East Terrace Rehabilitation & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2415 South Western Avenue, Los Angeles, California 90018
- CMS Provider Number
- 056114
- Inspections on file
- 72
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at East Terrace Rehabilitation & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with schizophrenia, depression, moderately impaired cognition, and documented wandering behavior, who was independent with mobility and used a Wander Guard, eloped from the facility while still wearing the device. The care plan and MD orders required daily checks of Wander Guard function and placement and monitoring for exit-seeking behaviors, but the resident was later found to be missing. Doors leading directly into the building had Wander Guard alarms, while two front doors to the street and parking lot did not, and the front gate operated on a timed open/close cycle. An RN reported that no staff were assigned to continuously monitor the front door video and that resident rounds were done but not formally documented, allowing the resident to leave without arrangements for medical care or housing.
A resident with muscle weakness, Alzheimer’s disease, anemia, and a known Stage III sacral pressure ulcer was readmitted with detailed hospital wound care orders, but facility staff failed to accurately assess, document, and care plan for the sacral pressure injury. The admission assessment noted only sacral redness without measurements and left the pressure ulcer section blank, and the post-readmission care plan lacked interventions for the wound. The treatment nurse used wound treatments that differed from transfer instructions, did not understand key wound assessment terminology such as “violaceous,” admitted to signing the TAR for a treatment on a day she was off duty, and did not obtain required wound photographs. The wound MD expressed concerns about the nurse’s assessment quality, and the medical record lacked the photographs required by the treatment nurse job description.
A resident with a known Stage III sacral pressure ulcer and multiple risk factors, including muscle weakness, incontinence, and Alzheimer’s disease, was admitted with specific hospital wound care orders, but staff did not fully assess and document the wound on admission, did not create a resident-centered care plan for the existing pressure injury, and did not update the care plan as the wound worsened or as MD orders changed. The existing care plan only addressed general skin integrity risk, and the turning program, specific wound treatments, and nutritional interventions were not incorporated. The RD and dietary department did not assess or address the pressure injury despite facility policy requiring RD evaluation with significant skin changes. Over time, the sacral wound progressed from a deep tissue pressure injury to an unstageable ulcer that increased in size, while required interdisciplinary care planning and policy-directed skin integrity management were not implemented, resulting in documented worsening of the wound and stated risk for infection and other complications.
A resident with COPD, generalized muscle weakness, moderate cognitive impairment, and dependence for ADLs was observed with yellowish‑purplish discoloration on the dorsal hand, which the resident vaguely associated with a BP cuff being applied too tightly. A treatment LVN first noted redness on the hand and later reassessed it without documenting the findings, while a CNA observed similar discoloration and reported it to an LVN. A wound MD subsequently identified the area as ecchymosis. Despite multiple staff observations and the resident’s inability to clearly explain the cause, the facility did not timely report this injury of unknown source to the proper authorities, delaying external investigation.
A resident with COPD, generalized muscle weakness, moderate cognitive impairment, and total dependence for ADLs developed yellowish‑purplish discoloration and later ecchymosis on the dorsal surface of the left hand that staff observed and reported to an LVN. Progress notes contained no evidence that the discoloration or ecchymosis were investigated, despite facility policy and staff statements that skin discolorations and injuries of unknown source require assessment, change of condition documentation, MD notification, and immediate investigation by the DON and Administrator to rule out abuse and determine the cause.
A resident with COPD, generalized muscle weakness, and moderate cognitive impairment experienced multiple documentation and follow-up failures. After redness was noted on the back of the hand and the MD ordered daily monitoring with Y/N documentation for 30 days, staff did not record the required observations on the TAR or in progress notes. Later, when the resident had self-inflicted lacerations to both lower legs, staff documented that they were awaiting an MD response but did not document any follow-up contact or orders. Additionally, the treatment LVN failed to include the hand redness in weekly skin checks, later altered skin notes to match a wound MD’s assessment, and created a backdated skin check weeks after the original assessment, contrary to facility policies requiring timely, accurate, and complete documentation of skin status, treatments, and MD notifications.
A central supply staff member failed to perform hand hygiene before entering and after exiting a resident's room, despite touching the resident's bedding and clothing. The resident had significant cognitive impairment and required extensive assistance with daily activities. Facility policy required hand hygiene upon entering and exiting resident rooms, which was not followed.
A resident with mental health diagnoses was transferred to a hospital for psychiatric evaluation, and although a physician ordered a 7-day bed hold and the resident's representative was notified, the facility failed to reserve a bed as required by policy. Staff confirmed that the bed was given to a new admission and no bed was held for the resident's return during the required period.
A resident with Parkinsonism, dementia, and epilepsy was discharged to a lower level of care without the required Notice of Proposed Transfer and Discharge being signed or provided to the resident or their family. The resident lacked capacity to make medical decisions, and the family was not included in discharge planning or informed prior to the transfer. The facility did not follow its policy to ensure proper notification and preparation for discharge.
A resident with moderate cognitive impairment and mobility issues experienced an unwitnessed fall resulting in a head injury. The incident was documented and the resident was sent to the hospital, but facility leadership was unaware and the event was not reported to CDPH within the required 24-hour timeframe, contrary to facility policy.
A resident with cognitive impairment and multiple mental health diagnoses sustained a hand injury requiring sutures, but the facility did not develop or implement a care plan to address wound care as ordered by the physician. Staff confirmed that no interventions or goals were documented for the injury, despite facility policy requiring comprehensive, individualized care planning.
Three residents with complex medical conditions who tested positive for COVID-19 did not have individualized care plans addressing their infection. Nursing staff confirmed that care plans specific to COVID-19 were not created, despite facility policy requiring comprehensive, person-centered care planning for all residents.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with cognitive impairment was sexually abused by another alert resident after staff failed to monitor the new resident's whereabouts and enforce policies prohibiting male residents from entering female residents' rooms. The incident was discovered by an RN during routine rounds, and there was no prior assessment or consent process for sexual relationships between the involved residents.
Staff failed to report a sexual abuse incident between two residents within the required two-hour timeframe, despite facility policy mandating immediate notification to CDPH, law enforcement, and the Ombudsman. The delay in reporting was acknowledged by both the RN and ADM, and the incident was not communicated to authorities as required, resulting in a delayed investigation and increased risk to other residents.
A resident who was totally dependent on staff for bed mobility and had significant medical conditions, including morbid obesity and paraplegia, was being repositioned by two CNAs who both stood on the same side of the bed, contrary to facility policy and training. This improper technique led to the resident falling from the bed, resulting in a femur fracture, severe pain, and hospitalization. Staff interviews confirmed that established safety protocols were not followed during the incident.
A facility failed to implement its abuse prevention policies for a resident with severe cognitive impairment, resulting in unreported bruises and skin tears. The DON admitted the facility did not follow its protocol for reporting injuries of unknown origin, which required immediate investigation and notification to relevant authorities.
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's and dementia, experienced several instances of skin discoloration and tears. Despite facility protocols requiring investigations for such occurrences, no investigations were conducted, as confirmed by interviews with staff. This failure to investigate had the potential to increase the risk of abuse for the resident and others.
A resident with multiple health conditions was admitted to a facility but did not receive proper orientation, assessment, or medication for 22 hours. The facility failed to notify the attending physician for admission orders, and the resident was left without necessary care, leading to a 911 call and transfer back to a hospital. The staff was inadequately trained on the admission process, and the facility lacked sufficient staffing to meet the resident's needs.
A resident's personal belongings were moved without permission during a transfer to a GACH, resulting in missing items upon return. The facility failed to complete an inventory list as required by policy, violating the resident's rights and potentially impacting their psychosocial well-being.
A resident in an LTC facility refused Olanzapine for 22 days without the physician being notified, as required by policy. This led to the resident, diagnosed with schizophrenia, engaging in physical aggression towards another resident, causing severe pain. The incident was reported to the police, and the aggressive resident was arrested. The facility failed to adhere to its policy on notifying physicians of significant changes in a resident's condition.
A resident with schizophrenia and bipolar disorder was denied readmission to the facility after being arrested following an altercation. Despite the facility's policy to readmit residents requiring skilled nursing care, the DON and LVN insisted on the arrest and later refused the resident's return, violating the facility's policy and state guidance on equal access to care.
A resident with dementia and Alzheimer's Disease, requiring a 1:1 sitter for safety, was observed wandering unsupervised in the facility. Despite physician orders and care plan interventions for constant monitoring, the resident was seen entering other residents' rooms without supervision, posing potential safety and privacy risks.
A resident with Parkinson's, schizoaffective disorder, and diabetes, identified as a high fall risk, fell and sustained a forehead laceration due to the facility's failure to provide a 1:1 sitter as required by the care plan. The assigned sitter was responsible for monitoring four high-risk residents, which was deemed a safety risk by staff.
A resident with Parkinson's, schizophrenia, and DM returned from a hospital transfer to find personal belongings missing, with no inventory list completed by the facility. CNAs were responsible for maintaining this list, but it was not done, violating facility policy.
A facility failed to provide a privacy bag for a resident's foley catheter, compromising dignity and posing an infection risk. Another resident felt trapped by bedrails, which were not discussed with them, affecting their dignity. The facility's policies on dignity and privacy were not followed.
A resident's essential personal items, including reading glasses and dentures, were not replaced after going missing, and two residents experienced a lack of a homelike environment due to unresolved maintenance issues. The facility failed to adhere to its policies for safeguarding personal property and maintaining a comfortable environment.
The facility failed to develop comprehensive care plans for two residents, leading to a G-tube being dislodged multiple times for one resident and missing dentures affecting another's ability to chew. The care plans lacked necessary interventions and documentation, contrary to facility policy.
A resident with a G-tube was hospitalized twice due to the tube's dislodgement. The facility failed to provide an abdominal binder to secure the G-tube, as confirmed by interviews with nursing staff. This oversight was contrary to the facility's policy on enteral tube management, which mandates ensuring the safety of such tubes.
A resident's G-tube was dislodged three times due to the facility's failure to secure it properly. Despite the resident being a candidate for an abdominal binder, which could have prevented the dislodgement, no such preventive measure was ordered or implemented. Facility staff acknowledged that the repeated dislodgement was not in accordance with nursing standards of care.
The facility failed to update and transfer an accurate POLST form for a resident, did not obtain an Advance Directive acknowledgment for another, and neglected to update the code status for a third resident who could no longer make medical decisions. These deficiencies could have led to delays in care and actions contrary to the residents' wishes.
A resident with multiple health conditions was found unable to reach their call light, a necessary tool for requesting assistance, during an observation. Staff interviews confirmed the importance of the call light being within reach, as per facility policy, to ensure the resident's needs are met and to prevent feelings of isolation.
A facility failed to submit an accurate PASRR for a resident with psychosis and other mental health issues, as required by federal regulations. The resident's PASRR inaccurately indicated no mental illness due to incorrect information, and a new PASRR was not submitted. This oversight was acknowledged by the QA Nurse, who stated that the lack of a proper PASRR could result in the resident not receiving necessary mental health services.
A facility failed to resubmit a PASRR for a resident with mental health diagnoses, including bipolar disorder and schizophrenia, after the initial screening indicated unresponsiveness from staff. The resident was dependent on staff for daily activities, and the oversight was acknowledged by the QA Nurse, highlighting a lapse in following the facility's policy for PASRR updates.
A resident with multiple health conditions was found to have long, untrimmed toenails, despite being dependent on staff for personal hygiene. The facility's policy required CNAs to maintain short and manageable nails, but this was not adhered to, leading to potential discomfort for the resident.
A resident's LAL mattress was incorrectly set at 350 pounds despite the resident weighing 142 pounds, risking pressure injuries. The resident, with conditions like osteomyelitis and MRSA, was dependent on staff for care and at risk for pressure ulcers. The DON and an LVN confirmed the incorrect settings could lead to skin breakdown, contrary to the facility's policy requiring proper mattress inflation.
A resident with dementia and muscle weakness did not have their splints applied as scheduled, which are necessary to prevent contractures. Observations showed the splints were not applied during specified hours on two days, and there was no documentation of their application. Interviews with the RNA and PT confirmed the importance of the splints and the lack of adherence to the facility's policy on documentation.
A resident with a history of wandering and bipolar disorder entered another resident's room, resulting in an altercation where she was pushed out. Despite the facility's knowledge of her behavior, supervision was insufficient, leading to the incident. An LVN witnessed the event, and observations showed the resident continued to wander, being redirected by staff.
A facility failed to date the oxygen tubing for a resident with COPD and chronic respiratory failure, as observed during a survey. The resident was receiving 2.5 liters of oxygen via nasal cannula without a date label on the tubing. The DON confirmed that the facility's protocol requires oxygen tubing to be changed and dated every seven days, which was not followed, posing an infection control issue.
A facility failed to obtain informed consent for bedrail use for a resident with metabolic encephalopathy, major depressive disorder, and spinal stenosis. Despite the resident's cognitive ability to understand, staff did not discuss the risks and benefits of bedrails, and no consent was documented. Observations confirmed the presence of bilateral bedrails, and staff interviews acknowledged the oversight, which contradicted the facility's policy requiring consent prior to bedrail installation.
A resident was found to have bedrails in use without a physician order, contrary to facility policy. The resident, with conditions including metabolic encephalopathy and spinal stenosis, was dependent on staff for care. An RN confirmed the absence of necessary orders, highlighting the risk of entrapment and the importance of compliance with facility procedures.
The facility failed to ensure proper food storage and labeling, as two bowls of ice cream were stored past their use-by date, and an opened package of tapioca pudding mix was not labeled with the date it was opened and to be used by. The Dietary Manager acknowledged these oversights, which could potentially lead to foodborne illness. The facility's policy required all storage products to be labeled and dated, but this was not followed.
The facility failed to ensure that one of four trash dumpsters had its lid closed completely. During an observation and interview with the Dietary Manager, it was noted that the lid of one trash dumpster was open and not closed completely flat. The Dietary Manager acknowledged that trash container lids should be closed completely to prevent pests from entering the container and causing an infestation. A review of the facility's policies and procedures indicated that waste containers must be closable.
A resident expressed interest in voting but was not provided with voting materials or the opportunity to leave the facility to vote, resulting in frustration and sadness. The facility's staff failed to communicate and document the resident's request, and the facility's policy on assisting residents in community activities was not followed.
A resident with schizophrenia refused Risperdal, an antipsychotic medication, multiple times without the physician being notified, contrary to facility policy. This led to the resident experiencing auditory hallucinations and physically assaulting another resident with dementia, causing harm. The incident was witnessed by an LVN and another resident, highlighting a failure in communication and adherence to medication administration protocols.
A resident, diagnosed with schizophrenia and bipolar disorder, was disrespected by a staff member during an interaction involving a vending machine. The staff member used inappropriate language, telling the resident to "get your a** outside." The DON confirmed the incident, noting the behavior was against the facility's policy requiring respectful communication with residents.
A resident with Alzheimer's and dementia was physically abused by another resident with schizophrenia and bipolar disorder, who choked her after hearing voices. The incident was witnessed by an LVN and another resident, leading to the aggressor's transfer for psychiatric evaluation. Facility policies emphasize protecting residents from abuse.
The facility failed to report an alleged physical abuse incident between two residents to the CDPH within the required timeframe. A resident with Alzheimer's and dementia was grabbed by another resident with schizophrenia, resulting in neck redness. The incident was witnessed by an LVN but not reported as required. The facility's policy mandates immediate reporting and investigation, which was not followed, delaying the CDPH investigation and potentially risking further abuse.
A resident with Alzheimer's and dementia was physically abused by another resident with schizophrenia and bipolar disorder, resulting in redness on the neck. The incident was not reported or investigated as per the facility's policy, and the Director of Nursing was initially unaware of the event. The facility failed to report the incident to the California Department of Public Health within the required timeframe.
A facility failed to reassess fall risk for a resident after two falls and did not provide required fall mats for another resident. The first resident, with conditions like muscle weakness and hemiplegia, was not re-evaluated after falls, contrary to policy. The second resident, with schizophrenia and bipolar disorder, lacked bedside fall mats, as confirmed by staff, despite orders for their use.
Elopement of Wander-Guard Resident Due to Unmonitored, Unalarmed Exits
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement for one resident identified as an elopement risk and wearing a Wander Guard device. The resident was admitted with schizophrenia, depression, cellulitis, and a local skin infection, and a subsequent H&P documented that the resident could make needs known but could not make medical decisions. The resident’s MDS showed moderately impaired cognition and independence with mobility, including walking and transfers, and indicated daily use of a wander/elopement alarm. An elopement evaluation documented that the resident wandered, and the care plan identified the resident as an elopement risk with interventions to check Wander Guard placement on the right wrist and document wandering behavior. Physician orders directed staff to check Wander Guard functioning and placement every night shift and to monitor for exit-seeking behaviors and related signs every shift. Despite these identified risks and interventions, a health status note documented that the charge nurse was unable to locate the resident at 6:21 p.m., and the resident had eloped from the facility while wearing a Wander Guard device. The Maintenance Supervisor reported that all doors leading directly into the facility had Wander Guard alarms that were checked and audible, but the two front doors leading to the street and the parking lot did not have Wander Guard alarms. The front entrance gate to the parking lot took 25 seconds to open and 25 seconds to close. An RN stated that no one was assigned to watch the front door monitor at the nursing station and that rounds were conducted in the morning, afternoon, and evening to ensure residents were not missing, but there was no official documentation of these rounds. As a result of these conditions, the resident was able to leave the facility with no arrangements for medical care or housing.
Inadequate Wound Care Competency and Documentation for Sacral Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed staff possessed and used appropriate wound care competencies for a resident who was readmitted with a sacral pressure injury. The resident had multiple diagnoses, including muscle weakness, a Stage III sacral pressure ulcer, anemia, and Alzheimer’s disease, and had fluctuating capacity to understand and make decisions. Assessments showed the resident had high risk for pressure ulcers due to occasionally moist skin, chairfast activity level, very limited mobility, and dependence on staff for toileting and bathing. Upon readmission, the interfacility transfer report from the hospital specified a wound care regimen using Vashe, Therahoney, and Optifoam for the sacral Stage III pressure injury, but the facility’s clinical admission assessment only noted a sacral wound with redness and did not describe the wound’s appearance or measurements, and the documented pressure ulcer section was left blank. Subsequent facility documentation showed inconsistencies and omissions in wound assessment and care planning. A skin and wound evaluation the day after readmission described a medical device–related pressure injury on the sacrum with specific measurements and characteristics, and listed xeroform as the primary dressing, which differed from the hospital’s transfer instructions. The resident’s care plan after readmission did not include interventions addressing the sacral pressure injury, despite the presence of the wound. Physician orders later directed cleansing the sacral pressure injury with normal saline, applying Santyl, and covering the wound. Over time, the wound progressed from a deep tissue pressure injury with smaller measurements to an unstageable pressure injury with larger dimensions and a wound bed containing both epithelial tissue and slough, with documentation of violaceous skin and concern for possible osteomyelitis. Interviews and record reviews revealed gaps in the treatment nurse’s wound care competencies and documentation practices. The treatment nurse stated that all licensed nurses were responsible for initiating and implementing resident-centered care plans when wounds were identified, yet acknowledged that the resident had no care plan interventions for the sacral pressure injury on readmission. The treatment nurse did not understand the term “violaceous” in the wound physician’s assessment and incorrectly equated it with simple skin redness, and stated that without understanding prior wound assessments, she would not know if the wound was improving or worsening. She also admitted to mistakenly signing the treatment administration record for providing sacral wound care on a day she was off duty and confirmed she never photographed the resident’s pressure injury, despite a job description requiring photographs of residents with specified pressure ulcers. The wound physician reported concerns about the quality of the treatment nurse’s assessments, noting her inability to differentiate violaceous skin from redness, and the medical records director confirmed there were no wound photographs in the resident’s record, contrary to facility policy and job expectations.
Failure to Care Plan and Manage Sacral Pressure Injury Resulting in Wound Worsening
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary services and resident-centered care planning to manage and promote healing of a sacral pressure injury for one resident. The resident was admitted and later readmitted with diagnoses including muscle weakness, a Stage III sacral pressure ulcer, anemia, and Alzheimer’s disease with fluctuating decision-making capacity. An interfacility transfer report from an acute care hospital specified a detailed wound care regimen for the sacral Stage III pressure injury, including cleansing with Vashe, application of Therahoney, and coverage with Optifoam. Upon admission, the facility’s clinical admission assessment documented a sacral wound with redness but did not include a description of the wound’s appearance or measurements, and the section for documented pressure ulcers was left blank. A subsequent skin and wound evaluation identified a medical device–related pressure injury at the sacrum with specific measurements and characteristics, but the primary dressing listed was Xeroform, differing from the hospital’s recommended treatment. The resident’s existing care plan addressed only a general risk for potential impairment to skin integrity related to anticoagulant use, poor bed mobility, and advanced age, with broad interventions such as education, encouraging nutrition and hydration, following facility protocols, and keeping skin clean and dry. After the resident’s readmission, there was no care plan with specific interventions for the sacral pressure injury, and the turning program and wound treatments were not incorporated into the care plan. Physician orders were written to cleanse the sacral pressure injury with normal saline, apply Santyl, and cover, but these changes and later modifications were not reflected in updated care plan interventions. Over time, the resident’s sacral wound worsened. Skin checks documented that the sacral pressure ulcer became unstageable and increased in size from the initial measurements to 4 cm by 4.5 cm. Wound physician assessments showed progression from a deep tissue pressure injury to an unstageable wound with a mix of epithelial tissue and slough, violaceous skin, and concern for further decline, prompting an order for an x-ray to evaluate for osteomyelitis. Interviews with the treatment nurse and an RN confirmed that nursing staff did not create a resident-specific care plan for the sacral pressure injury at admission and did not update the care plan when the wound worsened or when physician orders changed. The wound physician stated that the resident’s risk factors, including incontinence, muscle weakness, and cognitive limitations, placed the resident at high risk and that the wound was not assessed and measured by nursing staff upon admission. The registered dietitian reported that neither she nor the dietary department addressed the pressure injury after it was identified, and no RD assessment or nutritional recommendations were made despite facility policy requiring RD evaluation upon significant changes in skin condition. Facility policies on skin integrity management, comprehensive person-centered care planning, and the treatment nurse’s job description all required development and updating of a plan of care, weekly skin evaluations, RD involvement, and interdisciplinary discussion, which were not implemented for this resident’s sacral pressure injury. The facility’s failure to develop and update a comprehensive, resident-centered care plan for the sacral pressure injury, to accurately assess and document the wound on admission, to integrate physician orders into the care plan, and to involve the RD and IDT as required by policy resulted in the resident’s sacral wound worsening. The report states that this failure resulted in the resident’s worsening sacral wound condition and placed the resident at risk for wound infections and other complications, including hospitalizations.
Failure to Report Injury of Unknown Source on Resident’s Hand
Penalty
Summary
The facility failed to timely report an injury of unknown source for one of five sampled residents, delaying investigation by the California Department of Public Health. The resident had COPD, generalized muscle weakness, moderate cognitive impairment, and was dependent on staff for ADLs and bed mobility. On observation, the resident had yellowish‑purplish discoloration on the left dorsal hand and stated it occurred after someone took her blood pressure too tightly on that hand, but could not recall when or who did it. The discoloration met the definition of an injury of unknown source because the event was not observed, could not be clearly explained by the resident, and involved suspicious discoloration. The Treatment LVN reported first identifying redness on the resident’s left dorsal hand on 1/2/2026, attributing it to a BP cuff being too tight, and stated the resident could not provide when or who caused it. The Treatment LVN reassessed the left dorsal hand on 1/21/2026 but did not document this in the progress notes. A wound MD later examined the area and identified it as ecchymosis. A CNA reported that on 1/21/2026 she observed yellowish‑purplish discoloration on the same hand and notified an LVN. A photograph taken on 1/23/2026 showed discoloration consistent with what the CNA had seen earlier. Despite these observations and notifications, the injury of unknown source was not reported as required, resulting in a delay in external investigation.
Failure to Investigate Injury of Unknown Source to Resident’s Hand
Penalty
Summary
The facility failed to investigate an injury of unknown source when a resident developed yellowish‑purplish discoloration and later ecchymosis on the dorsal (back) surface of the left hand. The resident, who had COPD, generalized muscle weakness, moderate cognitive impairment, and was dependent on staff for ADLs and bed mobility, was originally admitted and later readmitted to the facility. Review of progress notes from 1/21/2026 to 1/23/2026 showed no documentation that the discoloration noted on 1/21/2026 or the ecchymosis noted on 1/23/2026 were investigated. During observation and interview on 1/23/2026, the resident had yellowish‑purplish discoloration on the left dorsal hand and stated it happened after someone took her blood pressure too tightly on that hand, but could not recall when. A CNA reported observing the same yellowish‑purplish discoloration on the resident’s left dorsal hand on 1/21/2026 and stated she notified an LVN at that time. The Treatment LVN reported that on 1/23/2026 the wound MD saw ecchymosis on the resident’s left dorsal hand. The LVN interviewed later stated that when staff report discoloration on a resident’s skin, the LVN should notify the DON and Administrator for investigation due to the possibility of abuse. The DON stated that when staff see skin discolorations, the charge nurse should assess the resident, ask how it happened, complete a change of condition assessment, and notify the MD, and that injuries of unknown origin must be investigated and reported to CDPH. The Administrator stated he was not aware of the unexplained bruising and described that an injury of unknown origin requires investigation and may need to be reported to CDPH if determined to be alleged abuse. The facility’s Abuse Prevention and Management policy defined injury of unknown source and required the Administrator or designee to immediately initiate an investigation upon receiving such a report; however, no such investigation was documented for this resident’s hand injury.
Failure to Monitor Skin Condition, Follow Up on Change in Condition, and Maintain Accurate Skin Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards for one resident with COPD, generalized muscle weakness, and moderate cognitive impairment who was dependent on staff for ADLs and mobility. On a change in condition (COC) dated 1/2/2026, the resident was noted to have redness on the left dorsal hand during treatment, and the resident reported that the blood pressure cuff on the wrist was too tight. The physician ordered monitoring of the left dorsal hand discoloration for hematoma formation, skin breakdown, and pain/discomfort, with instructions to document "Y" if observed and notify the MD, or "N" if not observed, on every shift for 30 days. Review of the Treatment Administration Record (TAR) and progress notes for January 2026 showed no documentation of the required Y/N monitoring or any indication that the left dorsal hand was monitored as ordered. A second deficiency occurred on 1/20/2026 when the resident experienced a change in condition involving self-inflicted lacerations to both lower legs. The COC note documented that staff were awaiting the MD’s response. However, review of the resident’s progress notes for that date did not show any follow-up with the MD for treatment orders for the bilateral lower leg wounds. Interviews with nursing staff indicated that if staff were unable to reach the MD, they should attempt to contact the MD’s nurse practitioner or the facility’s Medical Director, and if still unsuccessful, endorse the issue to the oncoming shift, but such follow-up and documentation were not evident in the record. The DON confirmed that the progress notes did not show that staff had followed up with the MD after this change in condition. A third deficiency involved inaccurate and late skin assessment documentation by the Treatment LVN. Weekly skin checks dated 1/4/2026, 1/9/2026, 1/16/2026, and 1/23/2026 did not include the status or description of the left dorsal hand redness. The Treatment LVN stated she could not explain why the left hand status was not documented and acknowledged that on 1/23/2026 she changed her skin check notes to "ecchymosis" to match the wound MD’s assessment from that date, even though this was not her original assessment, making the documentation inaccurate. On 1/27/2026, the Treatment LVN created another skin check form with an effective date of 1/2/2026 to reflect the redness that had been present on 1/2/2026 but not documented at that time, and she acknowledged that charting 25 days after the assessment made the documentation inaccurate. Facility policies required entries to be written promptly in chronological sequence, weekly skin evaluations with documentation of treatments and effectiveness, and detailed documentation of MD notification for changes in condition, including time, method, response time, and whether orders were received, which were not followed in these instances.
Failure to Perform Hand Hygiene Before and After Resident Contact
Penalty
Summary
A deficiency was identified when a central supply staff member entered a resident's room without performing hand hygiene, touched the resident's bedding and clothing, and then exited the room without performing hand hygiene. This was observed during a concurrent observation and interview, where the staff member stated they were attempting to help identify the resident's name. The facility's policy and procedure on hand hygiene, dated 9/1/2020, requires staff to perform hand hygiene immediately upon entering and exiting a resident's room. The resident involved had a history of psychosis, dementia, and schizophrenia, with documentation indicating fluctuating capacity to understand and make decisions, and moderately impaired cognition. The resident required substantial to maximum assistance from staff for activities such as toileting, showering, and lower body dressing. The Director of Nursing confirmed during an interview that hand hygiene should be performed before and after touching residents, their clothing, or linen.
Failure to Implement Bed Hold Policy for Hospitalized Resident
Penalty
Summary
The facility failed to implement its Bed Hold Policy and Procedure for a resident who was transferred to a General Acute Care Hospital (GACH) for psychiatric evaluation following aggressive behavior. The resident, who had diagnoses including schizophrenia, psychosis, and dementia, was assessed as able to make her needs known and understand others. Upon transfer, the physician ordered a 7-day bed hold, and the resident's representative was notified and provided verbal consent for the bed hold. Documentation indicated that the Bed Hold Agreement was completed at the time of transfer. Despite these actions, facility records and census data showed that the resident's bed was given to a newly admitted resident immediately after the transfer, and no bed was held for the returning resident during the 7-day period as required by the facility's policy. Interviews with staff, including the Business Office Manager and Administrator, confirmed that the bed hold policy was not followed, and the resident did not have a bed available to return to during the designated period. The facility's policy required that a bed be reserved for up to seven days for residents transferred to an acute care hospital, but this was not implemented in this case.
Failure to Provide Proper Notice and Discharge Planning for Resident Transfer
Penalty
Summary
The facility failed to ensure that the Notice of Proposed Transfer and Discharge form was properly completed and provided to a resident or their family representative prior to discharge to a lower level of care. Specifically, the notice was not signed by the resident or their representative, did not indicate the reason for discharge, and was not provided before the discharge occurred. The resident in question had diagnoses including Parkinsonism, dementia, and epilepsy, and was noted to be confused and lacking the mental capacity to make medical decisions. Despite this, the notice indicated the resident was self-responsible and capable of verbalizing needs. The facility's Social Service Director (SSD) did not contact the resident's family member as documented, and only left a message after the discharge had already taken place. Additionally, the discharge planning process did not include a tour or offer of a tour of the receiving facility to the resident or their family, and the family was not included in the interdisciplinary meeting or discharge planning. The receiving facility was not a board and care home and required residents to care for themselves, which was not communicated to the family prior to discharge. The facility's policy and procedure required that the notice be provided to the resident or representative prior to discharge, which was not followed in this case.
Failure to Timely Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury involving one resident to the California Department of Public Health (CDPH) as required. The resident, who had a history of polyarthritis, muscle weakness, difficulty walking, and moderate cognitive impairment, experienced an unwitnessed fall in their room and was found by a CNA with a significant bump on the forehead. The incident was documented in the resident's records, and the resident was transferred to the hospital for further evaluation. Despite the facility's policy requiring reporting of unusual occurrences and injuries of unknown source within 24 hours, the incident was not reported to CDPH in a timely manner. Interviews with facility leadership confirmed that the administrator was unaware of the fall and injury, and the assistant director of nursing acknowledged that the event met the criteria for mandatory reporting. The facility's policies on unusual occurrence reporting and abuse prevention both specified that such incidents affecting resident welfare, health, or safety must be reported promptly to state authorities. The failure to report the unwitnessed fall with injury resulted in a delay in investigation by CDPH.
Failure to Develop Care Plan for Resident's Hand Injury
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who sustained an injury to the right hand, which required sutures. Despite physician orders for daily wound care, including cleansing with normal saline and application of betadine, there was no care plan or documented interventions addressing the care of the sutures. This omission was confirmed during interviews and record reviews with facility staff, who acknowledged the absence of a care plan specific to the resident's hand injury. The resident involved had a history of schizoaffective disorder, depression, and anxiety, with moderately impaired cognition and a need for partial to moderate assistance with activities of daily living. The lack of a care plan was identified through observation, interview, and record review, and staff confirmed that the care plan should have included goals and interventions to maintain suture care and prevent complications. The facility's own policy required a comprehensive, person-centered care plan for each resident, reflecting their needs and physician orders, which was not followed in this case.
Failure to Develop Individualized COVID-19 Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents who tested positive for COVID-19. Each of these residents had complex medical histories, including conditions such as hypertension, hyperlipidemia, polyarthritis, schizoaffective disorder, cerebral palsy, and transient ischemic attack. Despite documented positive COVID-19 test results and varying levels of assistance required for activities of daily living, there was no evidence in their records that care plans specific to COVID-19 infection were created. This was confirmed during interviews and record reviews with nursing staff, who acknowledged the absence of such care plans. The facility's own policy required the development of comprehensive, person-centered care plans with measurable objectives and timeframes to address residents' medical, nursing, and psychosocial needs. However, for these three residents, the care plans did not include interventions or monitoring related to their COVID-19 status. Nursing staff stated that care plans should have been created and updated to guide care and monitor health status, but this was not done for the affected residents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Prevent Sexual Abuse Due to Inadequate Resident Monitoring
Penalty
Summary
The facility failed to protect a resident from sexual abuse by not adequately monitoring the whereabouts of another resident who was newly admitted and alert. On the night of the incident, staff did not ensure that the male resident was accounted for, which allowed him to enter the female resident's room unsupervised. Facility policy prohibited male residents from entering female residents' rooms, but this was not enforced, and there was no system in place to monitor the new resident's movements during the night shift. The incident was discovered during a routine room check by a registered nurse, who found the male resident on top of the female resident, with her pants down and his face near her genital area. The nurse intervened immediately and separated the two residents. Interviews with staff confirmed that the female resident was confused, could follow simple commands, and was only oriented to her name, while the male resident was alert, able to make himself understood, and had no cognitive or physical impairments. Further review revealed that the facility did not have a policy or procedure for assessing or documenting consent for sexual relationships between residents, nor had an interdisciplinary team meeting or consent process been conducted for these two residents. Staff interviews indicated that abuse allegations should be reported immediately, and that new residents should be closely monitored, but these protocols were not followed in this case.
Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an act of sexual abuse involving two residents within the required two-hour timeframe as outlined in its Abuse Prevention and Management policy. The incident occurred when a registered nurse (RN) observed one resident on top of another in a resident's room, with the victim's pants down and the perpetrator's face near the victim's genital area. The RN intervened immediately and separated the residents. Despite being aware of the incident, the RN did not report it to the California Department of Public Health (CDPH) or the police, as required, after being told by the Director of Nursing (DON) that the Administrator (ADM) would handle the reporting. The victim had a history of schizophrenia, major depressive disorder, and anxiety disorder, and was assessed as unable to make medical decisions but able to make needs known. The Minimum Data Set indicated no cognitive impairment and a need for partial to moderate assistance with activities of daily living. The perpetrator was newly admitted, alert, and had no cognitive or physical impairments noted. The incident was documented in the Interdisciplinary Team meeting notes, and both the RN and ADM acknowledged during interviews that the event should have been reported to the appropriate authorities within two hours, as per facility policy. A review of the facility's policy confirmed that any allegation of abuse, including those without serious bodily injury, must be reported by telephone and in writing to CDPH, the Ombudsman, and law enforcement within two hours. The failure to report the incident in a timely manner delayed the investigation by CDPH and placed other residents at risk for abuse, as explicitly stated in the findings.
Failure to Provide Adequate Supervision and Safe Repositioning Results in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow established procedures for turning and repositioning a dependent resident, resulting in a significant accident. Two CNAs, both of whom had received in-service training on proper repositioning techniques, attempted to turn and reposition a resident who was totally dependent on staff for mobility and required two-person assistance. Both CNAs stood on the same side of the bed, contrary to facility policy and training, which required one staff member on each side of the bed to ensure safety during such procedures. The resident involved had a complex medical history, including morbid obesity, paraplegia, chronic pain syndrome, and was bedridden and unable to assist with movement. The care plan and MDS assessments clearly indicated the need for two-person assistance for all bed mobility and emphasized safety measures to prevent falls. Despite these documented needs and interventions, the CNAs repositioned the resident while both were on the left side of the bed, leaving the right side unsecured. During the maneuver, the resident slipped off the right side of the bed and fell to the floor. As a result of this incident, the resident sustained a displaced fracture of the right distal femur, a skin tear, and experienced severe pain and fear. The resident required urgent transfer to an acute care hospital for evaluation and treatment. Interviews with the CNAs, DON, and other staff confirmed that the proper technique was not followed and that the accident could have been prevented if the established safety protocols had been observed.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and procedures for preventing abuse, neglect, and injuries of unknown origin for one of the sampled residents. Resident 3, who was admitted with diagnoses including Alzheimer's disease, dementia, and psychosis, was found to have unknown bruises and skin tears. The resident's Minimum Data Set indicated severe cognitive impairment and a need for supervision with activities of daily living. Despite these needs, the facility did not follow its protocol for reporting injuries of unknown origin, as evidenced by the unreported skin discolorations and tears documented in the resident's records. The Director of Nursing (DON) acknowledged awareness of some of the resident's skin discolorations but admitted that the facility's policy was not implemented or followed. The facility's policy required immediate investigation and reporting to the ombudsman, law enforcement, and the California Department of Public Health within two hours of receiving a report of such injuries. However, the DON confirmed that the facility did not report the resident's skin tears and discolorations to the appropriate agencies, which could result in possible abuse and safety issues.
Failure to Investigate Skin Discoloration and Tears
Penalty
Summary
The facility failed to investigate all areas of skin discoloration and skin tears for one resident, which had the potential to place the resident and other vulnerable residents at increased risk of abuse. The resident, who was admitted with diagnoses including urinary tract infection, Alzheimer's disease, dementia, and psychosis, had several instances of skin discoloration and skin tears documented in their records. These included a light greenish discoloration on the left hip, a skin tear on the front left shoulder and left elbow, and discoloration on the left arm, right upper thigh, left elbow, and right buttock. Despite these findings, there was no evidence of a risk management assessment or investigation report being completed for these occurrences. Interviews with facility staff, including a Licensed Vocational Nurse, a Registered Nurse, and the Director of Nursing, revealed that the facility's protocol required investigations for unusual skin discoloration and skin tears. However, the staff were either unaware of the full extent of the resident's skin issues or confirmed that no investigations were conducted. The facility's policy on unusual occurrence reporting and abuse prevention required timely and thorough investigations into such incidents, but these procedures were not followed, leading to a deficiency in care.
Failure to Provide Adequate Admission Care and Services
Penalty
Summary
The facility failed to provide adequate care and services to a resident who was admitted with multiple diagnoses, including hypertension, diabetes mellitus, depression, anxiety, and suicidal ideation. Upon arrival, the resident was not oriented to the facility, and an initial admission assessment was not completed. The facility did not notify the attending physician to obtain necessary admission orders, and no medications were ordered or administered to the resident. Additionally, the resident did not receive any activities of daily living support, such as diaper changes, for approximately 22 hours. The nursing staff was inadequately prepared to handle the admission process. LVN 1, who was informed of the resident's pending arrival, did not know how to conduct an initial assessment and left the task for the incoming shift, which was short-staffed due to a call-off. As a result, the resident did not receive any medications, including insulin and antihypertensives, and was left without food or drink. The resident's emergency contact found the resident in a soiled state and in pain, prompting a call to 911 for transfer back to a hospital. The facility's policies and procedures for admission and orientation were not followed, and there was a lack of staff training on the admission process. The Director of Staff Development had not conducted in-service training on admissions for two years, and the facility did not have a staffing agency to address shortages. This lack of compliance with established procedures and inadequate staffing led to the resident's distress and subsequent transfer to a hospital for further evaluation and treatment.
Removal Plan
- The DSD/designee initiated immediate education to Licensed Nurses, certified nursing assistants (CNAs) on every shift and Department Managers on the following facility's policies and procedures: Resident Initial Admission Assessment, Admission and Orientation of Residents, and Admission Criteria.
- The DON will assign an LVN to conduct the initial assessment of new residents.
- The facility will attempt to replace the nursing staff who called off from their scheduled shift by calling other nursing staff who are not scheduled and are available to work, including licensed department managers, to ensure adequate staffing.
- Staff were in-serviced on the new admission process by the DSD.
Failure to Adhere to Policy on Handling Resident Belongings
Penalty
Summary
The facility failed to adhere to its policy regarding the handling of residents' personal belongings, specifically for one resident who was transferred to a general acute care hospital (GACH) and then returned to the facility. The resident, who had intact cognitive skills and required supervision for activities of daily living, reported that his personal belongings were moved without his permission during his absence. Upon his return, he discovered that some items, including eyeglasses and a phone charger, were missing, and the facility was unable to provide an inventory list of his belongings. Interviews with facility staff, including a social worker and a certified nursing assistant (CNA), revealed that the facility's policy required an inventory list of residents' belongings to be completed upon admission, readmission, and as needed. However, the CNA admitted that the inventory list for this resident was not completed, and there was no record of the resident's permission to move his belongings. This oversight violated the facility's policy and the resident's rights, potentially impacting his psychosocial well-being.
Failure to Notify Physician of Medication Refusal Leads to Resident Altercation
Penalty
Summary
The facility failed to notify the physician of a resident's refusal to take Olanzapine, an antipsychotic medication prescribed for schizophrenia, for 22 consecutive days. This oversight involved Resident 3, who was diagnosed with schizophrenia, bipolar disorder, hypertension, and muscle weakness. The resident's Minimum Data Set (MDS) indicated moderately impaired cognitive skills for daily decision-making and required assistance with activities of daily living. Despite the refusal of medication being documented in the Medication Administration Records (MAR), there was no evidence that the physician was informed, as required by the facility's policy. The deficiency led to a significant incident where Resident 3 engaged in physical aggression towards another resident, Resident 2. On the morning of the incident, Resident 3, who had not taken Olanzapine for 22 days, hit Resident 2 on the chest, resulting in Resident 2 experiencing severe pain. The incident was reported to the police, and Resident 3 was arrested for aggressive behavior. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed the altercation and the subsequent police involvement. The facility's policy and procedure for Change of Condition Notification and Medication Administration required that the physician be informed of any significant changes in a resident's condition, including medication refusal. However, the staff failed to notify the physician about Resident 3's non-compliance with the medication regimen, which potentially contributed to the resident's aggressive behavior and the altercation with Resident 2. This lack of communication and adherence to policy resulted in a deficiency in the facility's care practices.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to implement its policy and procedure regarding the readmission of residents, resulting in the denial of a resident's right to return to the facility after hospitalization. The facility's policy, revised in 2013, stated that residents requiring skilled nursing care should be readmitted. However, this policy was not followed for a resident who had been involved in an altercation and subsequently arrested. The resident, who had diagnoses including schizophrenia, bipolar disorder, and hypertension, was not allowed to return to the facility after being released from jail, despite the facility's policy indicating they should be readmitted. The incident began when the resident had an altercation with another resident, leading to police involvement. The Licensed Vocational Nurse (LVN) on duty reported the incident to the police, resulting in the resident's arrest. The Director of Nursing (DON) and the LVN insisted on the arrest, despite the police officer's suggestion for a psychiatric evaluation. The resident was taken into custody and later released, but the facility refused to readmit them, contrary to their policy. Interviews with facility staff, including the DON and Administrator, confirmed the decision not to readmit the resident. The police officer also confirmed that the facility refused to accept the resident back after their release from jail. This refusal was in direct violation of the facility's readmission policy and the guidance from the California Department of Public Health, which mandates equal access to care for all residents, regardless of their condition or payment source.
Failure to Implement 1:1 Sitter for Resident at Risk of Wandering
Penalty
Summary
The facility failed to implement resident-centered care plan interventions for a resident at risk for wandering, identified as Resident 5. Despite having physician orders for a one-to-one sitter to ensure safety, observations on multiple occasions revealed that Resident 5 was walking unsupervised throughout the facility, including entering other residents' rooms. This lack of supervision was noted on several dates, with no staff member assigned to monitor Resident 5 as required by the care plan. Resident 5, who was admitted with diagnoses including dementia, Alzheimer's Disease, depression, and muscle weakness, was assessed to have severely impaired cognitive skills and required supervision for activities of daily living. The facility's policy mandates comprehensive care plans to meet residents' health, safety, and psychosocial needs, yet the care plan intervention for one-to-one monitoring was not implemented. This oversight posed a potential safety risk and privacy invasion for other residents, as acknowledged by a registered nurse during an interview.
Failure to Provide 1:1 Sitter Leads to Resident Fall
Penalty
Summary
The facility failed to provide a one-on-one sitter for a resident as indicated in the care plan, resulting in the resident falling and sustaining a laceration on the forehead. The resident, who had a history of Parkinson's disease, schizoaffective disorder, and diabetes mellitus, was identified as having moderately impaired cognitive skills and was dependent on staff for activities of daily living. The care plan specifically required a one-on-one sitter due to the resident's high risk for falls, but this was not adhered to, leading to the incident. Observations and interviews revealed that the assigned sitter was responsible for monitoring four high fall risk residents simultaneously, which was acknowledged as a safety risk by the staff. The Director of Staff Development confirmed that the facility's failure to provide the necessary one-on-one supervision was a deficient practice, which directly contributed to the resident's fall and injury. The facility's policies on safety and fall management were not effectively implemented, as evidenced by the lack of adequate supervision for the resident.
Failure to Maintain Personal Belongings Inventory
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards, specifically regarding the personal belongings inventory list for a resident. The resident, who had been diagnosed with Parkinson's disease, schizophrenia, and Diabetes Mellitus, was transferred to a general acute care hospital and upon return, found that his personal belongings had been moved without his permission. The resident reported missing items such as eyeglasses and a phone charger, and the facility was unable to provide him with a personal belongings inventory list. Interviews with facility staff revealed that it was the responsibility of Certified Nursing Assistants (CNAs) to complete and maintain the personal belongings inventory list upon a resident's admission, readmission, and as needed. However, the CNA responsible for the resident's inventory admitted that the list was not completed. The facility's policy required that a personal property inventory be conducted and placed in the medical record, with a copy provided to the resident, but this was not adhered to in this case.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide a privacy bag for a foley catheter for one resident, which compromised the resident's dignity and potentially posed an infection control risk. The resident, who had intact cognitive skills and required supervision for various activities, was observed with an uncovered foley catheter bag in a pink basin. The resident reported not having a privacy bag since the catheter was inserted and was not informed about the necessity of such a bag. The Director of Nursing confirmed that all residents with foley catheters should be provided with a dignity bag, as per the facility's policy, and acknowledged the potential for cross-contamination and self-esteem issues due to the lack of a privacy bag. Another resident's dignity was compromised by the use of bilateral bedrails, which the resident could not easily release, making them feel trapped and confined. The resident, who could make needs known but not medical decisions, expressed that the bedrails made them feel isolated and were not discussed with them by the staff. The Director of Nursing stated that if the resident could not easily and voluntarily release the bedrails, their use would be considered a restraint. The facility's policy emphasized the importance of promoting dignity and avoiding practices that compromise it, which was not adhered to in this case.
Deficiencies in Personal Item Replacement and Homelike Environment
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 28, had their essential personal items, specifically reading glasses and dentures, replaced after they went missing. Resident 28, who has diagnoses including end-stage renal disease, diabetes mellitus, and heart failure, reported the loss of these items following a room change. Despite the resident's ability to communicate effectively, the staff did not assist in locating the missing items. The Director of Social Services confirmed the absence of the glasses and dentures and acknowledged that the facility's process for tracking resident inventory during admissions, discharges, and room changes was not followed. Additionally, the facility did not provide a homelike environment for two residents, identified as Residents 10 and 6. Resident 10, who has cognitive skills intact and is dependent on staff for various needs, reported a broken window latch and blinds in their room, which had not been repaired despite informing the staff. The Maintenance Supervisor confirmed the poor condition of the window and blinds, noting that no repair requests were logged. Resident 6 also experienced a lack of a homelike environment due to missing slats on the blinds covering a glass patio door, which led them to use paper towels for privacy. The Maintenance Supervisor was unaware of this issue, indicating a failure in the facility's repair request process. The facility's policies and procedures, including those for theft and loss, accommodation of needs, and maintaining a homelike environment, were not adhered to, resulting in these deficiencies. The policies outlined responsibilities for safeguarding personal property, accommodating residents' needs, and ensuring a comfortable environment, but these were not effectively implemented, leading to the residents' dissatisfaction and unmet needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to create individualized comprehensive nursing care plans for two residents, leading to significant issues. Resident 90, who had a gastrostomy tube (G-tube) for nutrition, experienced the tube being dislodged three times. The care plans for Resident 90, reviewed from August 2023 to July 2024, did not include interventions to prevent G-tube dislodgement, such as the use of an abdominal binder. Charge Nurse 1 confirmed that the care plan lacked necessary interventions for G-tube management, which should have been included upon admission. The facility's policy required a baseline care plan to be developed within 48 hours of admission, reflecting the resident's needs and goals. Resident 28, who had end-stage renal disease, diabetes mellitus, and heart failure, was dependent on staff for personal care and had dentures delivered to the facility. However, Resident 28 reported missing dentures, affecting her ability to chew food. The Director of Social Services stated that a care plan should have been developed to address the refusal to wear dentures, including education on the benefits of wearing them. Registered Nurse 1 acknowledged the resident's right to refuse dentures but emphasized the importance of documenting the refusal and monitoring weight and chewing issues. The facility's policy required comprehensive person-centered care plans based on assessed needs, which were not adequately developed for Resident 28.
Failure to Prevent G-tube Dislodgement
Penalty
Summary
The facility failed to prevent the hospitalization of a resident due to a dislodged gastrostomy tube (G-tube). The resident, who had a G-tube as part of their medical care, was sent to the hospital on two occasions due to the dislodgement of the tube. A review of the nursing progress notes from late July to mid-August 2024 revealed that the resident did not have an abdominal binder, which is a device used to secure the G-tube and prevent dislodgement. Interviews with a Licensed Vocational Nurse and a Charge Nurse confirmed that the resident should have had an abdominal binder upon admission to prevent such incidents. The facility's policy and procedure on enteral tube management, dated September 2023, indicated that it is the facility's responsibility to ensure the safety of enteral tubes before initiating feeding. However, the absence of an abdominal binder for the resident suggests a failure to adhere to this policy, leading to the resident's hospitalization.
Failure to Secure G-tube Leads to Repeated Dislodgement
Penalty
Summary
The facility failed to secure a gastrostomy tube (G-tube) for a resident, resulting in the tube being dislodged three times. The resident, identified as Resident 90, had a G-tube as part of their medical care. A review of the resident's nursing progress notes indicated that the G-tube was dislodged on three separate occasions. Despite the repeated dislodgements, there was no indication in the nursing notes that an abdominal binder, which could have helped secure the G-tube, was used. Interviews with facility staff revealed that the resident should have had an abdominal binder to prevent the G-tube from being dislodged. A Licensed Vocational Nurse (LVN) and a Charge Nurse (CN) both acknowledged that the resident was a candidate for an abdominal binder, and that the repeated dislodgement of the G-tube was not in accordance with nursing standards of care. The facility's policy and procedure for enteral tube management emphasized the responsibility of the facility to maintain the safety of enteral tubes, but preventive measures were not ordered or implemented for Resident 90.
Failure to Update Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that an updated Physician's Order for Life Sustaining Treatment (POLST) form was transferred to the hospital for a resident. This resident, who had severe cognitive impairment and was dependent on staff for daily activities, was transferred to the hospital with an outdated Advance Directive. The Registered Nurse Supervisor confirmed that the outdated document was sent, which could have resulted in a delay of care during a medical emergency. Another resident, who had intact cognitive skills but was dependent on staff for daily activities, did not have an Advance Directive acknowledgment form in their chart. The Registered Nurse Supervisor acknowledged this omission, which could have led to a delay in care and uncertainty about the resident's code status in an emergency. Additionally, the facility did not update the code status for a resident who had experienced a decline in health and could no longer make medical decisions. The responsible party for this resident had expressed the resident's wish not to be on a breathing machine, but the facility's Social Services failed to follow up and update the code status. This lack of communication could have resulted in actions contrary to the resident's wishes.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident had their call light within reach, which is a necessary accommodation for their needs and preferences. The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and spinal stenosis, was observed unable to reach the call light. This observation was made during a room visit, where the resident attempted to reach for the call light but could not. The resident's Minimum Data Set indicated that they were dependent on staff for personal hygiene, showering, and dressing, and could understand and be understood, but could not make medical decisions. Interviews with facility staff, including a Restorative Nurse Assistant, a Certified Nursing Assistant, and a Licensed Vocational Nurse, confirmed the importance of keeping the call light within reach for the resident. The staff acknowledged that without the call light within reach, the resident would not be able to call for assistance, potentially leading to unmet needs and feelings of isolation. The facility's policy and procedure on the communication-call system, dated October 2024, stated that the call alert device should be placed within the resident's reach, which was not adhered to in this instance.
Failure to Submit Accurate PASRR for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening Resident Review (PASRR) was submitted for a resident with a mental disorder, which is a federal requirement to ensure appropriate care placement. The resident, identified as having psychosis, altered mental status, violent behavior, and encephalopathy, was admitted without a proper PASRR submission. The resident's Minimum Data Set (MDS) indicated moderately intact cognitive skills and dependency on staff for various needs, including toileting and dressing. During an interview and record review, the Quality Assurance Nurse acknowledged that all residents with mental illnesses require a PASRR submission. It was revealed that the resident's PASRR, dated earlier, inaccurately indicated no mental illness due to incorrect information on the Level 1 screening. The Quality Assurance Nurse confirmed that a new PASRR should have been submitted with accurate information, as the lack of submission could result in the resident not receiving necessary mental health services. The facility's policy stated that a new PASRR should be completed upon readmission from an acute hospital if there is a significant change in the resident's condition.
Failure to Resubmit PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening Resident Review (PASRR) was resubmitted for a resident with mental health diagnoses, including bipolar disorder, schizophrenia, and major depressive disorder. The resident was readmitted to the facility with these diagnoses, and the Minimum Data Set (MDS) indicated that the resident's cognitive skills were intact, but they were dependent on staff for certain activities of daily living. Despite the requirement for all residents with mental illnesses to have a PASRR submitted, the facility did not resubmit the PASRR for this resident after the initial Level 1 PASRR indicated that facility staff were unresponsive to communication attempts within 48 hours of the screening. The Quality Assurance Nurse acknowledged the oversight, stating that the PASRR should have been resubmitted. The facility's policy, dated April 2024, assigns the responsibility of ensuring PASRR updates to the MDS Coordinator, but this was not adhered to in this case. The failure to resubmit the PASRR had the potential to result in the resident not receiving necessary mental health services.
Failure to Trim Resident's Toenails
Penalty
Summary
The facility failed to ensure that a resident's toenails were trimmed, which had the potential to cause discomfort. The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and knee contractures, was observed to have long, untrimmed toenails. The resident's Minimum Data Set indicated dependency on staff for personal hygiene, showering, and dressing, and the care plan included interventions for nail care on bath days. However, during an observation, the resident's toenails were found to be long and untrimmed. Interviews with staff revealed that the responsibility for trimming the resident's nails fell to the Certified Nursing Assistants (CNAs), as per the facility's policy and procedure. The Registered Nurse acknowledged the need for the toenails to be cut and the potential harm and discomfort caused by long nails. The facility's grooming policy emphasized maintaining short and manageable nails to improve hygiene, comfort, self-esteem, and dignity. Despite these guidelines, the resident's toenails were not trimmed, indicating a lapse in the execution of the care plan and facility policies.
Incorrect LAL Mattress Settings Risk Resident's Skin Integrity
Penalty
Summary
The facility failed to ensure that a resident's low air loss (LAL) mattress was set correctly, which placed the resident at risk for pressure injuries. The resident, who was initially admitted and later readmitted to the facility, had diagnoses including osteomyelitis, adult failure to thrive, and methicillin-resistant Staphylococcus aureus (MRSA). The resident was assessed as having the capacity to understand and make decisions and was dependent on staff for personal hygiene, showering, and dressing. The Minimum Data Set (MDS) indicated that the resident was at risk of developing pressure ulcers. During an observation, it was noted that the LAL mattress was set at 350 pounds, while the resident's weight was recorded as 142 pounds. The Director of Nursing (DON) confirmed that the mattress settings were incorrect and acknowledged that this could lead to the development of pressure ulcers. A Licensed Vocational Nurse (LVN) also stated that incorrect settings would prevent the mattress from serving its purpose of preventing pressure ulcers, thereby increasing the risk of skin breakdown. The facility's policy and procedure on mattresses emphasized the importance of ensuring that mattresses are inflated properly and checked routinely to prevent skin breakdown.
Failure to Apply Splints as Scheduled for a Resident
Penalty
Summary
The facility failed to ensure that a resident's splints were applied as scheduled, which is necessary to maintain or improve range of motion and prevent contractures. The resident, who has diagnoses including dementia, major depressive disorder, and muscle weakness, was observed without the required splints during specified hours on two consecutive days. The physician's orders indicated that the splints should be applied to the resident's upper extremities and ankles for four to six hours, three times a week. However, there was no documentation that the splints were applied on the scheduled days. Interviews with the Restorative Nurse Assistant (RNA) and the Physical Therapist (PT) confirmed the importance of applying the splints as scheduled to prevent contractures. The RNA acknowledged the lack of documentation and the potential consequences of not applying the splints. The facility's policy on the Restorative Nursing Program requires RNAs to document the frequency, duration, and tolerance of activities, which was not adhered to in this case.
Inadequate Supervision of Wandering Resident Leads to Altercation
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a known wandering behavior, which led to an incident involving another resident. Resident 89, who has a history of bipolar disorder with mood swings and wandering behavior, entered Resident 34's room. Despite the facility's awareness of Resident 89's tendency to wander and intrude on others' privacy, she was not adequately supervised, resulting in Resident 34 pushing her out of his room. This incident occurred after the facility had already documented Resident 89's behavior and had interventions in place to distract her from wandering. The incident was witnessed by LVN 2, who heard Resident 34 yelling and saw him push Resident 89, causing her to stumble. Resident 34 admitted to pushing Resident 89, stating she was not supposed to be in his room. Observations on a subsequent day showed Resident 89 continuing to wander through the facility hallways, being redirected by a staff member. The facility's failure to provide consistent supervision and prevent Resident 89 from entering other residents' rooms led to the potential for injury, as evidenced by the altercation with Resident 34.
Failure to Date Oxygen Tubing for Resident
Penalty
Summary
The facility failed to ensure that oxygen tubing was properly dated for a resident, identified as Resident 63, who was receiving respiratory care. Resident 63, who has a medical history of Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, Type 2 Diabetes Mellitus, and anemia, was observed receiving 2.5 liters of oxygen via nasal cannula without a date labeled on the tubing. During an interview, Resident 63 could not recall when the tubing was last changed, only mentioning that it was changed sometime the previous week. The Director of Nursing (DON) confirmed that the facility's protocol requires oxygen tubing to be changed every seven days and labeled with the date of change. The DON acknowledged that the lack of a date label on Resident 63's oxygen tubing was a breach of protocol and posed an infection control issue, as it could lead to staff being unaware of when the tubing was last changed. The facility's policy, titled 'Oxygen Therapy' and dated November 2017, mandates that oxygen supplies be changed and dated every seven days.
Failure to Obtain Informed Consent for Bedrail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bedrails for one resident, identified as Resident 72. Despite the presence of bilateral bedrails observed during a facility visit, there was no documented consent indicating that the risks and benefits of bedrail use had been discussed with the resident or their representative. Resident 72, who has a history of metabolic encephalopathy, major depressive disorder, and spinal stenosis, was noted to be unable to make medical decisions according to their History and Physical. However, the Minimum Data Set indicated that the resident could understand and be understood, suggesting some level of cognitive ability. During an interview, Resident 72 confirmed that the staff did not discuss the use of bedrails with him, and he did not provide consent for their use. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that there was no consent on file for the use of bedrails for Resident 72. The staff acknowledged the importance of obtaining consent to ensure that residents are aware of the risks and benefits associated with bedrail use. The facility's policy and procedure on bedrails, dated June 2024, requires a bed rail evaluation and informed consent prior to installation, which was not followed in this case. The lack of consent placed Resident 72 at risk for potential entrapment, as the resident was unable to easily release the bedrails.
Lack of Physician Order for Bedrails Puts Resident at Risk
Penalty
Summary
The facility failed to ensure that a physician order was obtained for the use of bedrails for one resident, identified as Resident 72. This oversight was discovered during a review of the resident's admission records and Minimum Data Set (MDS), which indicated that bed rail restraints were not being used. However, during an interview and record review with a registered nurse (RN), it was confirmed that there were no current physician orders for bedrails, despite the facility's policy requiring such orders. The RN acknowledged the importance of having physician orders to prevent potential legal issues and to ensure resident safety, as the absence of such orders could lead to entrapment and harm to the resident. Resident 72 was initially admitted to the facility with diagnoses including metabolic encephalopathy, major depressive disorder, and spinal stenosis. The resident was dependent on staff for personal hygiene, showering, and dressing, and was able to understand and be understood, according to the MDS. The facility's policy and procedure on bedrails required a bed rail evaluation and informed consent from the resident prior to use, which was not documented in this case. The lack of a physician order for bedrails placed Resident 72 at risk for entrapment, as noted by the RN during the interview.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the kitchen, which could potentially lead to foodborne illness among residents. During an observation and interview with the Dietary Manager (DM), it was found that two bowls of ice cream were stored in the freezer past their use-by date of 12/2/2024. The DM acknowledged that the ice cream should have been discarded to prevent foodborne illness. Additionally, an opened package of tapioca pudding mix was not labeled with the date it was opened and the date it should be used by. The DM confirmed that all food items should be labeled with these dates to prevent foodborne illness. The facility's policy and procedure titled "P-DS52 Food Storage and Handling," dated 6/4/2024, indicated that all storage products should be labeled and dated. However, the facility did not adhere to this policy, as evidenced by the unlabeled tapioca pudding mix and the expired ice cream. This oversight in food storage and labeling practices was identified during the survey, highlighting a deficiency in the facility's adherence to its own food safety protocols.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that one of four trash dumpsters had its lid closed completely. During an observation and interview with the Dietary Manager, it was noted that the lid of one trash dumpster was open and not closed completely flat. The Dietary Manager acknowledged that trash container lids should be closed completely to prevent pests from entering the container and causing an infestation. A review of the facility's policies and procedures, specifically the Waste Management Administrative Manual dated April 21, 2022, indicated that waste containers must be closable.
Failure to Assist Resident in Exercising Voting Rights
Penalty
Summary
The facility failed to assist a resident in exercising their right to vote, which is a violation of the resident's rights to a dignified existence and self-determination. The resident, who had been admitted and readmitted to the facility, expressed interest in voting to the Social Services Assistant (SSA) in August 2024. Despite this, the resident was not provided with voting materials or the opportunity to leave the facility to vote, leading to feelings of frustration and sadness. The resident's medical history includes cerebral infarction, diabetes mellitus, and hypertension, and they were assessed as being able to understand and communicate effectively. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's expressed interest in voting. The Social Service Director was unaware of the situation, and the SSA admitted to not providing the necessary materials or documenting any efforts to assist the resident in voting. Additionally, a review of the resident's care plans and progress notes showed no indication that the resident was given the opportunity to vote. The facility's policy on resident rights, which includes assisting residents in participating in community activities like voting, was not followed in this case.
Failure to Notify Physician of Medication Refusal Leads to Resident Harm
Penalty
Summary
The facility failed to notify the physician of a resident's refusal to take Risperdal, an antipsychotic medication prescribed for schizophrenia and auditory hallucinations. This oversight involved Resident 10, who was admitted with diagnoses including schizophrenia, bipolar disorder, and hypertension. The resident's medication administration records indicated that from September 4 to September 17, 2024, 20 out of 24 doses of Risperdal were refused, yet there was no documentation that the physician was informed of these refusals. The facility's policy required that the physician be notified of significant changes in a resident's condition, including medication refusals, which was not adhered to in this case. As a result of the medication refusal and lack of physician notification, Resident 10 experienced auditory hallucinations and engaged in physical abuse towards another resident, Resident 9. On September 17, 2024, Resident 10 was found grabbing and choking Resident 9, who has Alzheimer's disease and dementia, and requires maximal assistance for activities of daily living. The incident was witnessed by a Licensed Vocational Nurse and Resident 11, who confirmed that Resident 10 was agitated and aggressive, leading to Resident 9 sustaining redness on her neck and experiencing fear. The facility's failure to follow its policy on notifying physicians of medication refusals and changes in resident condition contributed to the incident. The Director of Nursing acknowledged that the medication administration records showed multiple refusals of Risperdal without physician notification. The facility's policy and procedure documents emphasized the importance of timely communication with physicians regarding significant changes in residents' physical, mental, or psychosocial status, which was not executed in this situation.
Resident Disrespected by Staff Member
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as required by their policy. The incident involved a resident who was cognitively intact and had been diagnosed with schizophrenia and bipolar disorder. During an interaction with a staff member, the resident reported being spoken to in a loud and disrespectful manner when attempting to use a vending machine. The staff member allegedly responded to the resident's complaint about the vending machine by using inappropriate language, telling the resident to "get your a** outside." The Director of Nursing (DON) confirmed the incident, having overheard the exchange between the Activity Assistant (AA) and the resident. The DON acknowledged that the AA's behavior was inappropriate and not in line with the facility's policy, which mandates respectful communication with residents at all times. The facility's policy on Resident Rights-Quality of Life, dated March 2017, was not adhered to in this instance, leading to the deficiency.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where Resident 9 was choked by Resident 10. Resident 9, who has Alzheimer's Disease, dementia, major depressive disorder, and muscle weakness, was assessed to have moderately impaired cognitive skills and required maximal assistance for activities of daily living. On the evening of September 17, 2024, Resident 10 entered Resident 9's room and grabbed her by the neck, causing redness on her neck. This incident was documented in Resident 9's SBAR communication tool. Resident 10, who has schizophrenia, bipolar disorder, hypertension, and muscle weakness, was found to have intact cognitive skills for daily decision-making. According to Resident 10's SBAR, he heard voices telling him to choke Resident 9 and was unable to stop himself. Following the incident, Resident 10 was transferred to a general acute care hospital for psychiatric evaluation. A Licensed Vocational Nurse (LVN 5) witnessed the incident and confirmed that Resident 9 was scared and had redness around her neck. Another resident, Resident 11, who shares a room with Resident 9, also witnessed the incident. Resident 11, who has chronic obstructive pulmonary disease, diabetes mellitus, and respiratory failure, stated that Resident 10 was upset and agitated before choking Resident 9. The Director of Nursing confirmed that the incident was considered resident-to-resident physical abuse. The facility's policies on abuse prevention and management, as well as resident rights, emphasize the importance of protecting residents from abuse and ensuring their well-being.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to report an alleged physical abuse incident involving two residents to the California Department of Public Health (CDPH) within the required timeframe. Resident 9, who has Alzheimer's Disease, dementia, major depressive disorder, and muscle weakness, was grabbed by the head and neck by Resident 10, resulting in redness on Resident 9's neck. Resident 9's cognitive skills were moderately impaired, requiring maximal assistance for daily activities. Resident 10, diagnosed with schizophrenia, bipolar disorder, hypertension, and muscle weakness, had intact cognitive skills and claimed to have heard voices instructing the action. The incident was witnessed by a Licensed Vocational Nurse (LVN 5), who did not report the abuse to CDPH as required. The facility's Director of Nursing (DON) and Administrator (ADM) acknowledged that the incident should have been reported to CDPH within two hours, as per the facility's policy. The facility's policy on abuse reporting and investigations mandates immediate reporting of abuse allegations to the Administrator, initiation of an investigation, and reporting to CDPH within two hours. Additionally, a written report of the investigation results should be submitted to CDPH within five working days. The failure to adhere to these procedures resulted in a delay of an onsite investigation by CDPH and potentially placed all residents at risk for further abuse.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not investigating a resident-to-resident physical abuse incident involving two residents. Resident 9, who has Alzheimer's Disease, dementia, major depressive disorder, and muscle weakness, was grabbed by the head by Resident 10, resulting in redness on Resident 9's neck. Resident 9's cognitive skills for daily decision-making were moderately impaired, and they required maximal assistance for activities of daily living. Resident 10, diagnosed with schizophrenia, bipolar disorder, hypertension, and muscle weakness, had intact cognitive skills for daily decision-making and required supervision or touching assistance for activities of daily living. On the day of the incident, Resident 10 was found in Resident 9's room holding Resident 9's head and later stated that they heard voices telling them to do it. Resident 10 was subsequently transferred to a general acute care hospital for psychiatric evaluation. The incident was reported to the Director of Nursing (DON) by a Licensed Vocational Nurse (LVN), but the DON was initially unaware of the incident. The facility's policy required that allegations of abuse be reported immediately and investigated within two hours, but there was no documented evidence of an investigation. The facility's policies also required reporting to the California Department of Public Health within two hours, which was not done.
Failure to Reassess Fall Risk and Implement Safety Measures
Penalty
Summary
The facility failed to ensure that a fall risk reassessment was conducted for a resident after they were found on the floor on two separate occasions. The resident, who was admitted with conditions including muscle weakness, difficulty in walking, and hemiplegia, had a fall risk evaluation only upon admission. Despite being found on the floor twice, the required reassessment was not performed, as confirmed by a registered nurse who acknowledged that the evaluation should have been conducted after each fall to reflect changes in the resident's condition and identify necessary interventions. Additionally, the facility did not provide floor mats at the bedside for another resident, as ordered, to prevent injury from falls. This resident, who had diagnoses including muscle weakness, schizophrenia, and bipolar disorder, was observed without the required fall mats. Staff interviews confirmed the absence of the mats, which were intended to prevent injury if the resident fell out of bed. The facility's policy mandates a fall risk evaluation post-fall and the implementation of safety measures, which were not adhered to in this case.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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