Four Seasons Healthcare & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hollywood, California.
- Location
- 5335 Laurel Canyon Blvd., North Hollywood, California 91607
- CMS Provider Number
- 055932
- Inspections on file
- 64
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Four Seasons Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with chronic medical conditions and intact cognition had been discharged from PT and OT, and no therapy services were provided after that point. However, subsequent weekly LTC Evaluation forms completed by staff documented that the resident continued to participate in PT and OT as ordered by the physician. During surveyor interviews and record review, the IRD confirmed therapy had ended, and the DON acknowledged that the LTC Evaluation forms for that period were not accurate, contrary to facility policy requiring complete and accurate medical record documentation.
Surveyors found that three residents kept personal medications at their bedsides, including eye drops, Vicks VapoRub, and an Albuterol inhaler, all brought from home and lacking pharmacy labels, physician orders, and documented self-administration assessments. These residents had varying levels of independence and medical conditions such as DM, COPD, kidney disease with dialysis, and major depressive disorder, but all had documented capacity to make medical decisions. The DON reported she was unaware that these medications were present at the bedside and acknowledged that facility policy requires an IDT assessment, a physician’s order, proper labeling, and secure storage for any self-administered medications.
A resident with hemiplegia, morbid obesity, and lumbar radiculopathy had physician orders for MRI and CT imaging of the thoracic and lumbar spine, and the care plan directed nursing to obtain and monitor diagnostic work, report results to the MD, and follow up as indicated. The resident was transported by ambulance to an outside imaging appointment but returned without the tests being completed because the resident’s weight exceeded the capacity of the equipment. Nursing notes documented that the procedures could not be done and that a new location was needed, but there was no subsequent documentation of follow-up by nursing or case management to locate another imaging center or reschedule the tests, and the imaging was never completed. This failure to implement the care plan intervention and carry out the MD’s orders resulted in delayed treatment for the resident.
A resident with morbid obesity, hemiplegia, and lumbar radiculopathy had physician orders for MRI and CT imaging at an outside facility. Nursing notes documented that the resident was transported for the tests and returned without the procedures being completed because the resident could not fit into the machines, with a notation that a new location was needed. However, there was no subsequent documentation that an RN endorsed the cancelled tests to case management or to the next nursing shift, and no progress notes described any follow-up to reschedule the imaging. The DON and admissions staff confirmed that they were not informed through the record of the cancellation, and facility policy requires prompt, medically relevant documentation, resulting in an incomplete and inaccurate medical record.
A resident with asthma, depression, overactive bladder, and moderately impaired cognition reported burning with urination, triggering a documented change in condition that required every-shift monitoring for at least 72 hours per facility policy. However, nursing staff did not document any monitoring on five consecutive shifts across multiple days following this change. An RN and the DON both confirmed that there was no documentation of monitoring on those shifts and that care not documented is considered not provided, resulting in a failure to follow the facility’s COC policy and professional standards.
A resident with severe cognitive impairment, a history of cerebral infarction, an unstageable pressure ulcer, and a G-tube had their bed placed directly against a wall, leaving no usable space on one side and restricting movement. An LVN confirmed there was no physician order or care plan intervention authorizing this bed placement. An RN and the DON acknowledged that placing a bed against the wall, or less than one foot from it, is considered a restraint. Review of the facility’s restraint policy showed that restraints require a physician order and IDT involvement, which did not occur in this situation.
A resident with a history of cerebral infarction, gastrostomy, and a severe pressure ulcer on the back was care-planned for use of a low air-loss mattress (LALM) to manage pressure injuries. The LALM was observed to be set for a 300–350 lb range, while the resident’s documented weight was 161 lb and a physician order directed calibration to 180 lb. An LVN confirmed the LALM was not set according to the order, and the DON acknowledged the mattress setting was not adjusted based on the resident’s weight, contrary to facility policies on pressure injury prevention and mattress use.
A resident with a gastrostomy tube, severe cognitive impairment, and advanced pressure ulcers was ordered and care planned to be on Enhanced Barrier Precautions (EBP), but no EBP sign was posted outside the room as required by facility policy. An LVN, the IPN, and the DON all confirmed the resident was on EBP and acknowledged that the absence of signage could result in staff not using appropriate PPE and potentially contribute to infection transmission.
A cognitively intact, functionally quadriplegic resident who depended on staff for all ADLs was positioned in a hallway near a smoking area when another cognitively intact, wheelchair-using resident became upset over a perceived blockage of the hallway. The mobile resident lifted his wheelchair over the other resident’s legs and, after an exchange of words, retrieved a wooden back scratcher he had brought from home and struck the quadriplegic resident on the top of the head multiple times. A nearby cognitively intact resident witnessed the event and confirmed that the quadriplegic resident’s powered wheelchair had only accidentally bumped the other resident, who then stood, moved past, and intentionally hit the immobile resident on the head with the back scratcher. The struck resident later reported minimal scalp pain and described being protected somewhat by a hat, but the incident constituted physical abuse occurring while both residents were under facility care.
A resident with a history of seizures experienced three consecutive seizure episodes, but licensed nurses did not fully document the change of condition or complete required assessments in the medical record. Despite physician orders to monitor and document seizure activity, there was no evidence that an SBAR form was completed, and progress notes were incomplete. Interviews with nursing staff and the DON confirmed that documentation was not done according to facility policy.
A resident's report of a stolen coin purse containing identification, a Social Security card, and cash was not documented in the facility's Theft and Loss log as required by policy. The social service designee filed a police report and arranged for replacement documents but failed to complete the necessary internal documentation. Review of the facility's logs also showed missing information on other incidents, including estimated values and dates/times of loss or theft, in violation of facility policy.
Licensed nursing staff documented administration of an antibiotic on the MAR for a resident on three occasions when the medication had not yet been delivered to the facility. This resulted in the medical record inaccurately showing that the resident received the prescribed therapy, despite the medication only arriving several days later.
A resident's bathroom wall developed a rusty brown water stain following heavy rain, which was reported to a laundry aide but not addressed through a maintenance work order. The maintenance staff and DON were unaware of the issue until it was observed during the survey, resulting in a failure to maintain a clean and homelike environment as required by facility policy.
A resident with severe cognitive impairment and mobility limitations was found to have their call light placed out of reach, contrary to their care plan and facility policy. Staff acknowledged the resident could not use the call light to request assistance, and the DON confirmed the failure to follow procedures requiring call lights to be accessible to residents.
A resident with significant mobility and cognitive impairments, who required a floor mat for fall prevention, was found to have a side table and trash can placed on top of the mat. Staff and the DON confirmed this was improper and not in accordance with facility policy, as it compromised the mat's intended safety function.
A resident with severe cognitive impairment and a court-appointed conservator experienced a significant change in condition involving an alleged sexual interaction. Although the physician was notified and a room change was ordered, the conservator was not promptly informed as required by facility policy. Staff interviews confirmed that the conservator, as the healthcare decision-maker, should have been notified immediately, but notification was delayed until the following day.
A resident with a history of epilepsy, chronic pain, and depression experienced an alleged sexual interaction, and the facility failed to accurately document the time the responsible party was notified. The eInteract Change in Condition Evaluation recorded an incorrect notification time, which staff confirmed was not possible, resulting in inaccurate medical records and potential confusion during care.
A resident with anemia and recent gastrointestinal bleeding did not receive ordered STAT laboratory tests before being discharged to a hospital. Although initial labs were drawn, a repeat STAT hemoglobin and hematocrit (H/H) was ordered but not completed, as the lab phlebotomist did not arrive and staff did not document follow-up or completion. The DON confirmed the STAT labs were not done as required, resulting in a failure to provide necessary lab services and a potential delay in care.
A resident's legal representative requested access to medical records, but the facility failed to document the request in accordance with its own policy. Staff were unaware of the required log for tracking such requests and instead relied on informal methods, leading to a lack of proper documentation and potential delays in providing the requested PHI.
A resident with cognitive impairment and no decision-making capacity was found with prescribed eye drops left unsecured on the bedside table. Nursing staff confirmed there was no assessment, care plan, or physician order for self-administration, and facility policy requiring interdisciplinary assessment and secure storage was not followed.
Staff failed to accurately and promptly document meal intake percentages, bowel movements, and change in condition evaluations for three residents with complex medical histories, resulting in incomplete and inaccurate medical records. Documentation was sometimes entered before events occurred or without proper verification, contrary to facility policy.
A resident with a history of elopement and multiple medical conditions left the facility unassisted through the main entrance while the receptionist, responsible for monitoring, was present but distracted. Staff did not consistently monitor the resident's whereabouts, resulting in missed medications and a delayed response to the resident's absence. The facility's policies for supervising high-risk residents were not followed, leading to the resident's unsupervised exit.
Multiple residents with significant physical and cognitive impairments were found without accessible call lights, as staff failed to ensure the devices were within reach despite facility policies requiring this. Observations and interviews confirmed that call lights were left on the floor, tangled, or otherwise out of reach, preventing residents from summoning assistance when needed.
Staff failed to properly dispose of documents containing PHI, including a diet report with multiple residents' information found in a kitchen trash can and a handwritten medication list for two residents found in a regular trash bin at a nursing station. Both dietary and nursing staff acknowledged these actions violated confidentiality protocols, and the DON confirmed the facility did not follow required procedures for PHI disposal.
The facility did not follow its grievance policy in several cases, including when a resident's complaint about a CNA refusing to warm a meal was not reported, when a resident's concerns about salty food on a therapeutic diet were not properly investigated or communicated, and when a resident's missing home medications at discharge were not documented or followed up. These failures led to unresolved grievances and distress for the residents involved.
Surveyors found that several residents were subjected to physical restraints, such as beds placed against the wall or bed alarms, without required quarterly restraint assessments, physician orders, or care plan documentation. In multiple cases, residents with cognitive or physical impairments had their freedom of movement restricted without proper evaluation or documentation, contrary to facility policy. Staff interviews confirmed that restraint assessments and documentation were not consistently completed as required.
The facility did not develop or implement required care plans for two residents prescribed psychoactive medications, one resident receiving IV antibiotics, and one resident using CPAP therapy for sleep apnea. In each case, staff confirmed that care plans were missing or delayed, despite facility policy requiring timely, person-centered care planning to guide safe and effective care.
Staff failed to rotate subcutaneous insulin injection sites for three residents with diabetes, administering repeated injections in the same area despite physician orders, manufacturer guidelines, and facility policy requiring site rotation. This deficiency was confirmed through record review and staff interviews, affecting residents with cognitive impairment, hemiplegia, and other complex medical needs.
Two residents with limited ROM did not receive timely RNA services as ordered, resulting in a delay in the start of PROM exercises for both upper and lower extremities. Despite care plans and therapy recommendations specifying the need for ongoing RNA interventions, the facility failed to initiate these services promptly after discharge from therapy, as confirmed by staff interviews and documentation review.
Several residents were placed at risk due to beds not being kept in the low position, non-functioning bed alarms, exposed or frayed wires on bed remote controls, and fall mats obstructed by furniture or equipment. Staff interviews and record reviews confirmed that these deficiencies occurred despite care plans, physician orders, and facility policies requiring regular safety checks and interventions to prevent accidents.
Surveyors found that three residents with urinary catheters did not receive proper catheter care, including failure to keep catheter tubing free from kinks or loops, and failure to anchor a catheter or use the correct drainage bag. These actions were confirmed by nursing staff and were not in accordance with facility policy, increasing the risk of improper urine flow and potential complications.
Two residents with orders for continuous supplemental oxygen did not consistently receive oxygen therapy as prescribed. One resident was repeatedly observed without a nasal cannula and had no documentation of oxygen administration or refusal, nor was the physician notified of non-compliance. Another resident was found with oxygen tubing detached, and staff could not confirm how long the resident had been without oxygen. Facility policy requiring documentation and physician notification was not followed.
Two doses of controlled substances were unaccounted for after a nurse failed to document administration on the required accountability logs for two residents—one receiving oxycodone for pain and another receiving lacosamide for seizures. The nurse admitted to administering the medications but did not sign the records as required by facility policy, leading to discrepancies between the medication counts and documentation. The DON confirmed that this failure to document violated established procedures for controlled substance handling.
Two residents experienced medication errors when one did not receive a scheduled IV antibiotic dose due to delayed IV access, and another received an oral medication outside the prescribed time window. Nursing staff and the DON confirmed these errors resulted from not following physician orders and facility policy, leading to a medication error rate above the acceptable threshold.
Licensed staff failed to rotate subcutaneous insulin injection sites for three residents and administered expired insulin to another resident, contrary to physician orders, manufacturer guidelines, and facility policy. These actions were confirmed through record review, staff interviews, and observation, and involved residents with diabetes and cognitive impairment.
Surveyors found that staff failed to label an open bottle of artificial tears eye drops with a start date and did not remove an expired Lispro insulin pen from use, resulting in the administration of expired insulin to a resident. Both deficiencies were confirmed by the DON and were contrary to facility policy and manufacturer guidelines.
Kitchen staff were not properly trained or evaluated for competency in cooling cooked foods, resulting in improper cooling of roast turkey and roast beef. Cooling logs showed errors and failure to meet required time and temperature standards, and facility documentation lacked evidence of training on food cooling procedures. This affected a large number of medically compromised residents who received food from the kitchen.
A resident with diabetes and end stage renal disease received food that was too salty because a cook did not follow the standardized recipe for gravy on a therapeutic diet. The cook prepared the gravy by guessing the ingredients instead of using the required recipe, and the dietary supervisors confirmed the food was inappropriately salty for a renal diet. Facility policies require the use of standardized recipes to ensure nutritional needs are met, but this was not followed.
The facility did not prepare pureed foods, such as mashed potatoes and roast turkey, to the required consistency and shape for residents on a pureed diet. Observations showed that these foods were flat and did not hold their shape on the plate, despite passing texture tests. Dietary supervisors confirmed the foods did not meet both facility and IDDSI guidelines, affecting multiple residents who require pureed diets.
Surveyors identified multiple deficiencies in kitchen operations, including cracked and rusted refrigerator shelves, improper food cooling procedures, food stored at unsafe temperatures, unsanitary cleaning practices during food preparation, storage of dented cans with non-dented cans, and inadequate cleaning of kitchen equipment and utensils. These issues were confirmed through staff interviews, observations, and review of facility policies and food safety codes.
Surveyors found that food was not consistently served at safe or appetizing temperatures, with hot foods below recommended levels and cold foods above safe limits. Two residents on therapeutic diets received food that was too salty due to staff not following standardized recipes, and pureed foods did not hold their shape as required by facility and IDDSI standards. These deficiencies were confirmed by staff and resident interviews, as well as direct observation.
A resident with severe cognitive and physical impairments was assisted with eating by a CNA who stood over the resident instead of sitting at eye level, contrary to facility policy and staff training. The CNA admitted to forgetting to use a chair, and the DON confirmed that staff are expected to assist residents at eye level to maintain dignity.
A resident with decision-making capacity was administered lorazepam, a psychotropic medication, without documented informed consent or education about its risks and benefits. Staff interviews and record reviews confirmed that the required consent process was not followed, despite facility policy mandating written informed consent for such medications.
A resident admitted with multiple diagnoses, including dementia and muscle weakness, was identified as high risk for falls and had physician orders for side rails and a bed alarm. Despite these orders and assessments, staff did not develop or implement a baseline care plan for the use of these devices within 48 hours of admission, as required by facility policy. Staff interviews confirmed the omission, which had the potential to delay essential care.
A resident receiving IV antibiotics for osteomyelitis did not have their midline catheter dressing changed as ordered and did not receive proper aseptic technique during medication administration. Nursing staff failed to scrub the infusion port with antiseptic before flushing and attaching new IV lines, and the dressing was not changed every 48 hours as required. These actions were not consistent with physician orders or facility policy.
A registered nurse failed to follow proper aseptic technique when administering IV antibiotics to a resident, including not scrubbing the midline catheter infusion port and not changing the dressing as ordered. The nurse had not completed a documented IV skills competency, and facility protocols for infection prevention were not followed.
A resident receiving Cefepime HCl for osteomyelitis did not have monitoring for adverse effects as required for significant medications. Despite facility policy and staff acknowledgment that such monitoring is necessary, there was no order or documentation of monitoring for adverse reactions during the antibiotic course.
A resident with diabetes and end stage renal disease did not receive the physician-ordered renal diabetic diet with regular portion size because staff failed to update the diet order in the system, resulting in the resident receiving a large portion diet instead. The error was confirmed through observation, record review, and staff interviews, revealing a lack of consistency between the physician's order and the meal provided.
The facility did not properly document changes of condition for two residents who were hospitalized, omitting key assessments and communication details, and also failed to maintain accurate wound documentation for another resident, resulting in inconsistencies in the number and onset dates of wounds. These deficiencies were confirmed by staff interviews and were not in accordance with facility policies requiring thorough and timely documentation.
A resident with an indwelling urinary catheter was not placed on Enhanced Barrier Precautions (EBP) as required, with no EBP sign or PPE cart outside the room, despite facility policy and physician orders indicating the need for such measures. Both the IP and DON acknowledged the oversight, which resulted in a lapse in infection prevention protocols for device care.
Inaccurate Therapy Documentation on Long Term Care Evaluation Forms
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident in accordance with accepted professional standards. The resident was originally admitted with diagnoses including chronic obstructive pulmonary disease, osteoarthritis, and chronic pain syndrome, and had documented capacity to understand and make decisions, with intact cognitive functioning on a subsequent MDS. The MDS also indicated the resident required assistance with toileting hygiene, showers, and dressing, and was independent with ambulating 150 feet. According to the Interim Rehab Director, the resident was discharged from physical and occupational therapy on 5/19/2025 and did not receive these therapies after that date. During review of the resident’s Long Term Care Evaluation forms, the DON identified that weekly evaluations dated 6/8/2025 and 6/29/2025 documented that the resident continued to participate in occupational and physical therapy as ordered by the physician, despite the resident not receiving these services during that period. The DON stated that the Long Term Care Evaluation is a weekly assessment of resident progress for continuation of care and acknowledged that these evaluation forms were not documented accurately. This inaccurate documentation conflicted with the facility’s policy titled “Completion and Correction,” which requires medical record entries to be complete, legible, descriptive, and accurate, and to ensure that medical records are complete and accurate.
Unlabeled Bedside Medications and Lack of Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that medications were not left unattended at residents’ bedsides, that all medications had corresponding physician orders and pharmacy labels, and that required self-administration assessments were completed. One resident admitted with diabetes mellitus and COPD, who had documented capacity to make medical decisions and no memory loss, kept a bottle of eye drops brought from home on his nightstand. The bottle, labeled only with the manufacturer’s label “Colirio Oftal-mycin,” had no pharmacy label, and there was no physician’s order or self-administration assessment for this medication. A second resident with diabetes, kidney disease requiring dialysis, and major depressive disorder, who had capacity to make decisions but required maximum assistance with ADLs, kept a container of Vicks VapoRub on the over-bed table without a pharmacy label, physician’s order, or self-administration assessment. A third resident with COPD and diabetes, independent in all ADLs and with capacity to make medical decisions, kept a home Albuterol rescue inhaler on the nightstand without a pharmacy label, physician’s order, or self-administration assessment. The DON stated she was not aware these residents had medications at the bedside and confirmed that, per facility policy, residents should not have medications for self-administration without an assessment, a physician’s order, and appropriate labeling, and that these situations placed the residents at risk for medication errors and misuse.
Failure to Follow Up on Ordered MRI/CT Imaging After Cancelled Appointment
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s care plan intervention to obtain and monitor ordered diagnostic work, specifically MRI and CT imaging, and to follow up as indicated. The resident had multiple significant diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, morbid obesity, and lumbar radiculopathy, and was chairbound, used a manual wheelchair, and required substantial assistance with several activities of daily living. The resident’s care plan included a nursing intervention directing staff to obtain and monitor lab/diagnostic work as ordered by the physician, report results to the physician, and follow up as indicated. The physician ordered MRI of the thoracic and lumbar spine and a CT of the thoracic spine, with the tests scheduled at an outside testing center. Nursing documentation showed that on the scheduled date, the resident was transported by ambulance to the appointment and later returned without having the MRI and CT completed because the resident’s weight prevented use of the imaging equipment. Nursing progress notes documented that the resident could not undergo the procedures due to being overweight and that a new place was needed, but there were no subsequent notes describing any follow-up by the facility to arrange completion of the ordered tests. RN 2 recalled that the resident returned without the tests being done because of size limitations of the equipment and stated that a new diagnostic testing location was needed and that the matter was endorsed to the case manager. However, RN 2 acknowledged that after the progress notes from that date, there were no further notes describing follow-up by nursing to reschedule the MRI and CT, and confirmed that the tests had not been rescheduled. RN 1, upon review of the record, also could not locate any documentation of follow-up after the cancelled appointment and stated that the care plan intervention to follow up on diagnostic work as ordered was not implemented. The DON stated that there had been a delay in care when the MRI and CT appointments were cancelled and the facility did not follow up as indicated in the resident’s care plan. The Director of Admissions, who had assisted with case management, explained that the process for diagnostic imaging involved obtaining the physician’s order, securing insurance approval when required, and then scheduling at an appropriate testing center, often with assistance from corporate case managers. The Appointment Information sheet showed that the MRI and CT appointment had been scheduled, but the Director of Admissions reported not being informed that the appointment was cancelled and therefore did not initiate efforts to find another imaging center that could accommodate the resident’s size. Facility policies on comprehensive person-centered care planning required that care plans include physician orders and interventions addressing resident needs, and the RN job description required RNs to implement nursing interventions in the plan of care and complete medical treatments as ordered. Despite these requirements, the ordered diagnostic imaging and the care plan intervention to follow up on diagnostic work were not carried out after the initial failed appointment, resulting in delayed treatment for the resident.
Failure to Document Follow-Up After Cancelled MRI/CT Appointment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident when ordered diagnostic tests were not completed and follow-up actions were not documented. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, morbid obesity, and lumbar radiculopathy, was chairbound, used a manual wheelchair, and required varying levels of assistance with ADLs according to the MDS. A physician ordered MRI studies of the thoracic and lumbar spine and a CT of the thoracic spine, and these tests were scheduled at an outside testing center. Nursing documentation on the day of the appointment showed that the resident was transported by ambulance for the MRI and CT and later returned without having the procedures completed because of being overweight and not fitting into the scanning machines, with a note that a new place needed to be found. Subsequent review of the medical record by RN 1 revealed no further nursing progress notes describing any follow-up to arrange completion of the MRI and CT after the cancelled appointment. During interview, RN 2 recalled that the resident’s MRI and CT could not be completed due to the resident’s size and stated that a new testing location that could accommodate the resident was needed. RN 2 reported that she endorsed this information to the case manager and to the night shift but acknowledged there was no documentation in the resident’s record reflecting that these endorsements occurred or that any follow-up was initiated by nursing. RN 2 also stated that while the case manager is responsible for finding a new diagnostic testing site, nurses are responsible for follow-up as well. The Director of Admissions, who had been assisting with case management, explained that case managers rely on receiving information about diagnostic test needs and cancellations from nursing in order to obtain insurance approval and schedule appointments, and stated there was no recollection of being informed that the resident’s MRI and CT appointment had been cancelled. The DON confirmed awareness that the MRI and CT had been ordered and that the appointment was cancelled due to the resident’s size, and stated that RN 2 should have documented her endorsement of the cancelled tests so subsequent shifts could follow up. Review of the facility’s “Completion and Correction” policy indicated that medical records are to be complete and accurate, with entries recorded promptly as events occur and documentation reflecting medically relevant information concerning the resident. The lack of documentation of the endorsement and follow-up related to the cancelled MRI and CT resulted in an incomplete and inaccurate medical record for the resident.
Failure to Monitor and Document Resident After Change in Condition
Penalty
Summary
The facility failed to follow its change in condition (COC) policy and professional standards of nursing practice by not ensuring that a resident was monitored and documented every shift for at least 72 hours after a documented COC. The resident, admitted with diagnoses including asthma, depression, and overactive bladder, had a Minimum Data Set indicating moderately impaired cognitive skills for daily decision making. On 1/18/2026, a Change in Condition Evaluation documented that the resident complained of a burning sensation during urination. Facility policy required licensed nurses to document each shift for at least 72 hours when there is a change in the resident's condition, and both RN 1 and the DON stated the resident should have been monitored every shift during this period. During interview and record review, RN 1 identified that there was no documented evidence of monitoring on five specific shifts following the COC: the 11 p.m. to 7 a.m. shift on 1/18/2026; the 11 p.m. to 7 a.m. shift on 1/19/2026; the 7 a.m. to 3 p.m. and 11 p.m. to 7 a.m. shifts on 1/20/2026; and the 7 a.m. to 3 p.m. shift on 1/21/2026. RN 1 stated that care not documented is considered not provided and that failure to document monitoring could result in a failure to identify worsening symptoms. The DON confirmed there was no documented evidence of monitoring on the identified shifts and acknowledged that the facility failed to ensure the resident's health status was monitored every shift following the COC, as required by the facility's Change in Condition policy.
Improper Use of Bed Placement as a Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints when the resident’s bed was positioned directly against a wall in a way that restricted voluntary movement. The resident had been admitted with diagnoses including cerebral infarction, an unstageable pressure ulcer on the right upper back, and a gastrostomy tube, and had severely impaired cognitive skills for daily decision-making per the MDS. During observation with an LVN, the resident’s bed was noted to be placed so that there was no space on the left side between the bed and the wall, preventing the resident or staff from accessing that side. The LVN stated she was unsure whether there was a physician order for this bed placement and confirmed that the medical record contained no such order. Further review with the LVN showed that the resident’s care plan did not include any interventions addressing the bed being placed against the wall. In interviews, the LVN, an RN, and the DON each acknowledged that a bed positioned against the wall, or less than one foot from the wall, was considered a form of restraint that could limit the resident’s movement. The DON stated that the resident’s bed placement against the wall was considered a restraint and that the facility failed to ensure the bed was not placed in this manner. Review of the facility’s restraint policy indicated that restraints require a physician order, are to be used only when necessary as determined by the IDT, and must be in accordance with the resident’s assessment and plan of care, conditions that were not met in this case.
Failure to Set Low Air-Loss Mattress per Physician Order for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that a resident with significant pressure injury risk received pressure ulcer care consistent with professional standards and physician orders. The resident was admitted with an unstageable pressure ulcer on the right upper back and later had a documented Stage 4 pressure ulcer on the right back. The resident’s care plan, revised in early November, identified the resident as being at risk for further skin breakdown and delayed wound healing and included use of a low air-loss mattress (LALM) as an intervention for pressure injury management. The resident’s MDS showed severely impaired cognitive skills for daily decision-making, and the resident had multiple medical conditions including cerebral infarction and a gastrostomy. During observation and interview, an LVN reported that the LALM was programmed for a weight range of 300–350 lbs, even though the resident’s documented weight was 161 lbs. Review of the physician’s order showed that the LALM was to be calibrated to 180 lbs for pressure injury management, and the LVN acknowledged that the mattress should have been set to 180 lbs in accordance with that order. The DON confirmed that the physician’s order for the LALM setting was not followed and that the mattress setting was not adjusted based on the resident’s weight and the physician’s order. Facility policies on pressure injury prevention and mattresses indicated that pressure-redistributing devices and appropriate mattresses were to be used to provide pressure reduction and evenly distribute body weight, but the LALM settings for this resident were not aligned with those requirements.
Failure to Post Enhanced Barrier Precautions Signage for Resident on EBP
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to Enhanced Barrier Precautions (EBP) for one resident. The resident was admitted with diagnoses including cerebral infarction, an unstageable pressure ulcer of the right upper back, and a gastrostomy tube, and had severely impaired cognitive skills for daily decision making. Physician orders directed that the resident be placed on EBP due to the presence of the gastrostomy tube, and the resident’s care plan, revised later, documented EBP related to both the gastrostomy tube and a stage 4 pressure ulcer. The facility’s EBP policy required staff to post an EBP sign on the resident’s room door to inform caregivers of the appropriate tasks requiring PPE use. During observation, surveyors noted there was no EBP sign posted outside the resident’s room, despite the resident being on EBP. An LVN confirmed the resident was on EBP due to the gastrostomy tube and pressure ulcer and stated that EBP signage identifies required precautions and PPE to be used when providing care. The LVN indicated the IPN was responsible for ensuring EBP signage was posted and acknowledged that failure to post signage could result in staff not wearing appropriate PPE, increasing the risk for transmission of infection. The IPN confirmed the resident was on EBP and stated that if signage was not posted, staff might not implement appropriate PPE use, potentially contributing to the spread of infection. The DON also stated that an EBP sign should be posted outside the resident’s room to notify staff and visitors of required precautions and confirmed the facility failed to ensure the EBP signage was posted, in contradiction to the facility’s written EBP policy.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with functional quadriplegia, multiple sclerosis, optic atrophy, and major depressive disorder, who was cognitively intact but fully dependent on staff for all ADLs, reported being struck on the top of the head by another resident while positioned in a hallway near the smoking patio entrance and dining room. This resident used a specialized wheelchair operated by blowing air to move and could not move his arms or legs. A change of condition note documented that he was monitored for potential pain and emotional distress related to a claimed physical altercation and that he reported acute pain of 1 out of 10 on the top of his scalp. The other resident involved had intact cognition, required partial to moderate assistance with ADLs and mobility, and used a wheelchair. According to this resident’s own statements documented in an SBAR and interviews, he became upset when he perceived that the quadriplegic resident’s wheelchair was blocking his path in the hallway. He reported lifting his own wheelchair to pass, placing it over the other resident’s legs, and then, after an exchange in which he stated the other resident called him a “Nazi,” he retrieved a wooden back scratcher he had brought from home and “popped” the other resident on the head three to four times, clarifying that “popped” meant he hit the resident’s head. In another account documented by staff, he initially claimed to have made contact with the wheelchair headrest, but later confirmed in interview that he hit the top of the other resident’s head, not the wheelchair. A third cognitively intact resident witnessed the incident and reported seeing the quadriplegic resident accidentally bump the other resident’s wheelchair with his powered wheelchair. The witness stated that the other resident then stood up, moved his wheelchair past, grabbed what appeared to be a wooden back scratcher, and hit the quadriplegic resident on the top of the head. The witness emphasized that the quadriplegic resident could not move his arms or legs and that any contact from his wheelchair would have been accidental due to the way it is operated. The quadriplegic resident later clarified in a follow-up interview that he had been wearing a hat at the time, that he was hit on the top of his head with a wooden back scratcher rather than a wheelchair, and that although it did not hurt much because of the hat, he knew something had hit him. The facility’s own abuse prevention policy stated that it does not condone any form of resident abuse and that reports of abuse are to be promptly reported and thoroughly investigated, yet the described events show that one resident willfully struck another resident on the head with an object while both were under the facility’s care, constituting physical abuse. Interviews with nursing leadership and staff confirmed that an altercation occurred between the two residents in the hallway between the smoking area and activity/dining room, that the mobile resident lifted his wheelchair over the quadriplegic resident’s legs, felt that the other resident’s wheelchair had touched him, and then turned around and hit the quadriplegic resident with the wooden back scratcher. The quadriplegic resident did not immediately report the incident, and staff became aware only after the mobile resident reported it to the Administrator the following day. A skin check revealed no redness, and the quadriplegic resident initially reported that being hit did not hurt because of his hat, though he later reported minimal pain and was monitored for pain and emotional distress. Despite the absence of significant physical injury, the act of intentionally striking another resident with an object, as corroborated by the involved resident’s own admissions and a witness account, demonstrates that the facility failed to ensure the resident’s right to be free from physical abuse while in its care.
Failure to Document Change of Condition After Seizure Episodes
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that licensed nurses documented the resident's change of condition (COC) following three consecutive seizure episodes. The resident, who had diagnoses including type 2 diabetes mellitus, other specified disorders of the brain, and convulsions, was admitted with physician orders to monitor and document seizure activity every shift and notify the attending physician if seizures occurred. Despite these orders, there was no documented evidence that an SBAR (Situation, Background, Appearance, and Review) form was created for the seizure episodes, and the progress notes lacked complete documentation of the assessments performed after each event. Interviews with nursing staff and the DON confirmed that the required documentation, including the date, time, pertinent details of the event, subsequent assessments, and notifications to the physician and family, was not completed as per facility policy. The facility's policies on change in condition and completion and correction of medical records require prompt, complete, and accurate entries reflecting medically relevant information. The failure to document the resident's change of condition and related assessments resulted in incomplete and inaccurate medical records.
Failure to Document and Track Resident Property Loss
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's property from loss or theft by not documenting a reported incident of a lost or stolen coin purse containing identification and a Social Security card in the facility's Theft and Loss log. The resident, who had diagnoses including hypertension, osteoarthritis, and COPD, was cognitively intact and able to make decisions. She reported that her coin purse, which also contained $600, was stolen from underneath her pillow, and she requested that the social worker file a police report, which was subsequently done. Upon being informed of the incident, the social service designee arranged for the replacement of the resident's identification and Social Security card and filed a police report. However, the designee did not complete the required Theft and Loss Report or document the incident in the Lost and Stolen Property Log, as mandated by the facility's policy. The supervisor confirmed that such documentation should have occurred whenever resident property is reported lost or stolen. A review of the facility's Lost and Stolen Property Logs for the relevant months revealed additional deficiencies, including missing estimated values of lost or stolen items and lack of documentation regarding the date and time the loss or theft was discovered or occurred. The logs did not allow for determination of whether the documented date and time reflected the discovery or the actual occurrence of the incident, contrary to facility policy. The Director of Nurses acknowledged that the facility's theft and loss policy was not followed and that required information was missing from the logs.
Inaccurate Medication Administration Documentation
Penalty
Summary
Licensed nursing staff failed to maintain complete and accurate medical records for a resident by signing the Medication Administration Record (MAR) for an antibiotic therapy on three separate dates, despite the medication not being delivered to the facility on those dates. The MAR inaccurately indicated that the resident received Fidaxomicin for C-diff infection on those days, when in fact the medication was not available until several days later. This discrepancy was identified during a review of the resident's records and confirmed through interviews with nursing staff and the facility's pharmacist, who stated the antibiotic was first delivered several days after the MAR entries indicated administration. The resident involved had multiple complex medical diagnoses, including multiple sclerosis, sepsis, urinary tract infection, a stage three pressure ulcer, and neuromuscular dysfunction of the bladder. The resident was cognitively intact but dependent on staff for activities of daily living. The facility's policy required prompt, complete, and accurate documentation of care, but this was not followed, resulting in the medical record reflecting care that was not actually provided.
Failure to Maintain Clean and Homelike Resident Environment Due to Unaddressed Water Stain
Penalty
Summary
A deficiency was identified when a resident's bathroom wall was observed to have a rusty brown dry water streak, which had appeared approximately two weeks prior following heavy rainfall. The resident, who had diagnoses including COPD, emphysema, and a solitary pulmonary nodule, required assistance with certain activities of daily living but was able to communicate concerns. The resident reported the issue to a laundry aide, who acknowledged being informed of a water leak and observed the resulting brown and yellow water stain but did not submit a work order for maintenance. Further interviews revealed that the maintenance staff had no record of any work orders for the resident, and the Director of Nursing was unaware of the leak until the time of observation. Facility policies reviewed indicated a requirement for maintaining a clean, sanitary, and homelike environment, but these standards were not met in this instance, as the environmental concern in the resident's bathroom was not addressed in a timely manner.
Call Light Not Kept Within Reach of Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to keep the call light within reach of a resident who was dependent on assistance for mobility and activities of daily living. The resident had multiple diagnoses, including dementia, hemiplegia, hemiparesis, and parkinsonism, and was assessed as having severely impaired cognition and being at risk for falls. The resident's care plan specifically required that the call light be kept within reach and that staff anticipate and meet the resident's needs. During an observation, the call light cord was found hanging on the wall with the call button placed at the foot of the bed, out of the resident's reach. A CNA stated that the call light was placed there because the resident would throw it away, acknowledging that the resident would not be able to use it to call for help. The Director of Nursing confirmed that the call light was not within reach and stated that it was the responsibility of all staff to ensure proper placement, as outlined in the facility's policy and procedure. The DON also noted that staff are expected to check call light placement every two hours. Review of the facility's policy confirmed that call cords are to be placed within the resident's reach. The staff did not follow this policy, resulting in the resident being unable to summon assistance as needed.
Failure to Maintain Hazard-Free Environment Due to Improper Use of Fall Mat
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not maintaining the proper use of fall/floor mats. Specifically, a resident with hemiplegia, hemiparesis, muscle weakness, and impaired cognition, who required substantial assistance with mobility and ADLs, had a physician's order for a floor mat to be placed on the right side of the bed to decrease potential injury. During observation, it was found that a side table and a trash can were placed on top of the resident's floor mat. Both a CNA and the DON confirmed that no objects should be placed on top of the floor mat, as this defeats its purpose and can cause injury if the resident falls. Review of the resident's care plan and facility policies indicated interventions and requirements to maintain a safe, hazard-free environment, including specific instructions for the use of floor mats. The DON acknowledged that staff did not follow facility policies and user instructions for the floor mat, which are intended to reduce the incidence and severity of resident trauma by ensuring the mat is unobstructed. The failure to keep the floor mat free from furniture and equipment constituted a deficiency in providing a safe environment for the resident.
Failure to Promptly Notify Conservator of Significant Change in Resident Condition
Penalty
Summary
The facility failed to promptly notify the conservator of a resident with severe cognitive impairment and a legal conservatorship of a significant change in condition involving an alleged sexual interaction. The resident, admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and anxiety disorder, was documented as having severely impaired decision-making capacity and was under the care of a conservator for healthcare decisions. On the date of the incident, the facility's records show that the physician was notified and a room change was ordered, but the conservator was not informed until the following day during a care conference. Interviews with facility staff revealed that the registered nurse on duty did not notify the conservator, believing the resident was self-responsible and able to understand the situation. However, both the Director of Nursing and the MDS nurse confirmed that the conservator was the designated healthcare decision-maker and should have been promptly notified according to facility policy. The delay in notification was acknowledged by the Director of Nursing, who stated that the conservator should have been called immediately following the change in the resident's condition.
Failure to Accurately Document Notification Time in Resident Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident by not ensuring the correct time of notification was documented following an alleged sexual interaction. The resident, who had a history of epilepsy, chronic pain syndrome, and depression, was admitted with the capacity to make decisions, but later assessments indicated severely impaired cognitive skills. On the date of the incident, the eInteract Change in Condition Evaluation documented that the responsible party was notified at a time prior to the actual event, which was not possible according to the Director of Nursing (DON). The DON confirmed that the documentation of the notification time was incorrect and acknowledged that such errors could create confusion during incidents. Interviews with facility staff, including the DON and Administrator, confirmed the discrepancy in the recorded notification time. The facility's policy required licensed nurses to document the time and name of the individual notified in the event of a change in condition. The inaccurate documentation in the resident's medical record did not align with this policy and resulted in the record containing incorrect information regarding the notification of the responsible party.
Failure to Provide Ordered STAT Laboratory Services Prior to Resident Discharge
Penalty
Summary
The facility failed to provide laboratory services as ordered for a resident who was admitted with diagnoses including anemia, dysphagia, and cognitive communication deficit. The resident experienced an episode of passing stool with a small amount of bright red blood, prompting the physician to order a fecal occult blood test (FOBT), a complete blood count (CBC), and to hold anticoagulant medications. Initial labs were drawn and reported, revealing low hemoglobin and hematocrit levels. Following these results, the physician ordered a STAT repeat of the hemoglobin and hematocrit (H/H) levels. Despite the STAT order, the laboratory phlebotomist did not arrive to collect the repeat blood samples as required. Facility staff called the laboratory to request the STAT H/H, but there was no documentation of a confirmed timeframe for collection or evidence that the labs were completed prior to the resident's discharge. The Director of Nursing (DON) confirmed that there was no order for the repeat H/H and that the STAT labs were not documented as completed. The facility's policy required that STAT lab orders be called in and expedited, but this process was not followed as intended. The resident was ultimately transferred to a general acute care hospital at the request of the resident and family, with the STAT laboratory tests still pending. The lack of timely completion and documentation of the ordered STAT laboratory tests resulted in a failure to provide necessary laboratory services as ordered by the physician, with the potential for a delay in the resident's care.
Failure to Document and Track Medical Records Requests
Penalty
Summary
The facility failed to maintain a documented process for tracking medical records requests, resulting in a deficiency related to a resident's right to access personal medical records. Specifically, a legal representative for a resident with diagnoses including cellulitis, chronic kidney disease, and type 2 diabetes mellitus submitted a request for the resident's medical records. Upon review, it was found that the facility's log for tracking such requests had not been updated since a prior date, and the current request was not recorded. Interviews with the Medical Records Director and two Medical Records Assistants revealed that staff were either unaware of the log or had not used it, and instead relied on making copies and keeping email or fax confirmations as proof of completion. Further review of the facility's policy and procedure for resident access to protected health information indicated that all requests should be documented on a specific log, including the date of request, the staff member handling the request, and the date of the facility's response. The Administrator confirmed that the process was not being followed, and staff were not knowledgeable about the required documentation process. This failure to document and track medical records requests had the potential to delay the provision of requested documents to residents or their representatives.
Failure to Assess and Secure Medication for Resident Without Capacity
Penalty
Summary
A deficiency occurred when a resident's prescribed eye drops were found left on the bedside table without proper assessment or authorization for self-administration. The resident had been admitted with diagnoses including diabetes mellitus and chronic obstructive pulmonary disease, and a recent history and physical indicated the resident did not have the capacity to make decisions at the time. Despite this, the eye drops were accessible in the resident's room, and there was no documentation of a self-administration assessment, care plan, or physician's order permitting the resident to self-administer the medication. During observations and interviews, both a Licensed Vocational Nurse and a Registered Nurse confirmed the presence of the eye drops on the bedside table and acknowledged that the medication should have been stored securely in the medication cart. Both staff members also confirmed that there was no assessment or care plan in place for self-administration, and no physician's order had been obtained. The Director of Nursing further stated that a self-administration assessment, care plan, and physician's order are required for a resident to self-administer medication, and that medications should be stored in locked storage to prevent access by other residents. A review of the facility's policy on self-administration of medication indicated that the interdisciplinary team must assess a resident's cognitive, physical, and visual abilities before allowing self-administration, and that the assessment must be reviewed by the attending physician. In this case, these procedures were not followed, resulting in the medication being left unsecured and accessible to the resident and potentially to others.
Failure to Maintain Accurate and Timely Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and timely medical records for three sampled residents, as required by accepted professional standards. Certified Nursing Assistants (CNAs) did not document the percentage of food consumed by three residents at the correct times, instead recording meal intake percentages for multiple meals at the same time or before the meals were actually consumed. Additionally, there were instances where meal intake was not documented at all for certain meals. The Director of Staff Development (DSD) confirmed that these entries were inaccurate and should have been completed after the meals. For one resident, a CNA documented a bowel movement's appearance without direct observation, intending to verify with the resident later, which did not align with proper documentation practices. Furthermore, a Registered Nurse (RN) did not complete and sign a Change in Condition Evaluation (CIC) for the same resident after an incident where the resident could not be located in the facility. The Director of Nursing (DON) acknowledged that documentation should be accurate and timely, and that these failures resulted in incomplete and inaccurate records. The facility's own policy and procedure, last reviewed in January 2025, required that medical record entries be recorded promptly as events occur, be complete, legible, descriptive, and accurate, and never be documented before the event. The observed practices did not comply with these requirements, resulting in inaccurate information in the medical records of the affected residents.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A resident assessed as high risk for elopement, with diagnoses including type 2 diabetes mellitus, epilepsy, and schizophrenia, was admitted to the facility and had a documented history of elopement or attempted elopement. The resident's care plan identified the risk for elopement and included interventions to identify triggers for wandering. Despite these assessments and interventions, the resident was able to leave the facility unassisted and without permission through the main entrance, while the receptionist, who was responsible for monitoring the lobby and preventing elopement, was present but did not notice the resident leaving. Video surveillance footage confirmed that the resident moved through various areas of the facility, including the hallway, patio, and lobby, before exiting through the main entrance. The receptionist was at the desk but was distracted by personal activities and did not observe the resident leaving. Staff interviews revealed that the whereabouts of the resident were not consistently monitored, with some staff not checking on the resident for several hours. The facility's policy required staff to monitor residents at risk for elopement and to intervene if a resident attempted to leave, but these procedures were not followed. The resident was not located for several hours, during which time scheduled medications for epilepsy, diabetes, and schizophrenia were missed. Staff became aware of the resident's absence only after a significant delay, and a search was initiated. The facility's Director of Nursing acknowledged that staff failed to provide adequate supervision and monitoring as required by the resident's care plan and facility policy.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, each with significant medical conditions and high risk for falls or limited mobility. In multiple instances, staff observations and interviews confirmed that call lights were either on the floor, tangled, or otherwise not accessible to the residents. For example, one resident with epileptic seizures, muscle weakness, and impaired decision-making had a call light on the floor, out of reach, during an observation with a CNA, who acknowledged the risk this posed. Another resident with schizoaffective disorder, diabetes, and upper extremity impairment had a pad call light placed on her lap, which staff confirmed was not within her reach due to her physical limitations. Additional observations revealed that a resident with seizures, psychosis, diabetes, and left upper extremity impairment repeatedly had a call light tangled or on the floor, making it inaccessible. Staff interviews confirmed awareness of the resident's inability to reach the call light and the importance of its placement. Similarly, a resident with epilepsy, Parkinson's disease, and left-sided hemiplegia was found with a call light dangling off the bed and out of reach. Staff entering the room failed to notice or correct the situation, and the resident was unable to access water or the call light, as confirmed in interviews with both the resident and staff. Facility policies and procedures reviewed during the survey consistently required that call lights be within reach of residents to ensure prompt assistance and safety. Despite these policies, staff did not consistently follow them, as evidenced by repeated observations and staff admissions. The Director of Nursing and other staff acknowledged the expectation and necessity for call lights to be accessible at all times, but the deficiency persisted across multiple residents and shifts.
Failure to Protect Resident Confidentiality Through Improper Disposal of PHI
Penalty
Summary
The facility failed to protect the confidential personal and medical information of 15 sampled residents by improperly disposing of documents containing protected health information (PHI). During an observation in the kitchen, a diet type report listing 13 residents' names, room numbers, allergies, and diet orders was found in the handwashing trash can mixed with soiled paper towels. The Assistant Dietary Supervisor confirmed that the report contained sensitive information and should have been placed in a designated locked container for confidential disposal, as per facility protocol. Staff interviews revealed that the report was not handled according to established procedures, and it was unclear who discarded it in the trash. Additionally, in Nursing Station 3, a handwritten document listing the names of two residents along with their medications and dosages was found in a regular black plastic trash bin. Both the LVN who wrote the document and another LVN acknowledged that this was a violation of confidentiality and that such documents should be shredded. The Director of Nursing also confirmed that the facility failed to protect resident privacy by not ensuring proper disposal of documents containing medical information. Review of facility policy indicated that staff are required to receive training on the privacy and security of PHI, but these protocols were not followed in these instances.
Failure to Follow Grievance Policy and Protect Resident Rights
Penalty
Summary
The facility failed to follow its Grievance and Complaint Policy and Procedure in multiple instances involving several residents. In one case, a resident with end stage renal disease and other significant health issues complained to an LVN that a CNA refused to warm up the resident's meal after returning from hemodialysis, resulting in the resident eating a cold breakfast. The LVN did not report the complaint or initiate the grievance process as required by facility policy, and the assigned Social Services Assistant was unaware of the complaint. This led to a delay in addressing the resident's concern and the resident being assigned the same CNA again, potentially causing distress. Another incident involved a resident with diabetes, ESRD, and chronic kidney disease who repeatedly complained about the food being too salty despite being on a renal diabetic diet. The dietary staff did not follow standardized recipes for the resident's therapeutic diet, and the grievance process was not properly followed. The Grievance Official did not follow up with the resident regarding the findings of the investigation, and there was no documentation of communication with the resident about the results of a test tray or any resolution of the complaint. A third deficiency occurred when a resident with congestive heart failure and other conditions reported missing home medications at discharge. The LVN did not notify the Social Services Assistant of the complaint, and the medications were not documented in the resident's belongings inventory. The Social Services Assistant stated that if notified, a search and grievance log entry would have been initiated. The lack of documentation and follow-up resulted in the resident's grievance about missing medications going unresolved, causing distress to the resident.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from the use of physical restraints unless required for medical treatment, affecting six sampled residents. In several cases, beds were placed against the wall, restricting residents' freedom of movement, without proper quarterly restraint assessments, physician orders, or care plan documentation as required by facility policy. For example, one resident with severe cognitive impairment and total dependence for activities of daily living had their bed placed against the wall for safety, but the required quarterly restraint assessment was not completed. Another resident with hemiplegia and severe cognitive impairment had their bed placed against the wall without a physician's order or care plan, and the initial restraint assessment did not recommend this intervention. Additional deficiencies included inaccurate or incomplete restraint assessments for residents with beds placed against the wall, such as a resident with hemiplegia whose restraint assessments did not reflect the use of the bed against the wall, despite a physician's order for this intervention. In another instance, a resident with dementia and muscle weakness was using a bed alarm, but there was no restraint assessment completed for this device, even though it was being used to prevent falls. Staff interviews confirmed that restraint assessments are required on admission, quarterly, and annually, but these were not consistently completed or documented. Other residents were also affected by similar lapses, including a resident with a history of falls and a physician's order for the bed against the wall, but without a corresponding quarterly restraint assessment. In some cases, staff acknowledged that placing a bed against the wall constitutes a restraint and requires a physician's order, informed consent, restraint assessment, and care plan, but these steps were not always followed. Facility policy requires that restraints be used only as a last resort, with proper documentation and regular reassessment, but these procedures were not adhered to for the residents reviewed.
Failure to Develop and Implement Comprehensive Care Plans for Medications and Respiratory Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents in accordance with its own policies and procedures. For two residents with mood and behavioral concerns, there was no care plan created for the use of prescribed antidepressant and anxiolytic medications (trazodone and alprazolam). In both cases, staff interviews confirmed that care plans were not in place to guide the safe administration and monitoring of these psychoactive medications, despite facility policy requiring such plans to be developed within a specified timeframe after assessment. Additionally, a resident receiving intravenous antibiotic therapy (Cefepime HCl) for osteomyelitis did not have a care plan in place for the medication until after the deficiency was identified by surveyors. The care plan was only created after the issue was brought to staff attention, indicating a delay in the development and implementation of a care plan for this resident's antibiotic use. This was confirmed by both the reviewing nurse and the DON, who acknowledged the absence of a timely care plan. A further deficiency was identified for a resident with obstructive sleep apnea and a physician order for nightly CPAP therapy. Despite the resident's history of noncompliance with CPAP use, there was no care plan developed to address the use of the device or interventions for refusal. Staff interviews confirmed that a care plan should have been in place since admission to address CPAP administration and noncompliance, but none was found in the resident's record. Facility policy required baseline and comprehensive care plans to be developed and updated as needed, but this was not followed in these cases.
Failure to Rotate Insulin Injection Sites for Multiple Residents
Penalty
Summary
The facility failed to provide care in accordance with professional standards for three residents who were prescribed insulin, as staff did not rotate subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and facility policy. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, records showed repeated insulin injections were administered in the same area, such as the left arm or right lower quadrant of the abdomen, over multiple dates. Both the registered nurse and the Director of Nursing confirmed that injection sites were not rotated, which was contrary to the physician's orders and the facility's own policy on subcutaneous injections. Another resident with schizoaffective disorder, type 2 diabetes, and impaired upper extremity function also received insulin injections at the same site, specifically the left lower quadrant, on several occasions. The MDS Coordinator and the DON both acknowledged that the administration sites were not rotated, despite clear physician orders and care plan instructions to do so. The facility's policy and the manufacturer's prescribing information both require rotation of injection sites to prevent complications. A third resident, with hemiplegia following a stroke and severe cognitive impairment, similarly received insulin injections repeatedly in the same area, such as the right arm or left lower quadrant. The MDS Coordinator and the DON confirmed that the sites were not rotated as ordered. In all three cases, the failure to rotate injection sites was documented through record review and staff interviews, and was inconsistent with professional standards, physician orders, and the facility's own procedures.
Delayed Initiation of Restorative Nursing Aide Services for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide timely restorative nursing aide (RNA) services for two residents with limited range of motion (ROM), resulting in a delay in the initiation of passive range of motion (PROM) exercises as ordered by therapy staff. For one resident, who had diagnoses including metabolic encephalopathy and polyneuropathy and was assessed with severe cognitive impairment and functional limitations in both upper extremities, there was a documented order for RNA to provide PROM to both upper and lower extremities five times a week. However, the RNA flowsheet showed that no RNA services were provided during the week following the order, and RNA treatment did not begin until several days later, despite the expectation that services should start the day after the order was written. Interviews with staff confirmed the delay and acknowledged that RNA should have started immediately after the order was given. A second resident, with a history of acquired absence of the right leg above the knee and left foot, and moderate cognitive impairment, also experienced a delay in the start of RNA services. This resident had orders for PROM to the left lower extremity and right residual limb five times a week, but the RNA task flowsheet indicated that services were not initiated until several days after the order was written. Staff interviews confirmed that RNA should have started the day after the order and acknowledged the delay in providing the required services. Both residents were identified as being at risk for developing contractures or decreased ROM, with care plans and therapy discharge summaries specifying the need for ongoing RNA services to maintain joint mobility. Facility policy indicated that restorative nursing programs are to be initiated when a resident is discharged from formalized therapy, but in both cases, there was a failure to implement the RNA program as ordered, resulting in a gap in care for residents with limited ROM.
Failure to Maintain Safe Resident Environment and Prevent Accident Hazards
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for seven of nine sampled residents. In several instances, beds for residents at high risk for falls were not kept in the low position as required by their care plans and facility policy. For example, one resident with schizoaffective disorder, diabetes, and impaired mobility was found with their bed in a high position, despite being identified as a high fall risk and having a care plan intervention to keep the bed low. Staff interviews confirmed that the bed could have been lowered and that all staff are responsible for ensuring beds are kept at an appropriate height for safety. Multiple residents were found with bed remote control cords that had exposed or frayed wires. In several cases, staff observed and confirmed the presence of exposed wires on bed controllers, which were not reported or replaced in a timely manner. Facility policy and manufacturer guidelines both indicate that damaged cords should not be used, and staff interviews acknowledged the risk of electrocution from such hazards. Additionally, one resident's bed alarm was found turned off and not functioning, despite a physician's order and care plan requiring the alarm to be monitored and operational every shift. Staff confirmed the alarm should have been on to alert staff and prevent falls. Another resident's fall mat was found with furniture and medical equipment placed on top, creating dents and reducing the mat's effectiveness in preventing injury. Staff interviews confirmed that nothing should be placed on fall mats, as this compromises their function and could lead to injury if a resident falls. Facility policies reviewed consistently emphasized the need for a safe, hazard-free environment and regular checks to identify and mitigate risks, but these were not followed in the observed cases.
Deficient Catheter Care and UTI Prevention
Penalty
Summary
The facility failed to provide appropriate care and services to residents with urinary catheters, resulting in deficiencies related to catheter management and the prevention of urinary tract infections (UTIs). For one resident with a history of schizoaffective disorder, diabetes, and neuromuscular bladder dysfunction, surveyors observed that the urinary catheter tubing had a loop, which was confirmed by a licensed vocational nurse (LVN). The nurse acknowledged that the tubing should be free from kinks or loops to allow urine to flow freely, as per facility policy and physician orders. Another resident, diagnosed with neuromuscular bladder dysfunction and dementia, was also found to have a urinary catheter tubing with a loop during observation. The LVN present confirmed the improper positioning and stated that staff are required to ensure catheter tubing is free from kinks or loops. The Director of Nursing (DON) reiterated that maintaining unobstructed catheter tubing is an intervention to prevent UTIs, and the facility's policy specifies that catheter and collecting tubes must be kept free from kinking, with the collection bag below the bladder level. A third resident, with diagnoses including UTI, neuromuscular bladder dysfunction, and dementia, was observed to have a urinary catheter connected directly to a leg bag without a securement device or leg strap, and the bag was placed on the resident's thigh. The LVN confirmed that the catheter was not anchored and that leg bags are only to be used when residents are out of bed, unless otherwise ordered. The DON confirmed that the catheter should have been connected to a regular drainage bag and anchored with a leg strap, in accordance with facility policy, to ensure proper urine flow and prevent trauma.
Failure to Provide and Document Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents requiring supplemental oxygen. For one resident with diagnoses including paraplegia, morbid obesity, obstructive sleep apnea, and COPD, there was a physician's order for continuous oxygen via nasal cannula to maintain oxygen saturation at or above 92%. Despite this order, the resident was repeatedly observed without the nasal cannula in place and breathing room air. Documentation in the Medication Administration Record (MAR) was frequently left blank, indicating that oxygen administration or refusal was not recorded as required. Interviews with staff confirmed that the resident often refused oxygen, but these refusals were not documented, and the physician was not notified to clarify or update the order, as required by facility policy. The same resident's medical records showed multiple instances over several weeks where there was no evidence of oxygen being administered or refused, and no documentation of physician notification. The Director of Nursing acknowledged that the facility's policy was not followed, as refusals and non-compliance with the physician's order were not documented, and the physician was not informed. The facility's policy requires that refusals of treatment be documented in detail and that the physician be notified in a timely manner, especially when the resident is non-compliant with prescribed treatments. For a second resident with encephalopathy and acute respiratory failure with hypoxia, there was a physician's order for oxygen via nasal cannula to maintain oxygen saturation at or above 92%. During observation, the resident's oxygen tubing was found off and not attached, and staff were unable to determine how long the resident had been without oxygen. The Director of Nursing stated that staff should be rounding every hour to ensure medical equipment is properly in place and that oxygen should be administered as ordered. The facility's policy on oxygen therapy requires that oxygen be administered per physician orders and that staff ensure safe and appropriate use of medical devices.
Failure to Account for Controlled Substances Due to Incomplete Documentation
Penalty
Summary
The facility failed to properly account for two doses of controlled substances for two residents during a survey of one of the medication carts. For one resident with muscle weakness and surgical aftercare, a review of the Medication Administration Record (MAR) and the Individual Narcotic Record accountability log showed a missing dose of oxycodone 2.5 mg. The log indicated there should have been ten tablets remaining after the last documented administration, but only nine were present, with no documentation of further administrations. For another resident with epilepsy, a similar discrepancy was found with lacosamide 100 mg, where the log showed seven tablets should have been present, but only six were found, again with no documentation of additional administrations. During an interview and observation, the Licensed Vocational Nurse (LVN) responsible for administering these medications admitted to having given the doses earlier that day but failed to sign off on the Individual Narcotic Record accountability log as required by facility policy. The LVN acknowledged not following the policy of signing each controlled substance dose on the accountability log immediately after preparing the medication for administration. The LVN also recognized the importance of accurate documentation for accountability and prevention of controlled substance diversion and accidental exposure. The Director of Nursing (DON) confirmed that the LVN did not follow the facility's policy, which requires immediate documentation of controlled substance preparation and administration on the accountability records. A review of the facility's policy and procedures indicated that controlled substances must be handled, stored, and documented in accordance with federal and state regulations, including immediate entry of administration details on the accountability record by the administering nurse.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors out of thirty observed opportunities, resulting in a 6.67% error rate. One error involved a resident with immunodeficiency and a diagnosis of left pleural effusion, who was prescribed ceftriaxone 1 gram IV daily for ten days. On the observed date, the resident did not receive the scheduled dose of ceftriaxone at 9 a.m. because the RN did not have time to establish IV access until later in the morning, and the antibiotic was not administered as ordered. Another error involved a resident with diagnoses including gout, hypertension, depression, and muscle weakness, who was prescribed docusate 100 mg orally twice daily at 8 a.m. and 5 p.m. During the morning medication pass, the LPN administered docusate at 10:15 a.m., which was outside the facility's policy of a 60-minute window for scheduled medication administration. The LPN acknowledged that this was a medication error, as the medication was not given at the prescribed time. Interviews with nursing staff and the Director of Nursing confirmed that both errors were due to failure to follow physician orders and facility medication administration guidelines. The facility's policies require medications to be administered within one hour of the scheduled time and emphasize adherence to the five rights of medication administration, including the right time. Both errors were acknowledged by staff as deviations from these requirements.
Failure to Rotate Insulin Injection Sites and Administration of Expired Insulin
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to the administration of insulin. Specifically, licensed staff did not rotate subcutaneous insulin injection sites for three residents, despite physician orders and manufacturer guidelines requiring site rotation to prevent complications such as lipodystrophy and impaired insulin absorption. Documentation and interviews confirmed that insulin was repeatedly administered in the same anatomical locations for these residents, and staff acknowledged that this practice was not in accordance with professional standards or the prescriber's orders. Additionally, the facility did not remove expired insulin from a medication cart, resulting in the administration of four doses of expired insulin to a resident by several LVNs. The expired insulin was not discarded as required by facility policy and manufacturer instructions, which state that opened insulin pens must be used or discarded within 28 days. Both the LVN and the DON confirmed that expired insulin was administered, and that this constituted a significant medication error, as expired insulin may not be effective in controlling blood sugar levels. The residents involved had complex medical histories, including diagnoses of type 2 diabetes mellitus, cognitive impairment, and other comorbidities. The errors were identified through record reviews, interviews with nursing staff and the DON, and direct observation of medication storage and administration practices. Facility policies and manufacturer guidelines reviewed during the investigation clearly outlined the requirements for medication storage, administration, and site rotation, all of which were not followed in these instances.
Failure to Label and Remove Expired Medications
Penalty
Summary
Surveyors identified that the facility failed to properly label and remove expired medications in accordance with facility policy and manufacturer guidelines. Specifically, an open bottle of artificial tears eye drops for one resident was found in a medication cart without a date indicating when use began. The responsible LVN confirmed that the eye drops were not labeled with an open date, making it impossible to determine if the medication was still within its effective period. Facility policy and the manufacturer's instructions require multi-dose eye drops to be dated upon opening to ensure timely disposal. Additionally, an open Lispro Kwikpen insulin pen for another resident was found stored at room temperature and labeled with an expiration date that had already passed. The LVN acknowledged that the insulin pen had been opened and used beyond the 28-day period recommended by the manufacturer for potency and safety. The medication administration record (MAR) confirmed that four doses of expired insulin were administered to the resident after the expiration date had passed. The Director of Nursing (DON) reviewed the findings and confirmed that the expired insulin had not been removed from the medication cart as required, and that multiple LVNs had failed to identify and discard the expired medication. The DON also confirmed that the artificial tears eye drop bottle was not labeled with an open date, which is necessary to determine expiration. Facility policies reviewed by surveyors require that outdated or expired medications be immediately removed from stock and that multi-dose containers be dated when opened.
Failure to Train and Evaluate Kitchen Staff on Safe Food Cooling Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in the proper cooling process of cooked foods. Two staff members, including a cook, were unable to verbalize the correct procedures for cooling food, specifically roast turkey and roast beef. Observations and interviews revealed that the cooling logs contained errors in dates and did not consistently follow the required time and temperature parameters for safe cooling, as outlined in both facility policy and the Food Code 2022. The logs showed that meats were not cooled within the required six-hour window, and in some cases, food that did not meet cooling requirements was not discarded as required. Further review of facility documentation, including orientation and competency checklists, indicated that there was no specific training or verification of staff competency regarding the proper cooling of foods. The orientation checklists lacked topics on food cooling, and competency verification forms did not specify the methods used to confirm staff understanding or skills. The dietary supervisor acknowledged that the staff did not properly cool meats on several occasions and that the food should have been discarded when it failed to meet cooling standards. This deficiency had the potential to affect 164 out of 176 medically compromised residents who received food from the kitchen, as improper cooling of food can lead to bacterial growth and cross-contamination. The facility's failure to provide adequate training and competency evaluation for kitchen staff directly contributed to the improper handling and cooling of hazardous foods, as evidenced by the documented deviations from policy and regulatory requirements.
Failure to Follow Standardized Recipes for Therapeutic Diets
Penalty
Summary
The facility failed to follow the prescribed menu and standardized recipes for residents requiring therapeutic diets, specifically for those on consistent carbohydrate (CCHO) and renal diets. On the date in question, a cook did not follow the recipe for gravy intended for residents on these diets, instead preparing it by guessing the ingredients and using turkey juice, flour, and seasonings. The standardized recipe, which was not followed, did not include turkey juice and specified precise amounts of salt and Worcestershire sauce. The cook stated the recipe was not available in the binder and admitted to not following it, while the dietary supervisor confirmed that all food should be prepared using standardized recipes to ensure nutritional adequacy. A resident with significant medical conditions, including type 2 diabetes, end stage renal disease, and hypertensive chronic kidney disease, reported that the food served was too salty despite being on a special diet. Review of the resident's records confirmed orders for a renal diabetic diet with regular texture. During a test tray evaluation, both the dietary supervisor and assistant supervisor noted that the gravy served was salty, which is inappropriate for a renal diet. The assistant supervisor suggested that the amount of base used may have contributed to the saltiness, and both supervisors emphasized the importance of following recipes to ensure residents receive the correct nutrition and palatable food. Further review of facility policies indicated that all meals should meet the nutritional requirements set by national standards and that standardized recipes must be used for all food preparation, with specific modifications for therapeutic diets. The product specification for the turkey used in all diets already included added salt, making adherence to the recipe even more critical. The failure to follow the menu and recipes as required resulted in the potential for residents, particularly those on restricted diets, to receive food that did not meet their nutritional needs.
Pureed Foods Not Prepared to Required Consistency and Shape
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet individual needs for residents on a pureed diet. Observations during trayline revealed that pureed mashed potatoes and pureed roast turkey did not hold their shapes on the plate and appeared flat when served. The Dietary Supervisor and Assistant Dietary Supervisor confirmed that while the pureed foods passed the spoon tilt test for appropriate texture, they did not maintain their shape as required by both the facility's diet manual and standardized recipes. The facility's own policies and the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines specify that pureed foods should be smooth, moist, and able to hold their shape on the plate, in addition to passing texture tests. A review of the facility's menu, diet manual, and standardized recipes indicated that pureed foods must be smooth, free of lumps, and able to hold their shape, aligning with IDDSI Level 4 requirements. Despite these guidelines, the pureed items observed did not meet the shape-holding criteria, as confirmed by both dietary supervisors. This deficiency affected 12 residents on a pureed diet, as the food provided did not meet the specified consistency and presentation standards outlined in facility policies and national guidelines.
Multiple Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations and interviews. Kitchen equipment and utensils, such as refrigerator shelves and resident trays, were found to be cracked, chipped, rusted, or discolored, making them difficult to clean and potentially harboring bacteria. A broken thermometer was discovered in the vegetable freezer, and there were instances where food items, such as cottage cheese and mocha mix, were stored at temperatures above the recommended 41°F, with the internal temperature of the refrigerator also exceeding safe limits. Staff acknowledged these issues and stated that such conditions could lead to foodborne illness. Improper cooling procedures were documented for several cooked meats, including roast turkey, roast pork, and roast beef. Cooling logs and staff interviews revealed that these items were not cooled within the required timeframes, with some foods taking up to eight hours to reach safe temperatures. Staff did not consistently follow protocols such as slicing meats into smaller portions or using ice baths to expedite cooling, and there were errors in recording dates and times on cooling logs. The dietary supervisor confirmed that these practices did not align with facility policy or food safety standards. Additional deficiencies included unsanitary practices during food preparation, such as a dietary aide wiping a preparation table and leaving the cloth near uncovered salads, and the storage of dented cans with non-dented cans in the dry storage area. Equipment and kitchen areas were not properly cleaned and sanitized, with dried food residue found on a mixer, dirt debris in a plate warmer, and sticker residues on food containers. These findings were corroborated by staff interviews and a review of facility policies and relevant food safety codes.
Deficient Food Preparation and Service: Temperature, Palatability, and Diet Consistency Failures
Penalty
Summary
The facility failed to ensure that food and drink were prepared and served in a manner that conserved temperature, flavor, and appearance, as evidenced by multiple observations and interviews. Food temperatures were found to be outside of acceptable ranges, with roast turkey served at 125°F, apple sauce at 51°F, vanilla mousse at 46°F, and grape juice at 46°F. Residents and dietary staff confirmed that food was often not served at the proper temperature, and the facility lacked a policy regarding food preparation for palatability, flavor, appearance, and temperature. Standardized recipes and facility policies required higher standards for food temperatures than were observed. Additionally, the facility did not follow standardized recipes for therapeutic diets, specifically for residents on renal and consistent carbohydrate (CCHO) diets. The roast turkey served to these residents was reported as salty, and staff interviews revealed that recipes were not always followed, with ingredients being guessed or omitted due to missing recipe documentation. The turkey product itself contained added salt and other ingredients, and the gravy was prepared without following the standardized recipe, which could result in inappropriate sodium content for residents requiring dietary restrictions. The preparation and presentation of pureed foods also did not meet facility and IDDSI standards. Pureed mashed potatoes and pureed roast turkey did not hold their shape on the plate, appearing flat, despite passing the spoon tilt test for texture. The facility's diet manual and standardized recipes required pureed foods to be smooth, moist, and able to hold their shape, but this was not achieved. These deficiencies were observed during trayline and test tray observations, and staff acknowledged that the presentation could negatively impact residents' willingness to eat.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to maintain a resident's dignity during mealtime assistance. The incident involved a resident with a history of adult failure to thrive, dementia, and generalized muscle weakness, who required total assistance with all activities of daily living and had severely impaired cognition. During observation, the resident was positioned upright in bed, and the CNA stood over the resident while feeding them breakfast, rather than sitting at eye level as required by facility policy and best practices for maintaining dignity. The CNA acknowledged that staff are expected to sit at eye level when assisting residents with eating to respect their dignity, but admitted to forgetting to get a chair. The Director of Nursing confirmed that staff have been reminded of the importance of assisting residents at eye level and that the CNA should have followed this protocol. Facility policy emphasizes accommodating residents' physical limitations and maintaining dignity during care interactions, which was not followed in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided informed consent prior to the administration of a psychotropic medication, specifically lorazepam. The resident, who had diagnoses including end stage renal disease, dependence on hemodialysis, and monoplegia of the upper limb, was assessed as having the capacity to understand and make decisions. Documentation showed that the resident was able to communicate effectively and was self-responsible for medical decisions. Despite this, there was no evidence that informed consent was obtained or documented before lorazepam was administered. Review of the resident's care plan indicated that education regarding the risks, benefits, and side effects of lorazepam was required, and the facility's policy mandated written informed consent for psychotropic medications, with renewal every six months. Interviews with facility staff, including the MDS Coordinator, LVN, ADON, and DON, confirmed that informed consent was not obtained or documented for lorazepam, even though the process was followed for another psychotropic medication prescribed at the same time. The resident also stated that the risks and benefits of lorazepam were never explained and did not recall signing any consent form. Facility policy required the healthcare practitioner to obtain informed consent and the licensed nurse to verify and document this before administering any psychoactive medication. The absence of informed consent for lorazepam was acknowledged by multiple staff members, who stated that this was not in accordance with facility policy and procedures. The lack of documentation and resident education prior to administration of lorazepam constituted a failure to protect the resident's right to make informed medical decisions regarding psychotropic medication use.
Failure to Develop Baseline Care Plan for Use of Restraints and Bed Alarm
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with diagnoses including epileptic seizures, dementia, and muscle weakness. Upon admission, physician orders were in place for bilateral padded upper half side rails and a bed alarm to address the resident's high risk for falls and generalized muscle weakness. Documentation showed that the resident was unable to make decisions, and assessments confirmed the use of these devices as part of the resident's care. However, review of the resident's records revealed that no baseline care plan was created to address the use of side rails and bed/pad alarms as required. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that a baseline care plan was not developed or implemented for the use of these devices. Facility policies required that a baseline care plan be created within 48 hours of admission, reflecting physician orders and assessments, but this was not done. The lack of a baseline care plan had the potential to delay the provision of essential healthcare services and affected the resident's well-being.
Failure to Follow Aseptic Technique and Timely Dressing Changes for IV Therapy
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident requiring parenteral antibiotics. Specifically, a registered nurse did not follow proper aseptic technique when administering IV medications. The nurse was observed flushing the resident's midline catheter infusion port and attaching a new antibiotic IV line without scrubbing the hub/infusion port with an antiseptic solution, as required by both facility policy and physician orders. The nurse also allowed the infusion port to rest on the resident's bare skin during the procedure. Additionally, the facility did not comply with physician orders regarding the frequency of dressing changes for the resident's midline catheter. The dressing, which was supposed to be changed every 48 hours, was found to be overdue for replacement. Staff interviews confirmed that the dressing should have been changed on specific dates but was not, and that this lapse could predispose the resident to infection. The resident involved had a history of local skin infection, type 2 diabetes mellitus with skin ulcers, and was receiving IV antibiotics for osteomyelitis. The resident was alert, oriented, and able to communicate effectively at the time of the incident. Facility policies reviewed indicated that strict aseptic technique and timely dressing changes were required for all IV therapy procedures, but these standards were not met in this case.
Failure to Ensure RN Competency in IV Administration and Aseptic Technique
Penalty
Summary
A registered nurse (RN) failed to demonstrate proper competency in administering intravenous (IV) antibiotics through a midline/peripheral catheter for a resident. During an observed medication administration, the RN did not scrub the midline catheter infusion port with an antiseptic solution before flushing with normal saline or before attaching a new IV antibiotic line. The RN also allowed the port to rest on the resident's bare skin during the process. The RN acknowledged that the port should have been scrubbed prior to these steps to prevent infection. Further review of the resident's medical records and care plan confirmed that there were physician orders to flush the midline catheter with normal saline before and after medication administration and to change the peripheral IV line and dressing every 48 hours. However, the midline catheter dressing was not changed as ordered, with the dressing observed to be overdue for replacement. Another nurse confirmed that the failure to change the dressing as scheduled increased the risk of infection for the resident. The Director of Staff Development (DSD) and Director of Nursing (DON) both stated that the RN should have completed a competency check on IV administration within 90 days of employment, but no such documentation was found in the RN's file. Facility policies and procedures required strict aseptic technique, including scrubbing all injection ports with an antiseptic for a specified duration, and mandated timely dressing changes, but these protocols were not followed in this instance.
Failure to Monitor for Adverse Effects of Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for adverse effects associated with the administration of Cefepime HCl, an antibiotic prescribed for osteomyelitis. The resident, who was admitted with diagnoses including a local skin infection, type 2 diabetes mellitus, and a skin ulcer, was alert, oriented, and had intact cognition at the time of the incident. The order for Cefepime HCl did not include instructions for monitoring adverse effects, and there was no documentation that such monitoring occurred during the course of treatment. Interviews with nursing staff and the Director of Nursing confirmed that Cefepime is considered a significant medication requiring monitoring for adverse effects, and that such monitoring is necessary to promptly report any negative reactions to the physician. Facility policies reviewed indicated that nursing staff are expected to monitor for and document any adverse drug reactions, including side effects or allergic responses, and to notify the attending physician as appropriate. However, these procedures were not followed in this case, resulting in a deficiency related to the lack of monitoring for adverse effects of the antibiotic.
Failure to Provide Physician-Ordered Therapeutic Diet Due to System Update Error
Penalty
Summary
The facility failed to ensure that a resident received and consumed foods in accordance with the therapeutic diet prescribed by the physician. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and hypertensive heart and chronic kidney disease, was ordered to be on a renal diabetic diet with regular portion size. However, staff did not update the resident's diet in the system, resulting in the resident receiving a large portion diet instead of the prescribed regular portion. This discrepancy was observed during a meal service, where the meal ticket and tray provided to the resident indicated a large portion, contrary to the physician's order and the facility's diet list. Interviews and record reviews with the Dietary Supervisor confirmed that the resident's diet order had been revised to a regular portion, but the system was not updated, and the resident continued to receive large portions. The Dietary Supervisor acknowledged that the large portion diet was intended for residents needing more protein and calories, which was not appropriate for this resident's medical condition. The facility's policies required periodic review of tray cards and physician orders to ensure consistency, but this process failed, resulting in the resident not receiving the correct therapeutic diet as ordered.
Failure to Document Change of Condition and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to document changes of condition and maintain accurate medical records for multiple residents, as observed during interviews and record reviews. For two residents who were hospitalized, there was no complete documentation of the events leading to their transfers. One resident was transferred to a general acute care hospital for gastrostomy tube placement, and another was transferred for seizure episodes. In both cases, the progress notes lacked a full account of the incidents, including assessments prior to transfer, interventions provided, and communication with the resident or their representative. Staff interviews confirmed that required documentation, such as Situation, Background, Assessment, and Recommendation (SBAR) or change of condition (COC) notes, was missing, despite facility policy mandating such records. Additionally, the facility did not maintain accurate wound documentation for a resident with multiple pressure ulcers and other wounds. The nursing progress notes and wound assessments showed inconsistencies in the number and onset dates of wounds, with some wounds appearing in documentation before their actual onset dates. The treatment nurse and medical records director acknowledged discrepancies, suggesting possible electronic health record system issues. The director of nursing confirmed that wound documentation should accurately reflect the resident's current wounds to ensure proper care planning. Facility policies reviewed indicated that licensed nurses are required to document changes in condition, including assessments, physician notifications, and updates to care plans. Policies also require weekly documentation of wound status and accurate, timely entries in the medical record. The observed deficiencies in documentation and record-keeping did not align with these established policies and procedures.
Failure to Implement Enhanced Barrier Precautions for Resident with Urinary Catheter
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including urinary tract infection, obstructive and reflux uropathy, and generalized muscle weakness, required substantial assistance with activities of daily living and had a physician's order for regular catheter care. Despite these risk factors, there was no EBP sign or personal protective equipment (PPE) cart placed outside the resident's room, as observed during a facility visit. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the resident should have been placed on EBP due to the presence of a urinary catheter, which is considered a device requiring such precautions. Both the IP and DON acknowledged that the absence of an EBP sign and PPE cart was an oversight and that these measures are necessary to remind staff to perform hand hygiene and use appropriate PPE during high-contact care activities, such as dressing, bathing, transferring, and device care. A review of the facility's policy on Enhanced Barrier Precautions indicated that EBP should be implemented for residents with device care needs, including urinary catheters, and that appropriate signage and PPE should be made available outside the resident's room. The failure to follow these established protocols resulted in a deficiency, as the resident was not provided with the required infection control measures to help prevent the development and transmission of communicable diseases and infections.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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