and injury for the resident. Interviews with the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed that the facility's protocol required a post-fall Morse Fall Scale assessment and an IDT meeting to be conducted after any fall. The LVN admitted to forgetting to complete the post-fall assessment, and the ADON was not informed of the fall, resulting in the IDT meeting not being conducted. The DON confirmed that the lack of a post-fall assessment and IDT meeting prevented the identification of additional risk factors and the implementation of appropriate interventions to prevent further falls. The facility's policy and procedure on Accident Management, reviewed in January 2024, stated that residents should be assessed for fall risk factors upon admission, quarterly, after a change of condition, and annually. The policy also required the IDT to conduct a post-fall meeting to review risk factors and recommend further interventions. The failure to follow these procedures for the resident who experienced an unwitnessed fall on March 31, 2024, resulted in an increased risk of future falls and injury for the resident.
Failure to Administer Medications According to Manufacturer's Specifications
Penalty
Summary
The facility failed to ensure that Resident 621 was free from significant medication errors when Potassium Chloride ER, a medication that should not be crushed, was administered in a crushed form mixed with other medications. This was not in accordance with the manufacturer's specifications and the facility's policy and procedure on medication administration. The error was observed during a survey when LVN 6 was about to administer the crushed mixture to Resident 621, who has a history of dysphagia and difficulty swallowing medications. Resident 621's medical records indicated that the resident was not capable of giving informed consent and had a legal guardian. The resident's medication administration record showed that Potassium Chloride ER was crushed and administered along with other medications on multiple occasions. LVN 6 admitted to not realizing that the medication should not be crushed and acknowledged the potential health risks associated with this error. Other LVNs interviewed confirmed that they were aware of the guidelines against crushing certain medications, including Potassium Chloride ER. The Director of Nursing (DON) stated that nurses were supposed to check the order, electronic medical record, medication card, and medication bottle for special instructions before administering medications. The facility had a list of medications not to be crushed, and nurses were instructed to consult this list and ask supervisors if unsure. The facility's policy and procedure emphasized that medications should be administered as prescribed and in accordance with manufacturers' specifications, and that long-acting or enteric-coated dosage forms should generally not be crushed.
Failure to Serve Food According to Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure tortillas served during lunch were in accordance with a physician's order for a mechanical soft diet for one resident. This resident, who had missing teeth and was on a mechanically altered diet, was observed multiple times struggling to chew the tortillas served with her meals. Despite the resident's difficulty, the tortillas continued to be served in a manner that was not soft enough for her to chew easily, leading her to only eat the filling and leave the tortillas uneaten. Interviews with the resident revealed that she found the tortillas difficult to chew due to her lack of upper teeth. The Dietary Supervisor acknowledged that the preparation method could result in the tortillas becoming harder over time, making them difficult for the resident to chew. Both the Licensed Vocational Nurse and the Registered Nurse confirmed that serving food that was too hard for the resident to chew placed her at risk of choking and aspiration. The Director of Nursing also confirmed that the mechanical soft diet should ensure food is soft enough to chew without difficulty. The facility's policy indicated that the mechanical soft diet is designed for residents with chewing or swallowing limitations, and the food should be modified to a soft consistency. Despite this policy, the resident continued to receive tortillas that were not adequately softened, posing a risk to her safety and nutritional intake.
Failure to Provide Appropriate Call Light System for Resident
Penalty
Summary
The facility failed to assess and provide an appropriate call light system for Resident 124, who had significant physical and cognitive impairments. Resident 124, who was admitted with diagnoses including respiratory failure and blindness in one eye, had severe cognitive impairment and was dependent on staff for various activities of daily living. The resident also had functional limitations in both upper and lower extremities and left-sided weakness due to a stroke. Despite these limitations, the resident was provided with a standard call light system that they were unable to activate due to weakness in their hands and fingers. This was observed during an inspection where the resident attempted but failed to activate the call light, and the CNA confirmed the resident's inability to use the call light but had not taken any action to address this issue. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the facility's policy required providing a call light system that residents could use to communicate their needs. Both the DSD and DON acknowledged that a touch pad call light system would have been more appropriate for Resident 124, given their physical limitations. The facility's policy on Accommodation of Needs also indicated that residents' individual needs and preferences, including the need for adaptive devices, should be evaluated upon admission and reviewed on an ongoing basis. However, this was not done for Resident 124, leading to the deficiency in providing an appropriate call light system.
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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