Encinitas Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Encinitas, California.
- Location
- 900 Santa Fe Drive, Encinitas, California 92024
- CMS Provider Number
- 055761
- Inspections on file
- 36
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Encinitas Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple health conditions experienced a worsening of a right heel pressure injury from stage 2 to unstageable, but the care plan was not updated to reflect this change. The ADON confirmed the care plan should have been revised according to facility policy, which requires updates for acute changes in condition.
Two residents with cognitive impairment and pressure injuries did not receive appropriate pressure ulcer care. One resident's wound care orders were not implemented, the IDT did not meet to address the worsening wound, and the physician was not notified. Another resident's low air loss mattress was not set to the correct weight, contrary to care expectations. These failures resulted in deficiencies in pressure injury management.
Surveyors found that the facility's low-temperature dishwashing machine had visible chalky build-up and lacked proper cleaning documentation, despite facility policy requiring daily cleaning and weekly de-liming. Staff interviews revealed uncertainty about when the machine was last cleaned, and the cleaning schedule did not specifically include the dishwashing machine, resulting in unsanitary conditions and risk for foodborne illness.
Quarterly MDS assessments for several residents with complex medical histories were not completed or signed within the required timeframes, with some assessments left incomplete or finished weeks after the mandated deadlines. Staff interviews confirmed delays and a backlog in the MDS department, with acknowledgment of being behind on required assessments.
A resident was admitted with an anxiety disorder and later diagnosed with major depressive disorder and schizoaffective disorder. The facility did not complete or submit updated Level I PASARR screenings after these new mental health diagnoses, as confirmed by interviews with nursing leadership and a review of facility policy.
A resident was admitted with a diagnosis of generalized anxiety disorder and was receiving psychotropic medications, but the Level I PASARR completed prior to admission did not document the mental health diagnosis or medication use. Facility staff did not complete a corrected PASARR upon admission, resulting in the omission of the resident's mental illness from required screening.
A resident with severe cognitive impairment and a history of stroke was care planned to have a fall mat beside the bed due to high fall risk, but repeated observations showed the mat was missing while the resident was in bed. Staff interviews revealed confusion over responsibility for ensuring and documenting the intervention, and facility leadership confirmed the mat should have been in place at all times.
Two residents with respiratory conditions had their nebulizer and CPAP masks repeatedly left unbagged on bedside and overbed tables, exposing the face-contact portions to environmental surfaces. Despite facility policy requiring respiratory masks to be stored in labeled bags when not in use, staff failed to consistently follow this protocol, and interviews confirmed that the responsibility for proper storage was not always met.
Two residents were not properly notified of changes in Medicare coverage when discharged from Part A Skilled Services, as required beneficiary notices were signed only by staff without obtaining resident or representative signatures or documenting refusals. In both cases, staff did not follow procedures for timely delivery or documentation of the SNF ABN and NOMNC forms, and there was no evidence of attempts to contact responsible parties or record refusals.
The facility did not complete and sign comprehensive MDS assessments within 14 days of the ARD for two residents, one with multiple chronic conditions and another with neurological and psychiatric diagnoses. Staff interviews revealed that the MDS department was behind on assessments due to staffing changes and inexperience, resulting in assessments remaining incomplete or being signed late, in violation of federal requirements.
A resident with a history of wandering and aggressive behavior entered the dining hall unsupervised and hit another resident on the arm. Despite the need for 1:1 supervision, staff were not present during the incident, leading to the altercation. The facility's policy on abuse prevention was not followed, resulting in the incident.
A resident with Alzheimer's and delirium was not provided with an individualized care plan addressing the need for 1:1 supervision while in a wheelchair, leading to unsupervised wandering and altercations. Staff interviews confirmed the necessity of constant supervision, which was not documented in the care plans.
The facility did not report the results of an abuse investigation involving two residents to the CDPH within the required timeframe. Initially, the administrator and DON claimed the results were sent, but later confirmed they were not. The facility's policy requires reporting within five working days, which was not followed.
A facility failed to create a comprehensive care plan for a resident at risk for abuse, leading to staff unawareness of the resident's risk and necessary mitigation measures. The deficiency was noted during an investigation of an altercation between two residents. Despite the IDT's recommendations for specific interventions, these were not included in the care plan. The facility's focus was on protecting others from the resident, rather than considering the resident's potential victimization.
The facility failed to provide privacy for a male resident during bathing, leaving the shower room door wide open and only partially obscuring the shower stall with a curtain. The resident was seen without clothing, and staff admitted to not following the facility's policy requiring the door to be closed during bathing.
A resident did not receive six out of 14 prescribed medications for eight days due to an error in entering physician orders into the computer system. This oversight was discovered when the resident was sent to the hospital for treatment. The missed medications were critical for managing the resident's lung inflammation, heart rhythm, and preventing blood clots.
Failure to Revise Care Plan After Pressure Injury Worsened
Penalty
Summary
The facility failed to revise the written care plan for a resident after a pressure injury worsened from stage 2 to unstageable. The resident, who was admitted with multiple diagnoses including a left femur fracture, need for assistance with personal care, and cognitive communication deficit, developed a stage 2 pressure injury on the right heel. Documentation showed that the wound progressed to an unstageable pressure injury, but the care plan, which initially noted a right heel blister, was not updated to reflect this change in condition. During a joint interview and record review, the ADON confirmed that the care plan should have been revised when the wound worsened, emphasizing the importance of updating care plans to ensure appropriate care. The facility's policy requires the development of episodic or short-term care plans for acute or temporary changes in a resident's condition, but this was not followed in this case.
Failure to Provide Proper Pressure Ulcer Care and Equipment Settings
Penalty
Summary
Two residents experienced deficiencies in pressure ulcer care and prevention. One resident, admitted with a left femur fracture, cognitive impairment, and no pressure injuries, developed a stage 2 pressure injury (clear fluid-filled blister) on the right heel. The wound worsened to an unstageable pressure injury covered with slough. Despite a wound care recommendation to use medihoney and foam dressing, the treatment administration record showed only skin prep was applied, and the recommended treatment was not implemented. There was no documentation of an Interdisciplinary Team (IDT) meeting to address the worsening wound, nor was the attending physician notified of the change in the wound's status. A second resident, with severe cognitive impairment and a stage 3 pressure injury, was observed using a low air loss mattress intended for wound management. The mattress was set for a person weighing 250 pounds, while the resident's actual weight was 91 pounds. The treatment nurse confirmed the mattress was not set appropriately for the resident's weight, which is necessary for effective pressure redistribution and wound healing. The facility's policy required evidence-based interventions and appropriate support surfaces for residents at risk or with pressure injuries, but did not provide specific guidance on mattress settings. Both cases demonstrated failures to follow established protocols for pressure injury management, including prompt implementation of wound care orders, interdisciplinary assessment, physician notification, and proper use of pressure-relieving equipment. These inactions contributed to the deficiencies identified during the survey.
Failure to Maintain and Document Sanitary Conditions of Dishwashing Equipment
Penalty
Summary
The facility failed to maintain its low-temperature dishwashing machine in a clean and sanitary condition, as observed during multiple kitchen inspections. The dishwashing machine was found with a white and brown chalky build-up around the openings of both the dirty loading and clean exit doors, as well as on the top of the machine. Review of the facility's cleaning schedule and check-off forms revealed that there was no specific documentation indicating when the dishwashing machine was last cleaned, and the last recorded cleaning of the dish area walls/fan was nearly two weeks prior to the observation. The facility's policy required daily cleaning and weekly de-liming of the dishwashing machine, but these actions were not consistently documented or verifiable. Interviews with dietary staff, the Certified Dietary Manager, the Registered Dietitian, the Director of Nursing, and the Administrator confirmed that the expectation was for the dishwashing machine to be cleaned and documented according to the established schedule. However, staff were unable to confirm the last cleaning date, and the cleaning schedule did not specifically include the dishwashing machine. The lack of proper cleaning and documentation placed residents at risk for foodborne illnesses, as the equipment used for cleaning dishes was not maintained in accordance with professional standards and facility policy.
Failure to Complete and Sign Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed at least once every three months and signed as complete within 14 days of the Assessment Reference Dates (ARDs) for multiple residents. According to the CMS Long-Term Care RAI 3.0 User's Manual, quarterly assessments must be completed every 92 days following the previous OBRA assessment, and the MDS must be signed as complete within 14 days of the ARD. The survey found that for seven residents reviewed, these requirements were not met, with assessments either completed late, left incomplete, or not signed within the required timeframe. Specific examples included residents with complex medical histories such as sequelae of cerebral infarction, congestive heart failure, senile degeneration of the brain, hemiplegia, chronic kidney disease, and other significant diagnoses. For these residents, MDS assessments were either not completed within the mandated 92-day interval, not signed as complete within 14 days of the ARD, or left in progress well past the required deadlines. In some cases, sections of the MDS were completed weeks after the ARD, and in others, the assessments remained incomplete with no signature to indicate completion. Interviews with facility staff, including the DON, MDS Manager, and MDS Assistant, revealed that the MDS department was behind on assessments, with staff acknowledging delays and incomplete work. The MDS Assistant was relatively new to the role, and the facility had experienced staffing challenges, leading to a backlog of MDS assessments. The Administrator confirmed awareness of the issue and stated expectations for timely completion in accordance with the RAI manual, but the deficiency persisted at the time of the survey.
Failure to Update PASARR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a new Level I Preadmission Screening and Resident Review (PASARR) was submitted after a resident was diagnosed with additional mental disorders during their stay. The resident was initially admitted with a diagnosis of generalized anxiety disorder, and later received diagnoses of major depressive disorder, recurrent, moderate, and schizoaffective disorder, depressive type. Despite these new psychiatric diagnoses, there was no documented evidence that the facility completed or submitted updated Level I PASARR screenings as required by their policy. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that the facility was not updating Level I PASARRs when new psychiatric diagnoses were added to a resident's record. The facility's policy required prompt referral for a Level II review when a resident exhibited a newly evident possible serious mental disorder, but this process was not followed for the resident in question.
Failure to Accurately Reflect Mental Health Diagnosis in PASARR Screening
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed mental illness for one resident. The resident was admitted with a diagnosis of generalized anxiety disorder, which was documented in the admission record as an active diagnosis and classified as an admission diagnosis. The resident's Minimum Data Set (MDS) assessment confirmed the presence of an active anxiety diagnosis and indicated the use of antipsychotic and antidepressant medications. However, the Level I PASARR completed at the hospital prior to admission did not reflect the resident's diagnosis of generalized anxiety disorder or the use of psychotropic medications, resulting in a negative PASARR and no Level II evaluation being required. Interviews with facility staff revealed that hospital staff typically completed the Level I PASARRs, and facility staff were expected to review them for accuracy upon admission. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the facility had recently started checking PASARRs for accuracy due to previous omissions by hospitals, but had not reviewed all prior admissions. In this case, no corrected Level I PASARR was completed upon the resident's admission, despite the presence of a qualifying mental health diagnosis.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident identified as high risk for falls. The resident, who had a history of hemiplegia and hemiparesis due to a previous stroke, severe cognitive impairment, and was dependent on staff for transfers, was care planned to have a fall mat placed beside the bed whenever in bed. Despite this, multiple observations over two days revealed that the fall mat was not present at the bedside while the resident was in bed. Interviews with staff, including LVNs and CNAs, confirmed that the expectation was for a fall mat to be in place for the resident, and that both nursing and CNA staff were responsible for ensuring interventions were implemented. However, there was confusion among staff regarding who was responsible for placing and documenting the presence of the fall mat. Some staff believed it was the nurses' responsibility, while others thought CNAs should handle it, and documentation practices did not consistently include the fall mat intervention. Further interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that the fall mat should have remained in the resident's room and been in use whenever the resident was in bed. The absence of the fall mat was noted by staff, but no one could account for its removal or ensure its replacement, resulting in the resident being left without a key fall prevention intervention as required by the care plan and facility policy.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically nebulizer masks and CPAP masks, were stored in accordance with facility policy and standard precautions. Observations revealed that for two residents with significant respiratory conditions, their respiratory masks were repeatedly left unbagged on bedside tables, oxygen concentrators, or overbed tables, with the portions of the masks that made contact with the residents' faces exposed to environmental surfaces. The facility's policy required that oxygen masks be placed in labeled bags when not in use, but did not specifically address nebulizer masks. Despite this, staff interviews confirmed that the expectation was for all types of respiratory masks to be stored in bags to prevent contamination. For one resident with a history of pneumonia, COPD, and hypoxemia, the nebulizer mask was observed multiple times over several days to be unbagged and in direct contact with various surfaces in the resident's room. The resident reported using the mask twice daily and expressed concern about the mask being left out and not cleaned. Staff interviews revealed inconsistent practices regarding the replacement and storage of the mask, with some staff unsure if clean masks were provided or if used masks were properly bagged. The Director of Nursing and other staff acknowledged that masks should be stored in bags and that the responsibility for this task fell primarily to the nursing staff, with CNAs able to assist if they noticed improper storage. A second resident with acute hypoxic respiratory failure, pneumonitis, and obstructive sleep apnea also had both a CPAP mask and a nebulizer mask left unbagged on the overbed table. Multiple observations confirmed that the masks were not stored in bags as required. Staff interviews indicated that nurses were responsible for placing and removing the masks and that the expectation was for masks to be stored in labeled bags when not in use. However, staff were observed not following this protocol, and the Director of Nursing confirmed that all respiratory masks should be bagged to prevent contamination.
Failure to Provide and Document Required Medicare/Medicaid Coverage Notices
Penalty
Summary
The facility failed to provide appropriate and timely notices of payor source changes to residents when they were discharged from Medicare Part A Skilled Services, despite days of eligibility remaining. Specifically, staff did not ensure that required beneficiary notifications, such as the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC), were properly completed, signed by the resident or their representative, or documented when signatures were refused or not possible. In both reviewed cases, staff members signed the forms themselves without obtaining the required resident or representative signatures, and there was no documentation of attempts to contact responsible parties or to record refusals to sign. One resident, who had a history of hypertensive heart disease and stage 3 chronic kidney disease, was admitted with a responsible party and was assessed as independent in cognitive skills but with memory problems. The resident experienced a payor change, and the SNF ABN and NOMNC forms were signed by staff after the resident was discharged from Part A Skilled Services. The forms did not specify which care was not covered, and there was no evidence that the resident or their representative received or signed the forms. The case manager confirmed that she was unsure of the correct procedures, did not document any verbal consent, and had checked an option on the form without understanding its meaning. Another resident, with diagnoses including depression, cognitive communication deficit, and chronic kidney disease, was also subject to a payor change. The SNF ABN form for this resident was signed by two staff members, with no signature from the resident, who was cognitively intact and listed as their own responsible party. The resident stated they did not know who signed the form, and the case manager confirmed that the resident refused to sign but that this was not documented. Interviews with facility leadership confirmed that staff were expected to provide these notices timely and to document when they were given and whether the resident or responsible party signed or refused, but this was not done in these cases.
Failure to Complete MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed and signed as required within 14 days of the Assessment Reference Date (ARD) for two residents. According to facility policy and the CMS RAI 3.0 User's Manual, comprehensive assessments must be completed and signed within the specified timeframe. However, for one resident with a history of chronic obstructive pulmonary disease, adult failure to thrive, dementia, and disorientation, the annual MDS assessment with an ARD of 03/26/2025 was still marked as 'In Progress' at the time of the survey, with several sections incomplete and the assessment not signed as complete. Another resident, who had diagnoses including Parkinson's disease, restless leg syndrome, and schizoaffective disorder, had an annual MDS assessment with an ARD of 02/27/2025 that was not signed as complete until 04/25/2025, which exceeded the 14-day requirement. Interviews with the MDS Manager, MDS Assistant, and DON revealed that the MDS department was behind on assessments, with staff acknowledging delays and ongoing efforts to catch up. The MDS Assistant reported using a spreadsheet to track due dates, but assessments from previous months remained incomplete at the time of the survey. The Administrator confirmed that timely completion of MDS assessments was expected and acknowledged challenges within the MDS department. The DON and MDS staff indicated that staffing changes and inexperience contributed to the delays, and that part-time staff were being utilized to assist with the backlog. Despite these efforts, the required MDS assessments for the two residents were not completed within the mandated timeframe, resulting in noncompliance with federal requirements.
Failure to Protect Resident from Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of wandering and aggressive behavior, entered the dining hall unsupervised and hit the resident on the arm. The incident occurred when the resident was having a private conversation with another resident, and the aggressive resident intruded, taking food from their trays. Despite being told not to touch the food, the aggressive resident yelled and hit the resident, causing distress. Staff were not present during the incident, and the resident had to call for assistance using a cell phone. The aggressive resident had a documented history of wandering, entering other residents' rooms, and taking personal items, which was known to staff. Multiple staff members, including CNAs and the director of nursing, acknowledged the resident's behavior and the need for increased supervision. The resident's care plan indicated a need for 1:1 supervision when in a wheelchair to prevent such incidents, but this was not implemented, leading to the altercation. Interviews with other residents and staff revealed that the aggressive resident's behavior was a known issue, causing discomfort and fear among other residents. The facility's policy on abuse prevention emphasized the need for sufficient staff to meet residents' needs and prevent abuse, but this was not adhered to, resulting in the incident. The director of nursing admitted that the resident's care plan should have included increased supervision to prevent further incidents.
Failure to Individualize Care Plan for Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that the care plans for a resident with Alzheimer's Disease and delirium were individualized to address the need for increased supervision while in a wheelchair. The resident was admitted with a history of wandering and entering other residents' rooms, which led to altercations and an incident of physical abuse. Despite these behaviors being documented in the resident's care plans for elopement and mood, the necessary intervention of 1:1 supervision was not included. Interviews with staff, including CNAs and LNs, revealed that the resident required constant supervision to prevent unsafe wandering and potential altercations. The staff acknowledged that the resident's behavior of wandering and rummaging could lead to abuse, and the need for 1:1 supervision was recognized but not documented in the care plans. The Director of Nursing confirmed that the resident's care plan should have included increased supervision to prevent further incidents.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an abuse investigation to the California Department of Public Health (CDPH) within the required five working days. The incident involved two residents, where one resident hit another. The facility's administrator and director of nursing initially stated that the investigation results had been sent to CDPH, but upon further verification, it was revealed that the results were not reported. The director of nursing acknowledged that the results should have been sent by a specific date, which was not met. The facility's policy mandates that investigative findings be reported to the appropriate state agency within five working days, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident at Risk for Abuse
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident at risk for abuse, which resulted in staff being unaware of the resident's risk and the necessary measures to mitigate these risks. The deficiency was identified during an investigation of a physical and verbal altercation between two residents. Resident 1, who has a history of aggressive behaviors and is cognitively intact, was involved in the incident. The interdisciplinary team (IDT) had previously noted Resident 1's behaviors and recommended specific interventions, such as encouraging the resident to notify staff when others are aggressive and to remove themselves from situations. However, these recommendations were not included in the resident's care plan. The facility's policy on abuse prevention requires the identification, assessment, and care planning for residents with behaviors that might lead to conflict. Despite this, the care plan for Resident 1 did not include personalized interventions to keep the resident safe from altercations. Interviews with the Administrator and Director of Nursing revealed that the facility focused on protecting others from Resident 1, rather than considering the resident's potential victimization due to their behaviors. This oversight meant that the care plan lacked specific strategies to address the resident's behavior problems and ensure their safety.
Failure to Provide Privacy During Bathing
Penalty
Summary
The facility failed to provide privacy for a male resident during bathing. On the specified date, the shower room door was observed to be held wide open with a large magnet, and a curtain only partially obscured the shower stall. The resident was seen seated in a shower chair, facing the door, and rinsing himself with a hand-held shower head without any clothing. A staff member was present, giving verbal cues to the resident. Interviews with the Licensed Nurse (LN) and Certified Nursing Assistant (CNA) revealed that the facility's policy requires the shower room door to be closed and a sign indicating occupancy to be displayed when a resident is bathing. However, CNA 1 admitted to usually leaving the door open due to frequent staff movement in and out of the room to gather supplies. Further interviews with the resident confirmed that privacy is of utmost importance to him, and he would feel embarrassed if someone unknown saw him bathing or changing clothes. The Director of Nursing (DON) reiterated that privacy should be provided for all personal care to avoid discomfort and embarrassment. The facility's policies and procedures for bathing and resident rights, dated 2006 and 2022 respectively, also emphasize the importance of covering the resident with an appropriate drape and treating residents with respect and dignity.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer six out of 14 medications ordered by the physician for a total of eight days for one resident. This deficiency occurred because the licensed nurse responsible for processing the resident's admission paperwork did not enter all of the physician's orders into the computer system. As a result, the medications were not included in the Medication Administration Record (MAR), and the medication nurses were unaware that these medications needed to be administered. The resident was admitted with diagnoses including cancer in the right lung and pneumonia in the left lung, and was supposed to receive medications for these conditions, as well as for atrial fibrillation and depression. The error was discovered eight days later when the resident was sent to the hospital for radiation treatment. During this period, the resident missed critical medications such as Prednisone, Amiodarone, and Apixaban, which were essential for managing her lung inflammation, heart rhythm, and preventing blood clots. The resident's vital signs were monitored during this period, showing fluctuations in blood pressure, heart rate, and respiratory rate, but the omission of these medications posed significant health risks. The resident was eventually admitted to the hospital with pneumonia, sepsis, and rapid atrial fibrillation. Interviews with the Assistant Director of Nursing, licensed nurses, the facility's pharmacist, and the resident's medical doctor confirmed the oversight and the potential health risks associated with the missed medications. The licensed nurse responsible for the admission paperwork admitted to missing a page of the medication orders, which led to the medications not being entered into the system. The facility's policy on the admission of residents was reviewed, highlighting the requirement for designated staff to obtain information and perform assessments as per facility protocol, which was not fully adhered to in this case.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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