Dreier's Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 1400 West Glenoaks Blvd, Glendale, California 91201
- CMS Provider Number
- 555839
- Inspections on file
- 49
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Dreier's Nursing Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions, including post-surgical amputation, acute osteomyelitis, and DM, filed several grievances documented on GCT forms. Although the forms reflected that grievances, investigations, and resolutions occurred, they lacked written investigation findings, dates or documentation that the resident was informed of those findings, and details of corrective actions. The resident reported never being told the outcomes of the investigations, and the DON confirmed there was no documentation in the GCT forms, social service notes, or medical record showing that the resident was informed, despite facility policy requiring oral and written communication of grievance findings and actions.
The facility failed to follow its abuse reporting policy when an allegation was made by a cognitively intact resident, who had a right patella fracture and acute respiratory failure with hypoxia, that therapy staff had hit her and forced her to walk. The SSD learned of the allegation from the resident’s representative after a dialysis center reported the resident’s statements, and the SSD informed the DON and the IDT. Despite the facility policy requiring suspected abuse to be reported to state authorities within two hours, the allegation was not reported to CDPH within that timeframe, even though police later arrived after receiving a related report from APS.
A resident with limited English proficiency and a preference for Farsi was not provided with appropriate interpretation services, resulting in ineffective communication and incomplete assessment of care needs. Staff relied on gestures and did not utilize interpreter services as required by facility policy.
Several residents did not have individualized care plans addressing their specific needs, including food preferences for a resident with significant weight loss, oxygen therapy for three residents with respiratory conditions, and epilepsy medication management for another resident. Staff and DON interviews confirmed that care plans were not created as required by facility policy, resulting in a lack of guidance for staff on how to meet these residents' needs.
Surveyors found that staff failed to label opened insulin and over-the-counter medications with the date they were first accessed, as required by facility policy and professional standards. An insulin pen for a resident with diabetes and two bottles of multi-dose medications were found in medication carts without opened dates, and staff confirmed that all multi-dose medications must be labeled and discarded within specified timeframes.
Surveyors found that staff did not consistently monitor or document refrigerator and dry storage room temperatures, and failed to discard opened prune juice after five days as required by facility policy. The Dietary Supervisor and kitchen staff confirmed lapses in daily temperature checks and unclear labeling of food items, resulting in expired juice being stored and incomplete temperature logs.
Surveyors identified infection control deficiencies involving three residents: a resident on contact precautions for an MDRO had a nonfunctional hand sanitizer dispenser in their room; another resident receiving IV antibiotics had an uncapped IV line port touching the bedside curtain; and a third resident with a gastrostomy tube had an uncapped feeding tube port hanging exposed on an IV pole. Staff interviews confirmed these lapses, and facility policies required proper hand hygiene and equipment handling.
A resident with intact cognition and multiple serious health conditions was administered a hypnotic medication without a signed informed consent form. Facility staff confirmed that the required consent process was not completed, meaning the resident may not have been fully informed of the medication's risks and benefits, in violation of facility policy.
A resident with multiple chronic conditions and intact cognition was not provided with required information about the right to formulate an Advance Directive. Facility records and interviews revealed inconsistent documentation regarding the resident's AD status, and both the DON and Social Worker confirmed that the resident had not received the necessary information, in violation of facility policy.
A resident with significant limitations in range of motion (ROM) and a history of muscle weakness and neurological conditions did not receive restorative nursing (RNA) services as indicated in their care plan after readmission. Despite assessments and care plans identifying the need for RNA to prevent further decline, staff interviews and record reviews confirmed that RNA services were not provided for several months due to discontinued and unrenewed physician orders. Facility policy required such interventions, but the lapse was not addressed, resulting in a deficiency in care.
A resident with chronic pulmonary edema and acute respiratory failure experienced significant weight loss and poor meal intake after the facility failed to assess and document their food preferences during both admission and comprehensive nutritional assessments. The resident reported dissatisfaction with the food, and observations confirmed the meals were unappealing. Staff interviews revealed that food preferences were not considered or included in the care plan, contrary to facility policy.
Two residents receiving oxygen therapy did not receive care according to physician orders, including the lack of routine oxygen administration and missing 'No Smoking/Oxygen in Use' signage in their rooms. Both the DON and an LVN confirmed that facility policy required such signage for safety, and records showed that staff did not consistently follow orders for routine oxygen therapy.
A nurse failed to accurately check the gastric residual volume (GRV) for a resident with a G-tube, aspirating only 20 mL instead of all available gastric contents as required by facility policy and physician orders. The resident, who had severe cognitive impairment and required all medications via G-tube, was at risk due to this incorrect practice, which was later acknowledged by the nurse after re-assessment revealed a higher GRV.
A CNA was found to be providing direct resident care despite having an expired certification. The DSD confirmed the lapse in monitoring and follow-up, and the CNA acknowledged working scheduled shifts after her certification expired while awaiting renewal. Facility policy and the DON both require current certification for staff providing care, but this was not enforced in this instance.
The facility did not maintain a medication error rate below 5%, with errors identified during medication administration for two residents. One resident did not have their G-tube flushed after receiving methimazole, and another received ophthalmic medications without pressure applied to the inner eye as required. These actions were contrary to physician orders and facility policy, resulting in a cumulative error rate of 10.3%.
A resident with a history of heart failure and pulmonary embolism experienced shortness of breath and low oxygen saturation throughout the day, but did not receive oxygen therapy as ordered by the physician. Despite repeated complaints and low O2 readings, staff delayed administering oxygen for over eight hours, only providing it when the resident's condition became critical and required emergency transfer to a hospital.
A facility failed to maintain the confidentiality of a resident's medical records by mistakenly sending them with another resident to a hospital. During an emergency transfer, the records of a resident with chronic conditions and a DNR order were sent instead of the correct resident's records. The error was identified by hospital staff, and it was noted that both the RN supervisor and LVN on duty were from a Nursing Registry, contributing to the mix-up.
A resident with severe cognitive impairment was transferred to a GACH due to a change in condition, but the facility sent incorrect medical records meant for another resident. This error led to confusion and a delay in obtaining the correct information, as the resident arrived without proper identification. The RN on duty, from a nursing registry, was responsible for the mistake, which violated the facility's policy requiring accurate transfer records.
A resident with severe cognitive impairment was transferred to a GACH without proper identification and with incorrect medical records, leading to potential delays in treatment. The facility failed to follow its policy on transfers, as the RN supervisor, unfamiliar with procedures, sent the wrong records. The resident was not wearing an ID wristband, contributing to the mix-up.
The facility failed to maintain a safe environment due to multiple leaks and water damage in residents' rooms, the kitchen, and shared areas. Observations showed paint bubbling and water leaks, with staff using temporary measures like tarps and buckets. Despite the damage, the kitchen continued to operate, posing infection risks. Interviews revealed a lack of awareness and communication among staff, with no external contractors contacted for repairs.
The facility failed to provide a safe environment during a rainstorm, leading to water damage in the rooms of three residents. A resident with schizoaffective disorder and anxiety disorder felt anxious due to water leaking onto her roommate's bed. Another resident with hypertension and depression experienced anxiety from water leaks in her room and the activity room. A third resident with cerebral infarction and hemiplegia was worried about water pooling at the foot of her bed. The Maintenance Supervisor placed a tarp on the roof but did not inspect resident rooms due to kitchen damage.
A facility failed to develop and implement a comprehensive care plan for a resident following hip reduction surgery. Despite physician orders for a knee immobilizer and abduction pillow, the resident, who had severe cognitive impairment, was often found without these devices. Staff interviews revealed inconsistent use, and there was no care plan addressing the resident's refusal to wear them, potentially exposing the resident to complications.
A resident with a history of cerebral infarction and hemiplegia was not treated with dignity during routine care. Two CNAs made inappropriate comments about the resident's relationship with her boyfriend during diaper changes, which was against the facility's dignity policy. The incident was reported, but no formal investigation or documentation was conducted by the DSD, and the grievance logs showed no entries for this incident.
A resident with dementia was improperly discharged from a facility to another without proper documentation or consent from responsible parties. The facility failed to provide necessary information and resources, and did not involve the resident's family in the discharge planning process. The resident was returned after refusing to stay at the new facility, highlighting deficiencies in communication and adherence to discharge policies.
A facility failed to provide a written notice to a resident with dementia and their responsible party before transferring the resident to another SNF. The transfer occurred without notifying the Ombudsman in writing, violating the facility's policy. The DON confirmed there was no urgent need for the transfer, and no interdisciplinary team meeting was held for discharge planning.
A facility failed to create a care plan for a resident's left eye injury after an altercation with another resident. Despite documentation of the incident, no care plan was developed to address the injury. Interviews with staff confirmed the oversight, which was acknowledged as necessary by the RN and DON. The facility's policy requires ongoing assessments and revisions of care plans, which was not followed in this instance.
A resident with type 2 diabetes had consistently elevated blood sugar levels over several days, but the facility failed to notify the physician promptly. The resident's blood sugar levels were significantly above normal, yet the facility's staff did not report these levels due to a lack of specific parameters for notification. The facility's policy required prompt notification of significant changes, but this was not followed, leading to a deficiency.
A resident with severe sepsis and pneumonia, using an indwelling urinary catheter, was not monitored for fluid intake and output as per facility policy, leading to hospitalization for a UTI and sepsis. The facility's failure to document daily urine output, as required by their catheter care policy, resulted in a deficiency.
A facility failed to provide adequate respiratory care to a resident by not assessing respiratory status, obtaining a physician's order for oxygen, or reassessing the effectiveness of oxygen therapy. The resident, with pneumonia and respiratory failure, experienced fluctuating oxygen saturation levels, and despite receiving oxygen therapy, there was no documented reassessment or physician order, contrary to facility policy.
A resident reported being threatened and possibly hit, but the LTC facility failed to report the allegation to law enforcement as required by their policy. Staff interviews revealed confusion about the reporting process, and the DON, responsible for the investigation, was unaware of the need to report to law enforcement. The facility's policy mandates immediate reporting of abuse allegations to various authorities, including law enforcement.
A resident with multiple diagnoses reported being threatened, but no care plan was developed to address the allegation of abuse. Despite the facility's policy requiring a comprehensive care plan, interviews revealed that no plan was initiated, and there was no documentation of monitoring the resident for emotional distress. The deficiency was acknowledged by the DSD and DON, highlighting a lapse in the facility's practices.
The facility failed to protect the privacy and dignity of eight residents by allowing other residents to use their designated shower rooms, leading to discomfort and embarrassment. Despite awareness of the issue, staff cited a lack of alternative facilities as the reason for this practice, which contradicted the facility's policies on resident rights and dignity.
Two residents in an LTC facility were not accommodated in their preferences for private showering arrangements, affecting their privacy and dignity. One resident's bathroom was used as the sole male shower room, despite his preference for privacy. Another resident, who required moderate assistance, found the situation embarrassing. Staff interviews confirmed the lack of alternative shower facilities, despite awareness of privacy issues.
A resident with epilepsy and a history of falls was not placed on a low bed as required by their care plan, leading to a fall and injury during a seizure. Despite the care plan's intervention for a low bed, staff confirmed it was not implemented, resulting in a deficiency in care.
A resident with severe cognitive impairment and contractures was injured due to inadequate supervision and care planning. The facility failed to communicate the resident's specific needs for assistance with bathing and transfers, resulting in the resident being showered inappropriately, leading to multiple fractures and hospitalization. Staff were not informed of the resident's limitations, and no care plan was developed to address the resident's needs.
A resident experienced a significant change in condition, including decreased blood pressure, increased heart rate, and severe pain, but the facility failed to notify the physician or conduct appropriate assessments. The resident, with a history of severe cognitive impairment, continued to decline and eventually died. The facility did not adhere to its policies for managing changes in a resident's condition, leading to inadequate care.
A resident with a history of TIA and CVA was not properly assessed or monitored by the facility's staff, leading to a failure to notify the physician of significant changes in vital signs and pain levels. The resident's condition deteriorated, resulting in their death. The facility did not follow its policies for pain management and change of condition notification, nor did it develop a care plan for the resident's medical conditions.
The facility failed to designate a medical director for six months, affecting all residents, including one who died without a thorough evaluation of their change in condition. Outdated healthcare policies had not been reviewed or approved by a medical director, potentially leading to substandard care.
A resident's personal information was improperly disposed of in a kitchen trash can, exposing it to unauthorized individuals. The Dietary Supervisor acknowledged that name cards with personal information are routinely discarded in the trash after meals. The Director of Staff Development confirmed the breach and noted that such information should be shredded or placed in a locked bin, as per facility policy.
The facility failed to transmit MDS assessments to CMS in a timely manner for three residents. One resident's admission assessment was submitted 43 days late due to the absence of a full-time MDS coordinator. Another resident's 5-day assessment was delayed by 20 days, with no evidence of a comprehensive or discharge assessment submitted. A third resident's quarterly assessment was delayed by 51 days, with no discharge assessment documented. These actions violated the facility's policy and OBRA regulations.
The facility failed to ensure proper monitoring and documentation for two residents receiving psychotropic medications. One resident was prescribed Olanzapine and Divalproex Sodium without specific behavior monitoring, while another was given Risperdal without a care plan for monitoring auditory hallucinations. Interviews confirmed the absence of necessary documentation and care plans, contrary to the facility's policy on psychotropic medication use.
A facility failed to develop a system to identify and investigate adverse events, as demonstrated by the case of a resident whose change in condition leading to death was not properly addressed. The resident, with severe cognitive impairment and multiple diagnoses, experienced significant changes in vital signs and pain levels that were not communicated to the RN or physician. The facility's QAPI program lacked a comprehensive approach, focusing only on fall reduction and relying on limited data sources.
A resident reported that his personal extension cord was removed from his room, and despite addressing the grievance to the Social Service Director (SSD), there was no follow-up or resolution. The SSD admitted to not logging the grievance or following up, contrary to facility policy, which requires grievances to be documented and resolved.
The facility failed to develop comprehensive care plans for three residents, resulting in inadequate monitoring of medications such as Lexapro, Vistaril, Apixaban, Divalproex, Olanzapine, Eliquis, and Risperdal. The Director of Staff Development confirmed the absence of care plans necessary for identifying side effects and managing specific behaviors associated with these medications.
A resident receiving oxygen therapy had their tubing touching the floor, contrary to the facility's infection control policy. The resident, with conditions including dementia and atrial fibrillation, was observed with the tubing on the floor, which was confirmed by an LVN and the Director of Staff Development.
A facility failed to ensure that two LVNs had the necessary competencies to assess and communicate changes in a resident's condition. A resident with a history of TIA, CVA, and A-fib was not properly monitored for significant changes in vital signs, and the LVNs did not notify the RN or physician about these changes. The DON acknowledged the lack of competency and communication, noting that the LVN Competency Checklist did not include respiratory assessments.
The facility did not update nurse staffing information daily as required. An observation revealed outdated staffing data at a nursing station, and the Director of Staff Development admitted to forgetting to post the current day's information. The facility's policy requires daily posting of staffing numbers for each shift, including RNs, LPNs, LVNs, and CNAs, in a clear and prominent manner.
A resident with a G-tube was prescribed Ativan to be administered via the tube, but the order was incorrectly transcribed to be given by mouth. The LVN did not notice the error and administered the medication incorrectly. Interviews with the DON and DSD confirmed the error, and facility policies for medication administration were not followed.
The facility failed to decrease the risk of preventable falls for two residents by not completing the required 72-hour post-fall monitoring and lacking a formal system for communicating fall risks and prevention measures between shifts, placing residents at increased risk for preventable falls and possible injury.
Failure to Inform Resident of Grievance Investigation Findings and Actions
Penalty
Summary
The facility failed to honor a resident’s right to be informed in writing of the findings and corrective actions related to multiple grievances, as required by its grievance policy. The resident, who had intact cognitive function and no documented behavioral symptoms, had been admitted with conditions including post-surgical amputation, acute osteomyelitis of the right ankle and foot, and diabetes mellitus. Review of nine Grievance/Complaint/Theft and Loss (GCT) forms filed by this resident over several months showed documentation of the grievance, investigation, recommended corrective action, and resolution, but did not include the investigation findings, the date or documentation that the resident was informed of those findings, or the corrective actions that would be taken. The forms also lacked a date indicating when the resident signed in acknowledgment of resolution. During interview, the resident reported signing the GCT forms when the former Social Service Director initially presented them but stated he was never informed of the investigation findings or actions taken. The DON’s review of the GCT forms, Social Service Progress Notes, and the medical record confirmed there was no documentation that the resident was informed of the investigation findings or corrective actions. The DON stated that the resident had signed the form at the time of filing the grievance, but in the section designated for resolution, and that no follow-up actions were relayed to the resident regarding the filed grievances. The facility’s written policy required that the resident or representative be informed of the investigation findings and corrective actions, both orally and in writing, and that a written summary be provided to the resident and filed in the Social Service office, which did not occur in this case.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a cognitively intact resident with decision-making capacity who had diagnoses including a right patella fracture and acute respiratory failure with hypoxia. The resident’s Change in Condition Evaluation noted behavioral changes with false allegations toward staff. On 1/7/2026, the Social Services Director (SSD) documented that the resident’s representative reported receiving a call from the dialysis center stating the resident claimed that “the walking ladies” at the facility hit her and forced her to walk. The representative told the SSD she believed the allegation was not true and that family had not observed any signs of abuse. The SSD reported the allegation to the Director of Nursing (DON), and the interdisciplinary team was made aware, but the allegation was not reported to the California Department of Public Health (CDPH) within two hours as required by the facility’s abuse reporting policy. Later that evening, a registered nurse documented that the police arrived and stated they had received a report from Adult Protective Services that the resident had reported to the dialysis center that three female physical therapy staff were forcing her to walk. The facility’s policy titled “Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating” required that all suspected abuse be reported immediately to the administrator and appropriate officials, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. During interview and policy review, the DON acknowledged that the policy was not followed because the incident was not reported to CDPH within two hours, explaining that the resident was not in the facility at the time the allegation was received.
Failure to Provide Language-Appropriate Communication Services
Penalty
Summary
The facility failed to ensure that a resident whose preferred language was Farsi was provided with appropriate communication and interpretation services. The resident, who was cognitively intact and able to make decisions, had a medical history including a right patella fracture, acute respiratory failure, and diabetes. Despite documentation indicating the resident's language preference as Farsi, the comprehensive care plans did not address the resident's communication needs or language preference. Additionally, the psychosocial assessment incorrectly listed Armenian as the primary language/interpreter. Interviews with staff revealed that the resident could not communicate effectively in English and only responded with simple yes or no answers and hand gestures. Staff members assumed the resident was 'ok' based on mannerisms and did not utilize interpreter services or contact the resident's family for interpretation. The facility's policy required access to translation services for residents with limited English proficiency, but this was not followed in the resident's case, resulting in a failure to accurately assess and address the resident's needs.
Failure to Develop Person-Centered Care Plans for Nutrition, Oxygen Therapy, and Epilepsy Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, resulting in deficiencies related to individualized care. For one resident with chronic pulmonary edema and acute respiratory failure, there was a significant weight loss and poor meal intake, yet the nutritional screening and care plans did not include the resident's food preferences. Interviews with the resident and staff confirmed that food preferences were never assessed or incorporated into the care plan, despite the resident expressing dissatisfaction with the food and the facility's policy requiring person-centered care planning. Three residents receiving oxygen therapy did not have care plans initiated after physician orders for oxygen were placed. These residents had varying degrees of cognitive function and required different levels of assistance, but in each case, the care plans failed to address the specifics of their oxygen therapy, including interventions, goals, and monitoring. Staff interviews confirmed the absence of these care plans and acknowledged that this omission could result in staff not knowing the full regimen for oxygen therapy or the specific needs of each resident. Another resident with epilepsy was prescribed multiple anticonvulsant medications, including Lacosamide, Keppra, and Lamictal, but no care plans were developed for these medications after the orders were placed. The DON confirmed that care plans should have been created to guide staff in monitoring for side effects and managing the resident's condition. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not followed, as evidenced by the lack of individualized care plans for the residents involved.
Failure to Label and Store Medications According to Policy
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications in accordance with professional standards and facility policy for two residents. Specifically, one insulin pen belonging to a resident with diabetes mellitus and a pressure ulcer was found in a medication cart without a label indicating the date it was first opened or when it should be discarded. The resident's records showed they had moderately impaired cognition and received insulin as part of their treatment. The nurse interviewed was unaware of when the insulin was first opened and acknowledged that all medications, including insulin, must be labeled with the opened date, as insulin should be discarded 28 days after opening. Additionally, another medication cart contained two bottles of over-the-counter medications, Naproxen Sodium and Vitamin B1, that were opened but not labeled with the date they were first accessed. Both the nurse and the Director of Nursing confirmed that multi-dose medications must be labeled with the opened date, and that some medications require discarding before the manufacturer’s expiration date once opened. Review of facility policies confirmed the requirement for labeling and timely discarding of multi-dose vials and containers.
Failure to Monitor Food Storage Temperatures and Discard Expired Juice
Penalty
Summary
The facility failed to adhere to professional standards for food storage and safety by not consistently monitoring and documenting refrigerator and dry storage room temperatures, as required by federal guidelines. During a kitchen tour, surveyors observed that temperature logs for the refrigerators and freezer were not completed for certain days, and staff interviews confirmed that daily temperature checks and documentation were sometimes missed. The Dietary Supervisor acknowledged that it was the responsibility of the morning cook to check and log temperatures daily, but this was not always done. Additionally, the facility did not follow its own policy regarding the storage of opened fruit juice. A jar of prune juice labeled with a date indicating it had been opened more than five days prior was found in the refrigerator, contrary to the facility's policy that opened fruit juices must be discarded after five days. The Dietary Supervisor was unsure whether the dates on food items referred to the opening or use-by dates and stated that staff should clearly label items. These practices were not in accordance with the facility's written policies and placed residents at risk for foodborne illness due to expired juice and inconsistent temperature monitoring.
Infection Control Deficiencies: Hand Hygiene, IV Line, and Enteral Feeding Tube Practices
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices for three residents. For one resident on contact precautions due to a multidrug-resistant organism (MDRO) in a foot wound, the alcohol-based hand sanitizer dispenser in the room was not functional, with the pump lever falling off when used. Staff interviews confirmed the importance of having a working hand sanitizer dispenser in the room for infection control, and facility policy required hand hygiene products to be readily accessible. Another resident, also on contact isolation for MRSA of the left leg and receiving IV antibiotics, was observed with an uncapped IV tubing port hanging from the IV pole and touching the bedside curtain. The nurse acknowledged the absence of a protective cap and stated she could not find one. Facility policy required all administration set connections to be secured, but this was not followed in this instance. A third resident with a gastrostomy tube (GT) for enteral feeding was observed with the GT administration set disconnected from the resident and hanging on an IV pole, with the tube port uncapped and exposed. The nurse responsible stated she did not cap the port, despite being responsible for preventing contamination. The Director of Nursing confirmed that all licensed nurses are required to follow infection prevention protocols, including proper handling and covering of feeding tube ports when not in use.
Failure to Obtain Informed Consent for Hypnotic Medication
Penalty
Summary
The facility failed to ensure that a resident with intact cognition and decision-making capacity was fully informed and provided with an opportunity to give informed consent prior to the administration of a hypnotic medication, specifically Zolpidem Tartrate (Ambien). The resident, who had significant medical conditions including acute respiratory failure with hypoxia, end stage renal disease, and heart failure, was admitted and readmitted to the facility. Documentation review revealed that the required informed consent form for the use of psychotropic and hypnotic medications was not signed by the resident, despite the resident's ability to understand and make decisions, as indicated in the medical record and assessment tools. Interviews with facility staff, including an LVN and the DON, confirmed that the informed consent process was not completed as required by facility policy. Both staff members acknowledged that the consent should have been obtained and that the omission meant the resident may not have been aware of the risks, benefits, or potential adverse effects of the medication. The facility's policy mandates that residents or their representatives must be informed and provide consent prior to the initiation of such medications, but this process was not followed in this instance.
Failure to Provide Resident with Advance Directive Information
Penalty
Summary
The facility failed to provide a resident with information regarding the right to formulate an Advance Directive (AD), as required by policy and regulation. Upon review, the resident's AD Acknowledgement Form indicated that an AD had been executed, but the facility did not have a copy on file. The resident's admission record showed multiple diagnoses, including congestive heart failure, Type 2 diabetes, and vascular dementia, and assessments confirmed the resident had the capacity to make decisions. However, during an interdisciplinary team conference, it was noted that the resident was not aware of having an AD, and the POLST form indicated no AD was present. Interviews with the DON and Social Worker confirmed that the documentation was inconsistent and that there was no evidence the resident had been provided with information about ADs. Further review of facility policy revealed that written information about the right to accept or refuse treatment and to formulate an AD should have been provided to the resident or their representative upon admission. The DON acknowledged that the facility was not following its own policy, which required inquiry about existing ADs and provision of information in an understandable manner. The resident also stated she did not have an AD and did not recall receiving information about it from the facility. This series of actions and inactions led to the deficiency, as the facility did not ensure the resident was informed of her rights regarding advance directives.
Failure to Resume Restorative Nursing Services for Resident with Limited Range of Motion
Penalty
Summary
A resident with a history of metabolic encephalopathy, generalized muscle weakness, and epilepsy was admitted and later readmitted to the facility with documented limitations in range of motion (ROM) in both upper and lower extremities. Assessments indicated moderate to severe ROM limitations, and the care plan specified the need for a Restorative Nursing Program (RNA) to maintain or prevent further decline in joint mobility. However, upon readmission, the physician's order for RNA exercises was discontinued and not reinstated, despite subsequent assessments and care plans continuing to indicate the need for such services. Observations and interviews with facility staff, including a CNA, LVN, RN Supervisor, and the Director of Rehabilitation, confirmed that the resident had not received RNA services for several months following readmission. Staff were unable to locate active orders for RNA in the resident's records, and several staff members acknowledged that the resident should have been receiving these services due to their limited ROM. The Director of Rehabilitation was unaware that the resident had returned to the facility without an active RNA order, and the DON could not explain why the RNA program was not resumed upon readmission. Facility policy and procedures required that residents with limited ROM receive restorative nursing care and interventions to prevent further decline. Despite these policies and the resident's documented needs, the facility failed to ensure the continuation of RNA services as indicated in the care plan and assessments. This lapse was identified through record review, staff interviews, and direct observation, demonstrating a failure to provide appropriate care to maintain or improve the resident's ROM.
Failure to Assess and Provide for Resident's Food Preferences During Nutritional Assessment
Penalty
Summary
A resident with chronic pulmonary edema and acute respiratory failure, who was cognitively intact and able to make decisions, was admitted to the facility. Upon review of the resident's records, it was found that neither the admission nor the comprehensive nutritional assessments included documentation of the resident's food preferences. The resident reported that no one had asked about their food preferences and expressed dissatisfaction with the food, specifically noting a desire for more meat, fresh vegetables, and less salty or overcooked food. Observations of meal trays confirmed that the food served was salty, mushy, and unappealing. Further review of the resident's records showed a significant weight loss of 7.54 lbs over approximately one month, with meal intake averaging only 25-50%. Interviews with the Director of Nursing and the Dietary Supervisor confirmed that the resident's food preferences were not assessed or incorporated into the care plan, and no measures were developed to address the resident's nutritional needs or prevent further weight loss. The facility's policy required that food preferences and dislikes be identified as part of the nutritional assessment, but this was not done for the resident.
Failure to Provide Routine Oxygen Therapy and Required Safety Signage
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who were receiving oxygen therapy. For one resident with diagnoses including acute respiratory failure with hypoxia, end stage renal disease, and heart failure, the physician's order specified routine oxygen therapy at three liters per minute via nasal cannula with a goal oxygen saturation above 92%. However, the resident was not consistently receiving routine oxygen therapy as ordered, and the oxygen saturation summary indicated only intermittent use. Additionally, there was no signage posted in the resident's room to indicate oxygen was in use, contrary to facility policy and safety protocols. For another resident with chronic obstructive pulmonary disease, dependence on supplemental oxygen, and atherosclerosis, the physician's order required routine oxygen therapy at two liters per minute via nasal cannula, with titration to maintain oxygen saturation above 92%. Observations revealed that this resident's room also lacked the required signage indicating oxygen use. Both the LVN and the DON confirmed that facility policy required a 'No Smoking/Oxygen in Use' sign to be posted outside the rooms of residents receiving oxygen therapy, and acknowledged that the absence of such signage was a safety hazard. Review of facility policies confirmed that 'No Smoking/Oxygen in Use' signs are necessary equipment when administering oxygen. The DON and LVN both stated that staff were not following physician's orders for routine oxygen therapy and were not adhering to facility policy regarding safety signage. These failures were identified through observation, interview, and record review, and were not in accordance with the facility's established procedures for oxygen administration.
Failure to Ensure Nurse Competency in Checking Gastric Residual Volume
Penalty
Summary
A deficiency was identified when a Licensed Vocational Nurse (LVN) failed to demonstrate appropriate competency in checking the gastric residual volume (GRV) for a resident with a gastrostomy tube (G-tube). The resident in question had diagnoses including dysphagia, muscle weakness, and required all medications via G-tube, with physician orders specifying that GRV should be checked every shift and tube feeding held if GRV exceeded 100 mL. During a medication pass, LVN 3 was observed aspirating only 20 mL from the resident's G-tube and stated that he routinely aspirated only 15 to 20 mL when checking GRV, unaware that more should be aspirated to obtain an accurate measurement. Further interviews revealed that another LVN and the Director of Nursing (DON) confirmed the correct procedure was to aspirate as much gastric content as possible until no more could be withdrawn or resistance was met. Upon re-assessment, LVN 3 found the actual GRV to be 110 mL, significantly higher than the initial 20 mL, acknowledging that the initial method was incorrect. Review of facility policies and procedures (P&P) confirmed that staff were required to aspirate all available gastric contents and take specific actions based on the volume obtained. The resident's records indicated severely impaired cognition and an inability to make decisions, further emphasizing the need for accurate and competent care. Although LVN 3's training records showed prior demonstration of the correct procedure, the observed practice did not align with facility policy or physician orders, resulting in a failure to ensure staff competency in a critical aspect of resident care.
CNA Provided Resident Care with Expired Certification
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) was found to be working with an expired certification. Record review and interviews with the Director of Staffing Development (DSD) confirmed that the CNA's certification had expired and had not been renewed, yet the CNA continued to provide direct resident care. The DSD acknowledged responsibility for monitoring certification status and stated that although the CNA was informed of the upcoming expiration, there was no follow-up to ensure renewal. The CNA herself confirmed she was aware of the expiration, had submitted a renewal application, but had not yet received the renewed certification, and continued to work scheduled shifts during this period. Further review of facility policies and job descriptions indicated that CNAs are required to maintain current certification in accordance with state laws and facility procedures. The Director of Nursing (DON) also confirmed that only staff with current, non-expired certifications or licenses are permitted to provide resident care. Despite these policies, the lapse in monitoring and enforcement allowed the CNA to work with an expired certification, contrary to facility and regulatory requirements.
Medication Error Rate Exceeds 5% Due to Improper Administration Techniques
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less during a medication pass, resulting in a cumulative error rate of 10.3% based on three medication errors out of 29 opportunities. Two residents were directly affected by these errors during observed medication administration by licensed nursing staff. The errors were identified through observation, interview, and record review. For one resident with a gastrostomy tube and diagnoses including diabetes mellitus, muscle weakness, and hyperthyroidism, the nurse did not flush the G-tube with the prescribed amount of water after administering methimazole. The resident's physician orders and facility policy required flushing the tube before and after medication administration to ensure the full dose was delivered. The nurse acknowledged forgetting to flush the tube, and the DON confirmed that failure to flush could result in the resident not receiving the correct medication dose. Another resident with glaucoma and diabetes mellitus received ophthalmic medications, Brimonidine and Brinzolamide, without the nurse applying pressure to the inner eye after administration. Physician orders and manufacturer instructions specified that pressure should be applied to the inner eye to ensure proper medication delivery and absorption. The nurse admitted to forgetting this step, and the DON confirmed its importance in medication administration for ophthalmic treatments.
Failure to Timely Administer Oxygen Therapy for Resident with Shortness of Breath
Penalty
Summary
A deficiency occurred when a resident with a history of hypertensive heart disease, heart failure, shortness of breath (SOB), and pulmonary embolism did not receive oxygen therapy as ordered by the physician. The resident had a physician's order for PRN oxygen at 2 liters per minute for SOB and wheezing, with the option to titrate up to 3-4 liters. On the morning in question, the resident began experiencing SOB and reported feeling unwell to staff at approximately 8 AM. Despite these complaints and a documented oxygen saturation as low as 88% on room air, oxygen was not administered until approximately 4:30 PM, resulting in an 8.5-hour delay. Throughout the day, multiple staff members, including a CNA, LVN, and RN, were made aware of the resident's symptoms. The resident continued to complain of SOB and headache, and family members were also informed by the resident of her distress and lack of oxygen administration. Vital signs taken during this period showed fluctuating oxygen saturation levels, with a notable drop to 91% and 88% at different times. Despite these findings and the resident's ongoing complaints, staff did not initiate oxygen therapy as per the physician's order, and instead, the resident was referred for a psychiatric consult for possible anxiety. It was not until the resident's condition worsened, with labored breathing, bilateral wheezing, and use of accessory muscles, that oxygen was finally administered using a non-rebreather mask, and emergency services were called. The resident was subsequently transferred to a general acute care hospital for respiratory distress, where further evaluation revealed edema and infection. Interviews with staff and the resident confirmed that oxygen was not provided in a timely manner, despite clear indications and physician orders.
Breach of Medical Record Confidentiality
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of medical records for one of its residents, Resident 2, by mistakenly sending their medical records to a general acute care hospital (GACH) with another resident, Resident 1. This incident occurred during an emergency situation when Resident 1 experienced a change in condition and required transfer to the hospital. The records sent included Resident 2's Face Sheet, MD Orders, POLST, and History and Physical, which were not relevant to Resident 1's condition. Resident 1 was admitted to the facility with diagnoses including influenza and dementia, and lacked the capacity to make medical decisions. Resident 2, on the other hand, had diagnoses of chronic obstructive pulmonary disease and pleural effusion, and had a POLST indicating a Do Not Resuscitate order. The mix-up of records was discovered when the emergency room case manager at the GACH noted that the records did not match Resident 1's condition, raising concerns about the accuracy of the information provided. The Director of Nursing (DON) stated that the RN supervisor was responsible for ensuring the correct medical records were sent with the resident during transfers. However, on the day of the incident, the RN supervisor and the LVN charge nurse were both from a Nursing Registry, and the RN supervisor, RN 1, admitted to sending the wrong records due to the emergency situation and lack of familiarity with the facility's resources. The facility's policy on confidentiality of information, which mandates safeguarding resident records, was not adhered to in this instance.
Resident Transferred with Incorrect Medical Records
Penalty
Summary
The facility failed to ensure that appropriate information and documentation were communicated to the receiving health care institution for a resident who was transferred to a General Acute Care Hospital (GACH) emergency room due to a change in condition. The resident was transferred with incorrect records meant for another resident, which included another resident's Advance Directive, history and physical, medication orders, and laboratory results. This error had the potential to result in a delay in treatment, inappropriate medical interventions, or the GACH not being able to follow the resident's wishes regarding life-sustaining treatments. The resident in question was initially admitted to the facility with diagnoses including influenza and dementia, and was noted to have severe cognitive impairment, requiring substantial assistance for daily activities. On the day of the transfer, the resident experienced a change in condition, including a decreased level of consciousness, hypotension, and tachycardia, prompting the transfer to the GACH for further evaluation. However, the records sent with the resident were for a different individual, leading to confusion and a delay in obtaining the correct medical information. Interviews with facility staff revealed that the error occurred because the registered nurse on duty, who was from a nursing registry, mistakenly sent the wrong records. The facility's Director of Nursing confirmed that the RN supervisor was responsible for ensuring the correct documentation was sent with the resident. The facility's policy requires that a complete and accurate transfer record accompany the resident to ensure continuity of care, but this protocol was not followed in this instance.
Failure to Ensure Safe Transfer of Resident to Hospital
Penalty
Summary
The facility failed to ensure a safe and orderly transfer of a resident to a General Acute Care Hospital (GACH) following a change in condition. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was transferred without proper identification and with incorrect medical records. The resident's medical history and medication information were not accurately communicated to the receiving facility, which could have led to delays in treatment or incorrect medical interventions. The incident occurred when the resident experienced a change in condition, including hypotension and tachycardia, and was transferred via emergency services. However, the medical records sent with the resident belonged to a different resident, who was the roommate of the transferred resident. This error was discovered after the resident arrived at the GACH, leading to confusion and a delay in obtaining the correct medical records. The facility's Director of Nursing (DON) confirmed that the RN supervisor was responsible for ensuring the correct documentation was sent, but the RN on duty was from a Nursing Registry and unfamiliar with the facility's procedures. Interviews with facility staff and the GACH ER Case Manager revealed that the facility identified residents by room and bed numbers, which contributed to the mix-up. The resident was not wearing an identification wristband, which was against the facility's policy. The DON acknowledged the error and the potential for delayed treatment due to the incorrect records being sent. The facility's policy on transfers and discharges was not followed, leading to this deficiency.
Facility Fails to Address Water Leaks and Safety Hazards
Penalty
Summary
The facility failed to maintain a safe environment for residents, staff, and the public, as evidenced by multiple leaks and water damage observed in various areas of the facility. Observations revealed plastic tarps covering parts of the roof, indicating potential water leaks. In Resident 2's room, paint was bubbling and discolored above bed B, and the resident reported a steady water leak that staff attempted to manage with bed linens and towels. Similar issues were noted in the activity room, where water was leaking from the ceiling near the entrance to the administrative office, and in the shared bathroom, where paint was bubbling and cracking above the toilet area. In the facility kitchen, paint was observed bubbling and cracking around the ceiling directly over the mechanical washing area, posing a potential infection control risk. The Dietary Supervisor confirmed that the roof started leaking, and despite the damage, the kitchen continued to operate and serve food. The Maintenance Supervisor acknowledged the leaks and placed plastic tarps on the roof but did not take further action to address the internal damage or contact an outside contractor for repairs. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of awareness and communication regarding the leaks. The Administrator instructed the Maintenance Supervisor to place tarps but did not notify the State Agency or seek external assistance. The facility's policy on safety and supervision emphasized the importance of maintaining an environment free from hazards, yet the observed conditions and staff responses indicated a failure to adhere to these standards.
Water Damage Causes Anxiety Among Residents
Penalty
Summary
The facility failed to provide a safe environment for residents during a rainstorm, resulting in water damage to the rooms of three residents. Resident 1, who has schizoaffective disorder and anxiety disorder, experienced anxiety due to water leaking from the ceiling onto her roommate's bed and the floor. The staff attempted to manage the situation by removing soaked linens, placing a plastic bag over the bed, and using a bucket to collect the water. Despite these efforts, Resident 1 remained in her room all day, feeling anxious about her safety. Resident 2, diagnosed with hypertension and depression, also experienced anxiety due to water leaking in her room and the activity room. The water was leaking from the ceiling and pooling on the floor, with staff using towels and linens to soak up the water. Resident 2 expressed concern about the potential for the ceiling to collapse due to the water damage. Similarly, Resident 3, who has cerebral infarction and hemiplegia, felt anxious when water started pooling at the foot of her bed. The staff used linens and towels to manage the water, but Resident 3 remained worried about the ceiling leaking over her bed. The Maintenance Supervisor acknowledged the water damage and took action by placing a tarp on the facility's roof. However, the supervisor did not have time to inspect the resident rooms due to significant damage in the kitchen. The facility's policy on safety and supervision emphasizes the importance of maintaining an environment free from accident hazards, but the water damage and subsequent anxiety experienced by the residents indicate a failure to uphold this policy.
Failure to Implement Post-Surgical Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident following a right hip reduction surgery. The resident, who was readmitted to the facility after surgery, had orders from the orthopedic surgeon to use a knee immobilizer and an abduction pillow to prevent further dislocation of the hip. However, the facility did not ensure that these devices were consistently used, as there was no documentation or care plan addressing the resident's use of the knee immobilizer or the abduction pillow. The resident, who had severe cognitive impairment and was unable to follow commands due to dementia, was noted to be restless and non-compliant with the post-surgical treatment plan. Despite the physician's orders, the resident was often found without the knee immobilizer or abduction pillow, and staff interviews revealed that the resident frequently removed these devices. The Director of Nursing and other staff members could not confirm consistent use of the knee immobilizer or the abduction pillow, and there was no care plan in place to address the resident's refusal to wear these devices. The facility's policies and procedures require the development of comprehensive, person-centered care plans based on resident assessments. However, in this case, the interdisciplinary team did not create a care plan to address the resident's specific needs post-surgery, including the use of the knee immobilizer and abduction pillow. This lack of a care plan and failure to implement physician orders potentially exposed the resident to post-surgical complications, such as recurrent hip dislocation.
Failure to Ensure Resident Dignity During Care
Penalty
Summary
The facility failed to ensure that Resident 2 was treated with dignity and respect during routine care. Resident 2, who was admitted with a diagnosis of cerebral infarction and hemiplegia, required moderate assistance with toileting hygiene. The care plan for Resident 2 included maintaining cleanliness and providing perineal care as needed. However, during diaper changes, two CNAs, CNA3 and CNA4, engaged in inappropriate behavior by teasing Resident 2 about her relationship with her boyfriend, making demeaning comments about her age and sexual activity. This behavior was reported by Resident 2 to her social worker and the Director of Staff Development (DSD), but no formal investigation or documentation was conducted by the DSD. The facility's policy on dignity, revised in February 2021, mandates that residents be treated with respect and prohibits demeaning practices. Despite this policy, the DSD did not investigate the incident further or address the behavior of CNA3 and CNA4. The employee records for these CNAs showed no past corrections or in-services related to resident dignity. Additionally, the grievance logs for 2023 and 2024 did not contain any entries regarding this incident, indicating a lack of formal grievance filing. This deficiency in ensuring resident dignity and respect was identified through observation, interview, and record review.
Improper Discharge of Resident Without Consent or Adequate Documentation
Penalty
Summary
The facility failed to properly manage the discharge of a resident, identified as Resident 1, from Skilled Nursing Facility (SNF) 1 to another facility, SNF 2. Resident 1, who had a history of dementia and was at risk for wandering, was discharged without adequate documentation or the consent of the resident or their responsible parties (RP 1 and RP 2). The discharge was initiated by SNF 1 due to their inability to meet Resident 1's need for supervision, but the necessary documentation outlining the specific needs that could not be met, the efforts made to meet those needs, and the services SNF 2 would provide was not completed. Additionally, the discharge occurred without the required 30-day advance written notice to the resident and their responsible parties, and without a proper interdisciplinary team (IDT) meeting to discuss the discharge plan. The discharge process was mishandled, as evidenced by the lack of communication and documentation. Resident 1 was transferred to SNF 2 without the knowledge or approval of RP 1 and RP 2, leading to distress and refusal of care by Resident 1 upon arrival at SNF 2. The facility's staff, including the Admissions Coordinator (ADC 1) and Case Coordinator (CC 1), failed to provide the necessary information and resources to the responsible parties, and did not involve them in the discharge planning process. The facility also did not have a wander guard system in place, which contributed to their decision to discharge Resident 1. The facility's actions resulted in Resident 1 being returned to SNF 1 after refusing to stay at SNF 2. Interviews with staff and responsible parties revealed a lack of communication and coordination in the discharge process. The facility did not follow its own policies and procedures regarding discharge planning and notification, leading to a deficiency in the care provided to Resident 1.
Failure to Provide Proper Notice for Resident Transfer
Penalty
Summary
The facility failed to adhere to its Policies and Procedures regarding the transfer or discharge of a resident, specifically Resident 1, who was diagnosed with dementia and exhibited wandering behavior. The facility did not provide a written notice to Resident 1 or their responsible party (RP 1) prior to discharging Resident 1 to another Skilled Nursing Facility (SNF 2). Additionally, the facility did not send a copy of the notice to the Ombudsman, as required by their policy. Resident 1 was admitted with diagnoses including dementia, altered mental status, and mobility issues. The facility's records indicated that a physician ordered a lateral transfer to SNF 2 on January 28, 2025, with the notice of transfer/discharge dated the same day, and the effective date set for January 31, 2025. However, Resident 1 was transferred on January 29, 2025, without the required written notice being provided to RP 1 or the Ombudsman. Interviews revealed that RP 1 was only informed of the transfer over the phone, and the Ombudsman was not notified in writing, which is a violation of the facility's policy. The Director of Nursing (DON) confirmed that there was no urgent need for the transfer, as Resident 1 had not endangered themselves or others, and there was no documentation from a physician or psychiatrist recommending an urgent transfer. The DON also acknowledged that there was no interdisciplinary team meeting for discharge planning, and Resident 1 missed a scheduled medication due to the transfer. The facility's policy requires a 30-day advance written notice for planned transfers, which was not followed in this case.
Failure to Develop Care Plan for Resident's Eye Injury
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for Resident 2 after an altercation with Resident 1, which resulted in Resident 2 being hit in the left eye. Despite the incident being documented in Resident 2's progress notes and SBAR Communication Form, there was no evidence of a care plan addressing the injury to Resident 2's left eye. Interviews with Resident 2, a CNA, and an RN confirmed the absence of a care plan for the injury, which was acknowledged as necessary by the RN and the Director of Nursing (DON). Resident 1, who has diagnoses including psychosis, altered mental status, and dementia, was noted to have severely impaired cognition and required supervision and assistance with daily activities. Resident 2, with diagnoses of diabetes mellitus, hypertension, and weakness, was noted to have intact cognition and the capacity to make decisions. The facility's policy on care plans emphasizes the need for ongoing assessments and revisions as residents' conditions change, which was not adhered to in this case, leading to the deficiency.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with type 2 diabetes mellitus, whose blood sugar levels were consistently elevated over a three-day period. Despite the resident's blood sugar levels being significantly above the normal range, the facility did not inform the physician until a day after the elevated levels were first recorded. The resident's blood sugar levels ranged from 212 mg/dL to 495 mg/dL, which is well above the normal range of 80 to 120 mg/dL. The facility's records did not show any notification to the physician about these elevated levels on the first two days. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the facility's standard practice was to notify the physician if blood sugar levels exceeded 400 mg/dL, despite the facility's policy requiring prompt notification for any significant change in condition. The LVN admitted to not reporting the elevated levels because there was no specific parameter set by the physician for when to report such levels, and the resident was receiving routine diabetes medications. The physician, however, stated that he should have been notified if the blood sugar level exceeded 200 mg/dL, as it could lead to serious health complications.
Failure to Monitor Urinary Catheter Output
Penalty
Summary
The facility failed to implement its policy and procedure for the care of a resident with a urinary catheter, resulting in a deficiency. The facility did not maintain an accurate record of the resident's daily urine output, which is crucial for preventing urinary catheter-associated urinary tract infections. This oversight was identified for a resident who was admitted with severe sepsis and pneumonia and had an indwelling urinary catheter. The care plan for the resident included monitoring and documenting fluid intake and output to prevent urinary tract infections, but this was not done according to the facility's policy. The deficiency was highlighted when the resident was hospitalized due to a urinary tract infection, sepsis, and a sudden decline in health condition. Interviews with the Director of Nursing and a review of the resident's medical records confirmed the lack of documentation for fluid intake and output monitoring. The primary physician emphasized the importance of monitoring to detect potential complications such as obstructions in the urinary system. The facility's policy on catheter care, revised in 2014, also underscored the need for accurate daily output records to prevent infections.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care to a resident by not assessing the respiratory status and reporting to the physician when the resident's oxygen saturation decreased to 92%. The facility also did not obtain a physician's order to administer oxygen and failed to reassess the effectiveness of the oxygen intervention. The resident, who was admitted with pneumonia and respiratory failure, had a severely impaired cognition and was observed with labored breathing and shortness of breath. Despite administering oxygen therapy, there was no documented physician order for this intervention, and the resident's condition was not reassessed to determine the effectiveness of the oxygen therapy. The resident's oxygen saturation levels fluctuated, and the facility did not document reassessment of the resident's respiratory status after administering oxygen. The RN eventually placed the resident on a high concentration of oxygen via a non-rebreather mask while waiting for emergency services, but again, there was no documentation of reassessment of the resident's oxygen saturation. Interviews with the DON and the physician confirmed the lack of documentation and reassessment, which was against the facility's policy on oxygen administration.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its abuse prevention policy for a resident by not reporting an allegation of abuse to law enforcement as required by their policy. The resident, who was admitted with diagnoses including Diabetes Type II, dysphagia, and cirrhosis of the liver, reported to a CNA that she was hit the previous night. The CNA informed an RN, who then assessed the resident and found no injuries. The resident was unable to provide details about the alleged perpetrator and later stated that she was threatened but not hit. Interviews with facility staff revealed a lack of clarity regarding the reporting process for allegations of abuse. An LVN was unsure if the allegation should be reported to law enforcement and needed to verify the process with the DON. An RN also did not know which agencies to report to and would defer to the DON. The DON, who was responsible for the investigation, reported the allegation to the California Department of Public Health and the ombudsman but did not report it to law enforcement, as she was unaware of this requirement. The facility's policy, revised in September 2022, mandates that suspicions of abuse, neglect, exploitation, or misappropriation must be reported immediately to the administrator and other officials, including law enforcement, according to state law. The policy specifies that such reports should be made within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. The failure to report the allegation to law enforcement as per the policy constitutes a deficiency in the facility's abuse prevention practices.
Failure to Develop Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to develop a resident-centered care plan and monitor a resident after an allegation of abuse. The resident, who was admitted with diagnoses including Diabetes Type II, dysphagia, and cirrhosis of the liver, reported to a CNA that she was hit the previous night. However, when questioned by the RN, the resident was unable to provide details about the alleged incident and later stated that she was threatened but not hit. A thorough body assessment revealed no injuries, and the incident was reported to the DON and the Administrator. Despite the report of the incident, the facility did not initiate a care plan for the resident to address the allegation of abuse. Interviews with the LVN, DSD, and RN confirmed that no care plan was developed, and there was no documentation of monitoring the resident for emotional distress. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timetables to meet the resident's needs. The lack of a care plan and monitoring for emotional distress was acknowledged by the DSD and DON, who stated that the licensed nurses should have developed a care plan and monitored the resident for emotional distress every shift. The Social Worker also noted that if she was unavailable, the nurses should have monitored the resident. The failure to develop a care plan and monitor the resident for emotional distress after the allegation of abuse was identified as a deficiency in the facility's practices.
Privacy and Dignity Violations in Shared Shower Rooms
Penalty
Summary
The facility failed to protect the privacy and dignity of eight residents by allowing other residents to use their designated shower rooms. Specifically, male residents were observed using the shower room located in the room of two residents, while female residents were using the shower room located in the room of three other residents. This practice was confirmed through observations and interviews with the residents, who expressed discomfort and embarrassment due to the lack of privacy and the presence of other residents in their personal spaces. The report details the medical conditions and cognitive statuses of the affected residents, highlighting their varying levels of dependency and need for assistance with personal care activities. Despite these needs, the facility's practice of using shared shower rooms compromised the residents' rights to privacy and dignity. Interviews with staff members, including CNAs and LVNs, revealed an awareness of the issue, but they cited the lack of alternative shower facilities as the reason for this practice. The facility's policies on resident rights and dignity emphasize the importance of maintaining privacy and respect for each resident's individuality. However, the longstanding practice of using shared shower rooms for all male and female residents, as confirmed by the maintenance supervisor and the Director of Nurses, directly contradicted these policies. The report concludes with the acknowledgment of the privacy and dignity concerns by the Director of Nurses, who indicated an intention to discuss the issue with the facility administrator.
Failure to Accommodate Shower Preferences Affects Resident Privacy
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents regarding their showering arrangements, which affected their privacy and dignity. Resident 1, who was admitted with conditions such as cerebral infarction, COPD, and cirrhosis of the liver, expressed a preference for not having other residents use his bathroom for showering. Despite being alert and oriented, Resident 1 required substantial assistance with bathing. However, the facility used his bathroom as the sole male shower room, leading to other residents, including Resident 3, using it regularly. Resident 3, who had been living in the facility for 21 months, also preferred to shower in a private room. Diagnosed with acute embolism and thrombosis, cervical spinal stenosis, and muscle weakness, Resident 3 required moderate assistance with personal hygiene. Despite his cognitive status being intact, he was subjected to showering in Resident 1's bathroom, which he found embarrassing, especially when other residents were lined up to use the shower. Interviews with staff, including a CNA, LVN, and the Director of Nurses, revealed that the facility had only one male shower room located in Resident 1's room. The staff acknowledged the privacy and dignity issues but believed there was a waiver in place. The facility's policies on resident rights and dignity emphasized the importance of personal privacy and maintaining residents' dignity, which were not upheld in this situation.
Failure to Implement Low Bed Intervention for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who was at high risk for falls and had experienced an actual fall with injury. The resident, who had a history of epilepsy, COPD, and cirrhosis of the liver, fell from bed during a seizure and sustained a laceration above the right eye. Despite the care plan intervention specifying the use of a low bed for safety, observations and interviews revealed that the resident was not placed on a low bed, which was a critical measure to prevent further injury. Interviews with the Director of Staff Development, a Licensed Vocational Nurse, and the Director of Nurses confirmed that the low bed intervention was not implemented as required by the care plan. The facility's policy and procedure on care plans and fall risk management emphasized the importance of implementing resident-centered interventions based on comprehensive assessments to prevent falls and minimize complications. However, the failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility failed to ensure that a resident with severely impaired cognition and severe contractures was free from accidents and hazards. The resident, who was dependent on staff for all activities of daily living, was not provided with adequate supervision and care planning. The facility did not develop a care plan to address the resident's specific needs for assistance with bathing and transfers, nor did they ensure that staff were informed of the resident's limitations and the appropriate methods for providing care. On the day of the incident, a Certified Nurse Assistant (CNA) from a nursing registry, who was unfamiliar with the resident, was assigned to provide care. The CNA was not informed of the resident's need for a bed bath due to severe contractures and instead attempted to shower the resident using a shower chair. During the process, the resident experienced severe pain, and it was later discovered that the resident had sustained multiple fractures and injuries, including a displaced fracture of the left acetabulum and multiple pelvic fractures. Interviews and record reviews revealed that the facility staff, including the Licensed Vocational Nurse (LVN) and Registered Nurse (RN), failed to communicate the resident's care needs and limitations effectively. The facility's policies and procedures for safety and supervision were not followed, and there was no documented evidence of a care plan addressing the resident's bathing needs. The lack of communication and proper care planning led to the resident's injuries and subsequent hospitalization.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to implement its policy and procedure regarding the notification of a physician for a significant change in a resident's condition. Specifically, the facility did not ensure that the physician was immediately notified when a resident experienced a significant change in vital signs, including decreased blood pressure and increased heart rate, as well as new pain, moaning, fidgeting, and agitation. The Licensed Vocational Nurse (LVN) did not notify the Registered Nurse (RN) or the physician about these changes, which were significant deviations from the resident's baseline condition. The resident, who had a history of severe cognitive impairment and required assistance with daily activities, was found with a blood pressure and heart rate that indicated a significant change from their baseline. Despite these changes, there was no documented evidence that the physician was notified. Additionally, the resident was observed to be in pain, with a pain level of 7 out of 10, but the physician was not informed, and no stronger pain medication was administered beyond Tylenol. The resident's condition continued to deteriorate, leading to unresponsiveness and eventually death. The facility's failure to notify the physician and conduct appropriate assessments and interventions resulted in the resident not receiving the necessary care to address the significant changes in their condition. The lack of timely notification and documentation of the resident's condition changes contributed to the resident's continued decline and eventual death, as the facility did not adhere to its policies for managing changes in a resident's condition.
Removal Plan
- Current licensed nurses were re-in serviced in person regarding identifying abnormal vital signs and documentation for a change of condition, including changes in pain level, respiratory status, oxygen saturation rate, and out of range blood pressure. The DSD/Designee will in-service licensed staff in person to complete 100% in-service to licensed staff.
- Current licensed nurses were re-in serviced in person on timely notification of a RN or the Director of Nursing (DON) regarding a change of condition, including changes in vital signs. The DSD/Designee will in-service license staff in person to complete 100% in-service licensed staff.
- A follow up in-service will be conducted to determine knowledge retention for timely notification of a RN and physician regarding a change of condition.
- Licensed nurses will be assessed for documentation competency, including notification of RN and physician for a change in condition, using the Documentation Competency Checklist. Competencies for all licensed staff will be completed within 30 days from initiation of Documentation Competency Checklist, 90 days after first licensed staff evaluation, and then annually thereafter.
- Licensed nurses will be in-serviced in person by DON/DSD/Designee regarding new Documentation Competency Checklist. DON/DSD/Designee will in-service license staff in person to complete a 100% in-service to license staff.
- Competency Checklist will be added to all new hire LVN/RN orientation.
- Policy and Procedure will be updated to reflect new audit tool, including elements to be incorporated into the audit such a documentation of changes in condition notification of RN and physician, and completion of appropriate assessments.
- Policy and Procedure will be updated to reflect procedure for documentation of change in condition, including parameters for notifying RN or physician.
- DSD/Designee will complete random audits to test knowledge of in-service regarding notification of changes to RN and physician. Results will be logged on the spot check tool. Audits will be complete 3 times per week for 4 weeks, then weekly for 4 weeks, then monthly for 4 months.
- LVN 1 will be provided an additional 1:1 in-service on proper notification of a physician and the RN for any changes in condition.
- LVN 1 will meet with the DON/Designee on a regular basis to review any changes in condition during the scheduled shift for the next 30 scheduled workdays. 1:1 in-service will be provided as needed.
- Certified Nursing Assistants (CNAs) were re-in-serviced regarding reporting of changes in condition to the supervisor or charge nurse.
- A follow up in-service will be conducted to determine knowledge retention for reporting of changes in condition.
- Residents with any changes in condition will be reviewed in morning meeting by the IDT. Any findings on the audit tool (Exhibit 1.1) will be addressed, 1:1 in-service will be provided as needed.
- Review of documentation of changes in condition, including notification of RN and physician, will be completed at various times weekly by DON/Designee for the next 30 days then semi-monthly for 1 month then monthly for 1 month. Issues noted will be resolved. 1:1 in-service will be provided as needed. Information for which charts to review will be based on the audit tool (Exhibit 1.1).
- Consultant will review a random sampling of resident charts, based on audit tool (Exhibit 1.1) on a regular basis for 30 days or CDPH revisit, whichever is longer, to verify that documentation has been completed for patients with any changes in condition, including notification to RN and physician. Issues noted will be resolved and additional in-services will be provided as needed.
Failure to Monitor and Assess Resident with TIA and CVA
Penalty
Summary
The facility failed to properly assess and monitor a resident, identified as Resident 53, who had a history of transient ischemic attack (TIA) and cerebral vascular accident (CVA). The resident was recently hospitalized for a change in mental status and was diagnosed with TIA and CVA. The facility did not ensure that Licensed Vocational Nurses (LVN) 1 and 2 assessed and monitored the resident for signs and symptoms of TIA and stroke, such as changes in mental status, blood pressure (BP), heart rate (HR), and respiratory rate (RR). Additionally, the facility did not notify the physician of significant changes in the resident's vital signs, including a decrease in BP and an increase in HR. The report highlights that LVN 1 did not assess the source of the resident's pain when the resident exhibited a pain level of 7 out of 10. Furthermore, LVN 2 delayed calling for assistance and notifying the physician when the resident was found unresponsive, with no BP reading and diminished respirations. The facility also failed to develop a care plan for the resident to address monitoring and assessment for TIA, stroke, and atrial fibrillation (A-Fib). These deficiencies resulted in the resident not receiving immediate care and emergency interventions, leading to a continued decline in vital signs and mental status. The resident's condition deteriorated, and they were pronounced dead by paramedics. The facility's policies and procedures for pain assessment and management, as well as for changes in a resident's condition, were not followed. The report indicates that there was no documented evidence of a care plan addressing the resident's medical conditions, and the facility did not notify the physician of significant changes in the resident's condition, contributing to the resident's death.
Removal Plan
- Current licensed nurses will be re-in serviced in person regarding assessment, monitoring, evaluation for a history of TIA and stroke.
- DSD/Designee will in-service licensed staff in person to complete a 100% in-service to licensed staff.
- DSD/Designee will complete random audits to test knowledge of in-service regarding assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke. Results will be logged on the spot check tool.
- LVN 1, LVN 2, and RN 1 will be provided an additional 1:1 in-service on assessment, monitoring, and evaluation for a history of TIA and stroke, including documentation for any changes.
- Residents with any changes in condition, including those with TIA and stroke will be reviewed in morning meeting by the Interdisciplinary Team (IDT).
- Any findings on the audit tool will be addressed, 1:1 in-service will be provided as needed.
- Review of documentation, including assessment, monitoring, and evaluation for a history of TIA and stroke associated with a change in condition, will be completed at various times by DON/Designee. 1:1 in-service will be provided as needed.
- Consultant will review a random sampling of resident charts, based on a list provided by the facility, to verify that appropriate assessment, monitoring, and evaluation for a history of transient ischemic attack and stroke associated with a change in condition has been documented. Issues noted will be resolved and additional in-services will be provided as needed.
Facility Lacks Medical Director and Updated Policies
Penalty
Summary
The facility failed to designate a physician to serve as the medical director responsible for implementing resident care policies and coordinating medical care. This deficiency persisted for six months, affecting all 46 residents, including a resident who was readmitted with significant medical conditions such as aftercare following surgery on the digestive system and dysphagia following a cerebral infarction. The facility did not have a designated medical director since June 2023, which led to a lack of thorough evaluation of the resident's change in condition and subsequent death. The resident's clinical record showed no evidence of investigation into whether the facility's failure to provide healthcare interventions within professional standards contributed to the resident's death. Additionally, the facility's healthcare policies and procedures were outdated and had not been reviewed or approved by a medical director to ensure they met current professional standards. Policies such as 'Change in a Resident's Condition or Status' and 'Pain Assessment and Management' had not been updated since 2017 and 2015, respectively. The facility's administrator acknowledged the absence of a medical director and was in the process of hiring one, but no decision or contract had been finalized. The lack of a medical director and outdated policies had the potential to result in substandard care delivery and failure to provide necessary care and services to residents.
Resident Privacy Breach in Kitchen Area
Penalty
Summary
The facility failed to protect the privacy of a resident's personal and medical information, as required by their policy and procedure titled HIPAA Privacy- Basic Do's and Don'ts to Remember. During an initial kitchen tour, a piece of paper containing a resident's name, room number, and medical record number was found in a trash can near the dishwashing area. This trash can also contained food and other residents' information, making the personal information readily observable by unauthorized individuals. The resident involved had a history of metabolic encephalopathy, severe protein-calorie malnutrition, and hemorrhage of the anus and rectum, and was noted to have moderately impaired cognition. The Dietary Supervisor admitted that residents' name cards, which contain personal information, are routinely discarded in the trash after meals because they become soiled with food. The Director of Staff Development confirmed the exposure of resident information in the kitchen trash can and acknowledged that such information should be shredded or placed in a locked bin for proper disposal. The facility's policy clearly states that any papers with patient health information should be shredded or placed in a locked bin, and not discarded in the trash in a readable form.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) for three residents. Resident 41 was admitted and readmitted to the facility with a diagnosis of Type 2 Diabetes Mellitus. The MDS Admission Assessment for Resident 41 was created but not completed or submitted to CMS until 43 days after the required deadline. The Director of Staff Development (DSD) indicated that the facility lacked a full-time MDS coordinator during this period, which contributed to the delay. Resident 45 was admitted with diagnoses including sepsis and bacteremia, and their 5-day MDS assessment was not signed by the RN assessment coordinator until 20 days after the admission. Additionally, there was no documented evidence of a comprehensive or discharge MDS assessment being submitted to CMS for Resident 45. Similarly, Resident 26, admitted with osteomyelitis and other conditions, had a Quarterly MDS Assessment that was not signed until 51 days after the due date, and there was no evidence of a discharge MDS being submitted. The facility's policy required all MDS assessments to be completed and transmitted in accordance with OBRA regulations, which was not adhered to in these cases.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were not receiving medications without proper indication, excessive dosage, or inadequate monitoring. Resident 1 was prescribed Olanzapine and Divalproex Sodium for schizophrenia and mood disorder, respectively, but there was no documented evidence of behavior monitoring specific to these medications. The facility's Medication Regimen Review for May and June 2024 did not include a review by the Pharmacist Consultant for the lack of monitoring of Resident 1's behaviors related to these psychotropic medications. Interviews with the Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN) 4 confirmed the absence of a care plan or physician order to monitor Resident 1's behaviors. Resident 44 was prescribed Risperdal for schizophrenia manifested by auditory hallucinations. However, there was no documented evidence of a care plan indicating specific concerns or how Resident 44 was being monitored for auditory hallucinations. Interviews with Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1 revealed that Resident 44 was initially verbal and talked to himself but no longer exhibited these behaviors. The DSD confirmed the lack of a specific care plan for monitoring the effectiveness of Risperdal for Resident 44. The facility's policy and procedure on psychotropic medication use, dated July 2022, emphasized the need for comprehensive review and adequate monitoring of residents receiving such medications. Despite this policy, the facility did not ensure proper monitoring and documentation for the use of psychotropic medications for Residents 1 and 44, increasing the risk of unnecessary medication use and potential adverse effects.
Failure to Investigate Adverse Events and Implement QAPI
Penalty
Summary
The facility failed to develop a system to systematically identify adverse events, monitor, investigate, analyze root causes, and implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI) for all 46 sampled residents, including Resident 53. This deficiency was highlighted by the case of Resident 53, whose change in condition leading to death was not investigated or analyzed to determine if it was due to the facility's failure to notify the physician and registered nurse of significant changes in the resident's condition. Resident 53 was readmitted to the facility with diagnoses including aftercare following surgery on the digestive system, insertion of a gastrostomy tube, and dysphagia following cerebral infarction. The resident had severe cognitive impairment and required assistance with eating and personal hygiene. The facility failed to ensure that the Licensed Vocational Nurse (LVN) notified the Registered Nurse (RN) and Physician of significant changes in Resident 53's blood pressure and heart rate, as well as the resident's pain level and subsequent unresponsiveness. The facility's QAPI program did not include a written system to identify adverse events, and the death of Resident 53 was not investigated to determine if there were quality deficiencies. The Director of Staff Development confirmed that the facility's QAPI was only focused on fall reduction and relied solely on the Minimum Data Set 3.0 Quality Measure Reports to identify issues. The Administrator was not involved in the QAPI program oversight, and the Director of Nursing, who was responsible, had resigned, leaving the facility without a comprehensive system to address and analyze adverse events.
Failure to Resolve Resident Grievance Regarding Missing Personal Belongings
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances verbalized by a resident, identified as Resident 32, which increased the risk for negative psychosocial impact on the resident's quality of life. Resident 32, who was cognitively intact and had the capacity to understand and make decisions, reported that his personal extension cord was removed from his room while he was out of the facility. Upon his return, he addressed the grievance to the Social Service Director (SSD), who informed him that the Maintenance Supervisor had removed the extension cord and promised to follow up on its location. However, three days later, the resident had not received his extension cord back, nor was there any follow-up notification regarding its location. During an interview and concurrent record review, the SSD admitted that there was no documented evidence of a grievance being logged for Resident 32's concern about his missing personal belongings. The SSD acknowledged that the facility's practice was to initiate a grievance and follow through to the completion of the problem whenever a resident or family member complained about an issue. The SSD stated that she forgot to file a written grievance and follow up with maintenance and Resident 32, despite having verbally spoken to him. The facility's policy and procedure on grievances/complaints indicated that staff members are encouraged to guide residents or their representatives on how to file a written complaint.
Deficient Care Plans for Medication Monitoring
Penalty
Summary
The facility failed to develop comprehensive and resident-centered care plans for three residents, leading to deficiencies in monitoring and managing their medication regimens. For Resident 48, the care plan did not include monitoring for side effects of Lexapro, used for depression, and Vistaril, used for anxiety. The Director of Staff Development (DSD) confirmed the absence of documented care plans for these medications, which are crucial for identifying side effects and behavioral changes. Resident 1's care plan was also incomplete, lacking specific interventions for the use of Apixaban, Divalproex, and Olanzapine. These medications are prescribed for conditions such as pulmonary thromboembolism, mood disorders, and schizophrenia. The DSD acknowledged that the care plan should have been developed when these medications were initially prescribed, emphasizing the importance of having specific goals and interventions for medication management. Similarly, Resident 44's care plan did not address the monitoring of side effects for Eliquis, an anticoagulant, and Risperdal, used for schizophrenia. The DSD could not find evidence of care plans detailing how these medications were monitored, including specific behaviors associated with auditory hallucinations. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, which were not implemented for these residents.
Oxygen Tubing Infection Control Deficiency
Penalty
Summary
The facility failed to ensure the safe administration of oxygen therapy for a resident, identified as Resident 44, by not adhering to its policy and procedure regarding oxygen tubing. During an observation, it was noted that the oxygen tubing used for Resident 44 was in contact with the floor, which is against the facility's infection control protocols. This observation was confirmed by a licensed vocational nurse (LVN) who acknowledged that the tubing should not be touching the floor due to the risk of contamination and infection. Resident 44 had been readmitted to the facility with diagnoses including unspecified dementia, atrial fibrillation, and wheezing. The resident was receiving oxygen therapy at 2 liters per minute via nasal cannula as needed for shortness of breath and wheezing. The facility's policy on oxygen administration, dated October 2010, emphasizes promoting resident safety, which was not upheld in this instance, as confirmed by both the LVN and the Director of Staff Development.
Deficiency in Nursing Competency and Communication
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 1 and LVN 2) possessed the necessary competencies and skills to adequately assess, monitor, and communicate changes in a resident's condition. Specifically, Resident 53, who had a history of transient ischemic attack, cerebral vascular accident, atrial fibrillation, and other conditions, was not properly monitored or assessed for significant changes in vital signs, including increased heart rate, declining blood pressure, and unresponsiveness. LVN 1 did not notify the Registered Nurse or Physician about the resident's significant changes in baseline blood pressure and heart rate, nor did they report the resident's high pain level and agitation. Additionally, LVN 2 failed to notify the Physician when the resident became unresponsive, with diminished respiration and an unreadable blood pressure. The Director of Nursing (DON) acknowledged that the LVNs did not have the competency skills required to manage changes in the resident's condition, including failing to notify the physician. The facility's policy on staffing and competency indicated that nursing staff should be trained and demonstrate competency in identifying, documenting, and reporting changes in resident conditions. However, the LVN Competency Checklist did not include respiratory assessments, which contributed to the oversight. The DON noted that LVN 1 administered Tylenol for pain without notifying the physician of the resident's high pain level, increased heart rate, and low blood pressure, and LVN 2's progress notes did not indicate that the physician was notified of the resident's condition.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted and updated daily, as required by their policy. During an observation, it was noted that the staffing information displayed at Nursing Station 1 was outdated, showing the date of the previous day. An interview with the Director of Staff Development (DSD) revealed that the staffing data should be posted daily before each shift begins. The DSD admitted that the staffing information for the current day was not posted due to an oversight, resulting in the display of the previous day's date. The facility's policy, titled 'Posted Direct Care Daily Staffing Numbers,' mandates that the number of nursing personnel responsible for direct resident care be posted within two hours of each shift's start. This information should include the number of Licensed Nurses (RNs, LPNs, and LVNs) and Certified Nursing Assistants (CNAs) and be displayed prominently in a clear and readable format. The failure to update the staffing information as per the policy led to the deficiency identified during the survey.
Medication Transcription and Administration Error
Penalty
Summary
The facility failed to ensure that a resident's medication was transcribed and administered correctly, leading to a medication error. The resident, who was readmitted with a gastrostomy tube and had difficulty swallowing, was prescribed Ativan to be administered via the G-tube. However, the medication order was incorrectly transcribed to be given by mouth. This error was not identified by the LVN who administered the medication, resulting in the Ativan being given via the incorrect route. Interviews with the Director of Nursing and the Director of Staff Development confirmed that the medication order should have been clarified with the physician to ensure the correct route of administration. The facility's policy and procedure for administering medications through an enteral tube were not followed, as the medication was not verified for the correct route before administration. This oversight increased the risk of serious medical complications for the resident.
Failure to Monitor and Communicate Fall Risks
Penalty
Summary
The facility failed to decrease the risk of preventable falls for two residents by not completing the required post-fall monitoring every shift for 72 hours as per the facility protocol. Resident 1, who was admitted with multiple diagnoses including generalized muscle weakness, fibromyalgia, and morbid obesity, had a high risk for falls as indicated by a Morse Fall Scale score of 95. Despite having a care plan that required 72-hour monitoring after falls, there was no documentation of monitoring during the evening shifts on specific dates. Additionally, a CNA assigned to Resident 1 was unaware of the resident's fall risks and prevention interventions, indicating a communication breakdown in reporting fall risks and interventions between shifts and staff members. Resident 2, diagnosed with Parkinson's disease and a history of falls, also had a high risk for falls with a Morse Fall Scale score of 90. The care plan for Resident 2 required 72-hour monitoring after a fall, but there was no documentation of monitoring during an evening shift. Interviews with staff revealed that the facility lacked a system to identify residents at risk for falls or with a history of falls, relying solely on verbal reports during shift changes. The facility's policies and procedures required documentation of fall monitoring and interventions, but these were not consistently followed. The Director of Nursing confirmed that the facility did not have a policy for endorsing resident information between shifts or to registry staff, relying instead on verbal huddle reports. This lack of a formal system for communicating fall risks and prevention measures contributed to the failure to adequately monitor and prevent falls for the residents, placing them at increased risk for preventable falls and possible injury.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
