Glendale Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 250 N. Verdugo Road, Glendale, California 91206
- CMS Provider Number
- 055523
- Inspections on file
- 61
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Glendale Post Acute Center during CMS and state inspections, most recent first.
A resident with multiple right foot and ankle fractures had physician orders for routine pain assessment, non-pharmacological interventions, and PRN Lyrica, Tramadol, and Tylenol based on pain scale scores, with care plans requiring administration of ordered medications and evaluation of intervention effectiveness. On one shift, the MAR documented an 8/10 pain score, but only non-pharmacological measures such as reassurance and diversion were provided, with no PRN pain medication given and no reassessment of pain or intervention effectiveness recorded. In interviews, the resident reported ongoing ankle pain and swelling, stated that staff did not provide pain medication when he reported pain, and expressed that non-pharmacological measures did not relieve his pain. An LVN stated she used non-pharmacological interventions first and had not documented their effectiveness, while an RN supervisor and the DON confirmed that no pharmacological intervention or reassessment was documented despite orders and facility policy requiring monitoring of pain and intervention effectiveness.
A resident with multiple comorbidities and critical electrolyte imbalances was ordered IV hydration and potassium replacement, but nursing staff were unable to start the IV and did not notify the physician of the failed attempts or the delay in treatment. The information was only passed to the next shift, and the physician was not informed, resulting in a breakdown of communication and failure to follow facility protocols.
A resident with multiple comorbidities experienced a critically low potassium level, but staff failed to promptly notify the physician, assess the resident, or initiate required interventions. There was a significant delay in administering ordered potassium and IV fluids, and the resident was not monitored for complications as outlined in the care plan. The resident was later found unresponsive and expired despite resuscitation efforts.
A resident with end stage renal disease and cognitive intactness reported feeling threatened and upset after an encounter with another resident's responsible party, but no individualized care plan was developed to address her psychosocial needs or guide staff monitoring, despite facility policy requiring such plans after significant events.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A facility area was not kept free from accident hazards, and supervision provided was inadequate to prevent accidents, as observed by surveyors.
A resident with severe cognitive impairment and mobility issues developed new skin redness and breakdown in the lower abdomen, which was observed by CNAs and treated by a nurse without physician notification, documentation, or a physician's order. The responsible party was not informed until they inquired, and the DON confirmed that required notifications and documentation were not completed.
A resident with dementia and severe cognitive impairment, who required significant assistance with transfers, was provided with a wheelchair that had a malfunctioning brake. Although some staff were aware of the issue and reported it verbally, there was no documentation or follow-up for repair, and the maintenance team and DON were not informed until the survey. The facility's policy to maintain and repair assistive devices was not followed.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment and multiple care needs was transferred using a shared wheelchair that was not cleaned or disinfected between uses. Staff confirmed the presence of food particles on the wheelchair and acknowledged that cleaning protocols were not followed, despite facility policy requiring disinfection of reusable equipment between residents.
A resident with a history of methamphetamine use was not properly monitored or supervised for substance abuse, despite positive toxicology screens and ongoing risks. The facility failed to update care plans, inform staff, or secure hazardous items such as lighters and a meth pipe, even though the resident was on continuous oxygen therapy. This lack of oversight led to a medical emergency requiring hospital transfer and intubation, with subsequent discovery of narcotics and smoking paraphernalia in the resident's room.
Nursing staff failed to document the removal and administration of controlled substances at the time of administration, resulting in discrepancies between medication counts and records for multiple residents. Additionally, controlled medications belonging to residents who were transferred or had expired were not removed from the medication cart or stored securely, contrary to facility policy. The DON confirmed that these actions did not comply with established procedures for handling controlled medications.
A resident with severe cognitive and physical impairments did not receive timely or consistent Restorative Nursing Assistant (RNA) services as ordered by the physician, including interventions for range of motion and use of supportive devices. RNA services were delayed by over two weeks, and documentation showed multiple missed or undocumented days of treatment. Staff and the DON confirmed that physician orders were not followed and that a required care plan for RNA services was not developed or implemented.
A resident with significant medical needs, including tube feeding and cognitive impairment, experienced a 10-pound weight loss over five months due to the facility's failure to perform weekly weights, follow RD recommendations for increased free water and probiotics, notify the physician of these recommendations and the weight loss, implement SBAR communication, and develop a care plan for the weight loss. Staff interviews confirmed that facility policies and procedures for nutritional assessment and care planning were not followed.
A resident with dementia and high fall risk experienced multiple unwitnessed falls due to the facility's lack of a fall prevention program. The facility also failed to follow physician orders for laboratory tests and urine collection, leading to delayed diagnosis and treatment of a urinary tract infection. These deficiencies resulted in severe health complications, including hypernatremia, dehydration, and severe sepsis, necessitating the resident's transfer to a hospital.
A facility failed to protect a cognitively impaired resident from sexual abuse by a CNA, who engaged in non-consensual sexual contact with the resident. The incident was captured on a hidden camera, leading to the CNA's arrest. The resident, who was unable to consent or defend himself, experienced significant negative psychosocial impacts. The facility's failure was identified as an Immediate Jeopardy situation by the California Department of Public Health.
A resident was improperly administered Depakote for seizures without a seizure diagnosis, and later for mood swings without adequate assessment. The facility failed to monitor the medication's efficacy and side effects, leading to the resident's hospitalization for adverse consequences. Additionally, a follow-up with a psychiatrist was not arranged as ordered.
A facility failed to implement an effective infection prevention and control program during a GI outbreak, affecting 26 residents and 16 staff. The facility did not place symptomatic residents on transmission-based precautions or prohibit symptomatic staff from working. Additionally, the facility failed to investigate the outbreak, notify the local health department timely, and ensure proper hand hygiene, leading to confirmed Norovirus 2 cases.
The QAPI committee at a facility failed to address a GI illness outbreak affecting 26 residents and 16 staff. Preventative measures were not implemented, and the local health department was not notified promptly. The committee did not meet as required, and the outbreak was not discussed, leading to inadequate response and continued spread of illness.
A facility failed to create a comprehensive care plan for a resident with anxiety disorder, despite the resident's admission diagnoses including bipolar disorder, anxiety disorder, and malignant neoplasm of the kidney. The MDS Nurse and DON confirmed the absence of a care plan for anxiety, which is required by the facility's policy to ensure proper care.
A resident did not receive their prescribed medications on three occasions due to a failure in documentation by a Licensed Vocational Nurse. The resident, with conditions such as diabetes and hypertension, had their Medication Administration Record (MAR) unmarked for specific dates, indicating non-administration. The Director of Nursing confirmed that the absence of documentation meant the medications were not given, as per facility policy.
A resident was not readmitted to their original facility after hospitalization due to a failure to follow bed-hold policies. The resident, with conditions including metabolic encephalopathy and psychosis, was transferred to a GACH for altered mental status. Despite being stable for discharge, the facility's ADM did not place the resident on bed hold, citing a need for a higher level of care. This decision was made without an IDT meeting or family involvement, leading to the resident's transfer to another facility.
The facility did not ensure that an RN and an LVN completed their annual competency assessments, as required by policy. Both nurses had initial skills checklists upon hiring, but no further evaluations were documented. The DON confirmed that the facility had not conducted the annual skills competency fair, risking substandard care for residents.
The facility failed to follow food storage and egg handling policies, leading to potential foodborne illness risks. Opened dry food items were improperly stored without labels, and unpasteurized eggs were used in meals, contrary to policy. The Dietary Supervisor and RN confirmed these practices could lead to contamination and illness.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple wounds and a Foley catheter. A CNA was observed providing care without wearing the required PPE, specifically an isolation gown, despite the resident's need for EBP due to wounds. The facility's policy mandates PPE use during high-contact care activities to prevent infection spread, but this was not followed, placing residents at risk.
A resident with Parkinson's disease, depression, and hypothyroidism was transported in a shower chair through a hallway without proper body coverage, exposing their buttocks. The CNA involved was unaware of the exposure, and facility staff emphasized the importance of maintaining resident dignity and privacy during such transports.
A resident was found with 17 bottles of medications at her bedside, which she self-administered without a physician's order or facility assessment. The facility's IDT did not evaluate her cognitive and physical abilities to self-administer, nor did they monitor for side effects or ensure medications were stored securely. Interviews with staff confirmed the lack of assessment and monitoring, contrary to facility policies.
The facility failed to ensure call lights were within reach for two residents, risking delayed care and potential accidents. One resident with severe cognitive impairment and another with intact cognition but limited mobility were both found with call lights on the floor. Staff confirmed the importance of accessible call lights to prevent falls, as outlined in the residents' care plans and facility policy.
The facility failed to maintain current copies of advance directives in the medical records for two residents. One resident, with multiple serious diagnoses, had an advance directive noted but not followed up on, while another resident's records showed conflicting information about the existence of an advance directive. The Social Services Director and DON acknowledged the importance of having these documents readily available, as per facility policy.
A resident experienced a significant weight loss of 23 pounds over 15 days, but the facility failed to notify the physician or update the care plan. Despite the resident's moderate cognitive impairment and dietary needs, no Change of Condition or Comprehensive Care Plan was completed. Interviews confirmed the oversight, which was against the facility's policies requiring documentation and physician notification for significant changes.
Two residents were unsafely discharged against medical advice (AMA) due to inadequate discharge planning and lack of proper documentation. One resident was informed she did not meet criteria to stay and was not informed of her right to appeal, while another was not allowed to return after going out on pass. Both residents did not receive necessary post-discharge resources, and the facility failed to follow its policies and procedures.
A resident with chronic conditions experienced daily pain, but the facility failed to revise the care plan to address ongoing pain management needs. Despite receiving pain medication, the resident's care plan was not updated to include alternative interventions, as confirmed by the DON and MDSC. The facility's policy required ongoing assessments and revisions, which were not followed in this case.
A resident's prescription glasses were broken by a CNA, and despite notifying multiple staff members, the facility failed to promptly assist in obtaining new glasses. The Social Service Assistant delayed contacting the optometrist, and the Director of Nursing was unaware of the prolonged issue. The facility lacked a specific policy for eyeglasses services, leading to the resident managing with broken glasses.
A resident with multiple health conditions received oxygen therapy without clear physician parameters, leading to potential risks. The LVN administered oxygen at 3L/min when the resident's saturation was 89%, despite the order being for 2L/min. The DON confirmed that orders should include parameters, which were missing in this case.
A resident in an LTC facility was found to be self-administering 17 bottles of herbal and oil-based medications kept at her bedside without physician approval or monitoring by facility staff. Despite having fluctuating decision-making capacity, the resident's self-administration was not documented or reviewed by the facility's pharmacist, posing a risk for potential side effects. The facility's DON acknowledged the oversight, and the facility's policies required the inclusion of such supplements in medication histories.
A facility failed to update a resident's representative contact information, leaving the Admission Record with an out-of-service number. The resident, with moderate cognitive impairment and receiving hospice care, had no capacity to make decisions. Despite obtaining the new contact number, the facility did not update the record, risking communication delays in emergencies.
A resident's electric wheelchair has been broken for two years, affecting her mobility and quality of life. Despite having a care plan that included checking the wheelchair's functionality, the facility did not address the broken wheelchair or implement repairs. The resident, who has morbid obesity, anemia, and paraplegia, expressed frustration over the situation, which has limited her ability to socialize and engage in activities.
The facility failed to meet the required minimum of 80 square feet per resident in 33 rooms, affecting the ability to provide safe care and privacy. Despite a request for a room waiver, the rooms were non-compliant with federal space requirements. Observations showed adequate space for mobility aids, but the facility's policy on room capacity was not followed.
A resident with COPD and fluctuating decision-making capacity was discharged against medical advice without adequate preparation, leading to a hospital admission for severe respiratory distress. The resident frequently left the facility without a physician's order, and the facility failed to address this in the care plan or use a translator to explain the AMA form, resulting in an unsafe discharge.
A resident with Alzheimer's disease engaged in non-consensual sexual contact with three female residents, despite the facility's awareness of his inappropriate behaviors. The facility failed to implement a comprehensive care plan or adequate monitoring, resulting in repeated incidents of abuse.
A resident's personal belongings, including a wallet, cash, debit cards, and a watch, were not documented or safeguarded by the facility, leading to their misappropriation. The facility failed to follow its policy for investigating theft, resulting in unaccounted valuables and inadequate reporting to authorities.
A resident's personal belongings went missing after their passing, and the LTC facility failed to report the misappropriation to the CDPH or conduct an investigation as required by their policies. The resident had severe cognitive impairment and was admitted with a diagnosis of malignant neoplasm of the lung. Despite the family member's report of the missing items, the facility did not notify authorities or take action to locate the belongings.
A resident with severe cognitive impairment and hemiplegia, requiring two-person assistance for ADLs, was inadequately assisted by a CNA, leading to a fall and a fracture. The facility also failed to implement immediate fall precautions, delaying necessary safety measures.
The facility failed to provide adequate incontinent care and ADL assistance for several residents due to staffing shortages, leading to significant distress and potential health risks. Residents reported long waits for care, feeling neglected and frustrated. Staffing issues, particularly during afternoon and night shifts, resulted in CNAs caring for too many residents, compromising care quality.
The facility failed to provide sufficient nursing staff, resulting in delayed care and increased falls. Residents experienced significant delays in receiving assistance with ADLs due to inadequate staffing levels, with reports of waiting hours for incontinence care. The facility recorded 11 falls in July, with three resulting in injuries. Staff confirmed the shortage, particularly during afternoon and night shifts, leading to delays in responding to call lights and providing necessary care.
A resident with dementia and high fall risk sustained a head injury after falling in a slippery shower room when left unattended by a CNA. Despite known risks and facility policies requiring constant supervision, the resident was left alone, leading to the fall. The slippery condition of the shower room floor, previously reported but unaddressed, contributed to the incident.
A resident with dementia and cognitive impairment was admitted to a facility without involving their representative in the admission process. Important documents were signed by the resident, who lacked decision-making capacity, without consulting the representative. The LVN assumed the resident could make decisions based on a previous admission and did not verify the current cognitive status. The facility's policy requires involving the representative in such cases, which was not followed.
A resident with Parkinson's Disease reported an alleged abuse by a CNA, described as a dark-skinned man wearing a baseball cap. Despite being informed, the LVN did not prevent the CNA from further contact with the resident, violating the facility's abuse prevention policies. The administrator confirmed that nursing staff should have conducted initial investigations to prevent reoccurrence.
A resident's responsible party requested access to medical records, but the LTC facility failed to provide them within the required 48-hour timeframe. Despite multiple requests and follow-ups, the responsible party did not receive the complete records, highlighting a deficiency in the facility's compliance with their policy and regulatory requirements.
A resident with a right heel skin concern did not receive an individualized care plan addressing their DTI and PVD in a timely manner. The facility delayed developing a care plan for PVD by 40 days and failed to implement interventions for wound healing, such as offloading and non-weight bearing, despite recommendations from wound specialists.
Failure to Administer and Reassess PRN Pain Management for Fracture-Related Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management for one resident with multiple right foot and ankle fractures and dislocations. The resident was admitted with diagnoses including displaced fracture of the anterior process of the right calcaneus, fracture of the right talus, fracture of the scaphoid of the right foot, and dislocation of the tarsometatarsal joint of the right foot. The resident’s history and physical documented that he had capacity to understand and make decisions, and his MDS indicated he had occasional pain. Physician orders directed staff to monitor pain every shift using a 0–10 pain scale, implement non-prescription behavioral interventions every shift with documentation of effectiveness, and administer PRN pain medications: Lyrica 100 mg for severe pain (7–10), Tramadol 50 mg twice daily PRN for moderate pain (4–6), and Tylenol 325 mg twice daily PRN for mild pain (1–3). The care plans for fracture-related conditions and risk for pain required staff to administer medications as ordered, assess pain intensity, monitor pain characteristics and side effects, and evaluate and document the effectiveness of pain interventions. On a specific date in January, the MAR showed that during the 7 AM to 3 PM shift the resident reported pain at 8/10. Documentation indicated that only non-pharmacological interventions—reassurance, diversion, redirection, verbal cues, and reassuring—were provided by an LVN. No PRN pain medication was administered despite the order for Tramadol for pain levels 7–10, and there was no documented reassessment of the effectiveness of the non-pharmacological interventions. The MAR for that date and shift contained no entry showing that the resident’s pain was reevaluated after these interventions. Review of the MARs from December through January confirmed that on that date no pharmacological intervention was provided and no reevaluation was documented for the high pain score. In interviews, the resident reported ongoing right ankle pain and swelling and stated that when he reported pain to nursing staff, they did not provide pain medication and that his pain was not being taken seriously. The LVN involved stated she was not informed that the resident was experiencing pain and also stated that the treatment nurse monitored residents for pain; she later explained that she provided non-pharmacological interventions first when a resident reported pain and acknowledged she had not documented their effectiveness. The RN supervisor confirmed that no pharmacological intervention or reassessment was documented for the 8/10 pain episode and stated that pain medication such as Tramadol should have been administered. The DON also confirmed that there was no reevaluation documented for the non-pharmacological interventions and stated that if the resident still had pain after such interventions, pain medications should have been given. The resident expressed a preference for pain medications over non-pharmacological interventions, stating that the latter did not relieve his pain and that he felt no one cared about his pain. The facility’s pain assessment and management policy required appropriate assessment and treatment of pain and monitoring for the effectiveness of interventions.
Failure to Notify Physician of Inability to Initiate IV Therapy
Penalty
Summary
The facility failed to notify the attending physician when nursing staff were unable to initiate an intravenous (IV) line for a resident who had a critical need for IV hydration and electrolyte replacement. The resident, who had a history of diabetes mellitus, fatty liver disease, acute kidney failure, hypertension, and cardiomegaly, was admitted with persistent nausea, vomiting, and impaired cognitive function. Laboratory results revealed critical electrolyte imbalances, including a potassium level of 2.7 mEq/L, elevated sodium, and low magnesium, prompting the physician to order immediate potassium replacement, D5W IV fluids, and magnesium supplementation. Despite these orders, the assigned RN attempted to start the IV line twice without success and then contacted a third-party IV provider, who was unable to send an IV nurse until the following morning. The RN did not inform the physician of the failed IV attempts or the resulting delay in administering the ordered IV fluids and medications. Instead, the information was only endorsed to the oncoming nurse, and no further attempts to notify the physician were documented. The physician was therefore not made aware that the resident's critical treatment could not be initiated as ordered. Interviews with nursing staff and the Director of Nursing confirmed that the facility's protocol required the physician to be notified if IV access could not be established, so that alternative interventions could be considered, such as hospital transfer or ordering a PICC or midline catheter. The facility's policy also required notification of the physician, supervisor, and oncoming shift in the event of complications with IV therapy. The failure to notify the physician of the inability to start the IV and the delay in treatment constituted a deficiency in communication and adherence to clinical protocols.
Failure to Provide Timely Intervention and Monitoring for Critically Low Potassium
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident with a critically low potassium level. After the laboratory notified the facility of a critical potassium result of 2.7 mEq/L, the nurse who received the result did not notify the physician, did not assess the resident, and did not initiate a Change in Condition Evaluation Form (CIC). There was no documentation of any assessment or communication regarding the abnormal lab result until several hours later, when another nurse became aware of the situation and contacted the physician. Following the physician's orders for urgent potassium replacement and IV hydration, there was a significant delay in administering the ordered potassium, as it was not given until approximately five hours after the order was placed and after a reminder from the supervising nurse. Additionally, the ordered IV fluids for hydration were not administered because staff were unable to establish IV access, and the physician was not notified of this delay. Documentation did not show that the resident was monitored for complications of hypokalemia, such as cardiac symptoms, as required by the care plan. The resident had a complex medical history, including diabetes, acute kidney failure, hypertension, and cognitive impairment, and was dependent on staff for all activities of daily living. Despite the critical nature of the lab results and the resident's vulnerability, the facility did not ensure timely notification, intervention, or monitoring. The resident was later found unresponsive and expired despite resuscitation efforts. Interviews with staff confirmed lapses in communication, assessment, and timely intervention in response to the critical lab findings.
Failure to Initiate Care Plan After Resident Reports Feeling Threatened
Penalty
Summary
The facility failed to initiate a resident-specific care plan for a resident who verbalized feeling upset, angry, and threatened following an incident involving another resident's responsible party. The incident occurred when the responsible party demanded that the resident lower the volume on her phone, using a loud and threatening tone, which left the resident feeling scared, upset, and uncomfortable. Despite the resident's cognitive intactness and ability to participate in care planning, there was no care plan developed to address her psychosocial needs or to guide staff in monitoring her well-being during and after the incident. Record review and staff interviews confirmed that while some interventions, such as wellness checks, were implemented, there was no documentation of a comprehensive care plan with measurable objectives or timetables as required by facility policy. The Director of Nursing acknowledged that a care plan should have been created to ensure consistent interventions and staff awareness, but none was initiated. This omission meant that the resident's specific needs related to the incident were not formally assessed or addressed through the care planning process.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents.
Failure to Notify Physician and Responsible Party of Resident's Change in Skin Condition
Penalty
Summary
The facility failed to notify the physician and responsible party when a resident experienced a change in condition involving new skin redness between the skin folds of the lower abdomen. The resident, who had diagnoses including dementia and impaired mobility, was found by a CNA to have skin breakdown during a scheduled shower. The CNA reported the abnormal skin condition to the Treatment Nurse, who assessed the area and applied Zinc Oxide cream without obtaining a physician's order or documenting the condition in the resident's records. The Treatment Nurse did not notify the physician or the responsible party about the skin redness, assuming it was due to heat and would resolve in a few days. Further interviews revealed that another CNA also noticed discoloration and itchiness in the same area and reported it to the nursing staff, but there was still no documentation or notification to the physician or responsible party. The Director of Nursing confirmed that the facility's policy requires nurses to document changes in condition and notify both the physician and responsible party. The lack of timely communication and documentation regarding the resident's skin condition constituted a deficiency in care.
Failure to Maintain Functional Wheelchair Brakes for Resident with Severe Impairment
Penalty
Summary
The facility failed to provide a safe and functional wheelchair for a resident with dementia and severe cognitive impairment, who required substantial assistance with transfers and was dependent for toileting and bathing. The resident's wheelchair had a malfunctioning left brake that could not lock the wheel securely, as observed by staff and confirmed during interviews. The issue was known to some staff members, including a CNA who reported the problem to the maintenance supervisor and assistant, but there was no documentation of a maintenance request or repair for the wheelchair in the facility's maintenance log for the past three months. Despite the resident using the wheelchair daily for activities and transfers, the malfunctioning brake was not addressed or communicated effectively to the maintenance team or the Director of Nursing. Multiple staff members, including the restorative nursing assistant and CNA, acknowledged the brake issue and its potential to cause harm, but the maintenance staff and DON were unaware of the problem until the day of the survey. The facility's policy required that assistive devices be maintained and repaired as needed, but this was not followed in the case of the resident's wheelchair.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Clean and Disinfect Shared Wheelchair
Penalty
Summary
The facility failed to provide a sanitary environment for one of five sampled residents by not ensuring that a wheelchair used by the resident was clean. Observation revealed food particles on the right side of the wheelchair next to the resident's bed. Staff interviews confirmed that the wheelchair was shared among residents and was not cleaned or disinfected after each use, contrary to facility policy. The Restorative Nursing Assistant acknowledged that the wheelchair should have been cleaned and disinfected before and after each use, but this was not done. The resident involved had a history of Alzheimer's Disease and hypertension, with severely impaired cognitive skills and required significant assistance with daily activities, including transfers and hygiene. The facility's policy required reusable items, such as wheelchairs, to be cleaned and disinfected between residents, but this procedure was not followed. The Infection Preventionist also confirmed that staff were expected to use disinfectant wipes on the wheelchair before and after each use to maintain a sanitary environment and prevent infection.
Failure to Monitor and Supervise Resident with Substance Abuse History and Oxygen Use
Penalty
Summary
The facility failed to identify and implement appropriate monitoring and supervision for a resident with a known history of methamphetamine use, despite multiple documented instances of positive toxicology screens for amphetamines. After a hospital toxicology report indicated a positive result for amphetamines, the facility's interdisciplinary team only provided education to the resident about the risks of recreational drug use and did not establish a care plan or interventions to monitor for ongoing substance abuse. There was no evidence that staff were informed of the resident's drug history, nor were there protocols in place to monitor for signs of substance use or to update the resident's care plan accordingly. Additionally, the facility did not secure or prevent the resident from possessing smoking items, such as cigarettes, a glass pipe, and lighters, even though the resident was assessed as a non-smoker and had active orders for continuous oxygen therapy. Staff discovered lighters in the resident's room on multiple occasions, but there was no documentation of a personal belongings inventory update or consistent monitoring of the resident's possessions. The facility's policies required confiscation and documentation of hazardous items, but these procedures were not followed, and staff were unaware of the presence of these items until after a critical incident occurred. The lack of monitoring and supervision resulted in the resident experiencing a medical emergency characterized by tachycardia, oxygen desaturation, and shortness of breath, necessitating emergency transport to a hospital where the resident tested positive for amphetamines and methamphetamines and required intubation. Subsequent investigation revealed the presence of narcotics and a meth pipe in the resident's room, as well as multiple lighters, despite facility policies prohibiting such items for residents on oxygen. Staff interviews confirmed that there was no training on recognizing signs of methamphetamine use, no communication about the resident's drug history, and no updated inventory of the resident's belongings.
Failure to Accurately Account for and Secure Controlled Medications
Penalty
Summary
The facility failed to accurately account for controlled medications for six out of seven residents in one of two inspected medication carts. Nurses did not document the removal and administration of controlled substances on the Controlled Medication Count Sheet (CMCS) at the time the medications were administered. For example, a nurse counted fewer tablets in the prescription bottle than recorded on the CMCS for a resident prescribed Amphetamine/Dextroamphetamine, and only documented the administration several hours after the scheduled time, expressing uncertainty about whether the medication had been given. Similar discrepancies were found for other residents, where the number of tablets in medication cards did not match the CMCS, and the nurse admitted to not documenting doses at the time of administration. Additionally, the facility failed to remove and securely store controlled medications belonging to residents who were no longer present in the facility. Medications for a resident who had been transferred to the hospital and another who had expired were found mixed with current residents' medications in the medication cart. The Director of Nursing (DON) confirmed that medications for residents who are no longer in the facility should be removed from the cart and stored securely until destruction, as per facility policy. The facility's policies require that licensed nurses immediately document the date, time, amount administered, and their signature on the accountability record when a controlled medication is removed from the supply, and to store discontinued or leftover controlled medications in a double-locked area until destroyed. These procedures were not followed, as evidenced by the discrepancies in medication counts, lack of timely documentation, and improper storage of medications for discharged or deceased residents.
Failure to Provide Timely and Consistent Restorative Nursing Services per Physician Orders
Penalty
Summary
The facility failed to provide timely and consistent Restorative Nursing Assistant (RNA) services as ordered by the physician for a resident with significant physical and cognitive impairments. Despite physician orders dated 1/10/2025 for daily and weekly RNA interventions—including left upper extremity (UE) elbow extension, left hand-roll, passive range of motion (PROM) for the left UE, and active assisted range of motion (AAROM) for the right UE—these services were not initiated until 16 to 19 days after the orders were given. Documentation showed that the resident received only a few days of the prescribed treatments in January, and there were additional missed or undocumented days in February and March. The resident in question had a history of cerebral infarction resulting in hemiplegia and hemiparesis, adult failure to thrive, and muscle wasting and atrophy. The resident was severely cognitively impaired, dependent on staff for all self-care and mobility, and unable to make decisions. The Minimum Data Set (MDS) indicated that the resident was supposed to be on restorative nursing programs, but actual service delivery did not match the orders or the care plan requirements. Interviews with staff, including the RNA and the Director of Nursing (DON), confirmed that the physician's orders were not followed and that the required care plan for RNA services was not developed or implemented. The DON acknowledged that without a care plan, staff had no guidance for providing the ordered services. Observations and interviews with the resident's responsible party and emergency contact further corroborated that the resident was not consistently receiving the prescribed RNA interventions, and documentation gaps were evident in the facility's records.
Failure to Prevent Weight Loss and Follow Nutrition Recommendations for Tube-Fed Resident
Penalty
Summary
The facility failed to prevent weight loss for a resident who was dependent on a gastrostomy tube for nutrition. Upon admission, the resident had multiple diagnoses, including cerebral infarction with hemiplegia, adult failure to thrive, and required tube feeding. Despite recommendations from the Registered Dietician (RD) to perform weekly weights, increase free water flushes, add a probiotic, and obtain new laboratory tests, these interventions were not implemented as documented in the resident's records. The facility did not perform weekly weights as recommended, nor did they follow through with the RD's nutrition care recommendations or notify the physician of these recommendations and the resident's ongoing weight loss. The staff also failed to implement a Situation, Background, Assessment, and Recommendation (SBAR) communication for the resident's weight loss, as required by facility policy. There was no evidence that a change of condition was documented or communicated to the physician, and the facility did not develop or update a care plan to address the resident's weight loss. Interviews with facility staff, including the Restorative Nursing Assistant, RD, Registered Nurse Supervisor, and Director of Nursing, confirmed that these steps were not taken, and acknowledged that the facility's policies and procedures regarding nutritional assessment, unplanned weight loss, and care planning were not followed. As a result of these deficiencies, the resident experienced a weight loss of 10 pounds over five months. The lack of adherence to recommended monitoring, communication, and care planning placed the resident at risk for further weight loss and potential harm, as directly stated in the report. The facility's failure to follow its own protocols and the RD's recommendations contributed to the resident's unaddressed nutritional decline.
Failure to Implement Fall Protocol and Follow Physician Orders
Penalty
Summary
The facility failed to follow physician orders for laboratory services and implement fall care plan interventions for a resident diagnosed with dementia and assessed at high risk for falls. The facility did not have a fall protocol or fall prevention program in place, as indicated in the resident's care plan and physician orders. This lack of protocol contributed to the resident experiencing multiple unwitnessed falls, resulting in acute pain and trauma. Additionally, the facility did not follow up with laboratory services when a blood sample could not be obtained due to excessive bruising. The resident's physician had ordered a complete blood count and comprehensive metabolic panel, but the facility staff did not ensure these tests were completed. Furthermore, the facility failed to collect a urine sample for culture and sensitivity after a probable contamination was identified, delaying the diagnosis and treatment of a urinary tract infection. As a result of these deficiencies, the resident experienced severe health complications, including hypernatremia, dehydration, urinary tract infection with severe sepsis, and thrombocytopenia. The resident was eventually transferred to a general acute care hospital for further treatment. The facility's failure to implement a fall prevention program and follow physician orders for laboratory tests and urine collection significantly impacted the resident's health and safety.
Facility Fails to Protect Resident from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a Certified Nurse Assistant (CNA). The incident occurred when the CNA engaged in non-consensual sexual contact with the resident, who was severely cognitively impaired and unable to consent or defend himself. The abuse was captured on a hidden camera installed by the resident's emergency contact, which showed the CNA using the resident's hand to stroke his own penis. This incident was reported to the police, leading to the CNA's arrest. The resident involved in the incident had a history of severe cognitive impairment, cerebral infarction, and was dependent on facility staff for all self-care and mobility. The resident's condition made him unable to communicate verbally or physically defend himself. The abuse had a significant negative psychosocial impact on the resident, as noted by the facility's social services director and a psychologist, who observed changes in the resident's behavior, including difficulty sleeping, hopelessness, and frustration. The facility's failure to protect the resident from abuse was identified as an Immediate Jeopardy situation by the California Department of Public Health. The facility was notified of this situation due to their non-compliance in ensuring the resident's safety from non-consensual sexual contact. The incident highlighted a severe deficiency in the facility's ability to safeguard residents from abuse, particularly those who are cognitively impaired and unable to advocate for themselves.
Removal Plan
- Resident 1 was assigned a different Certified Nurse Assistant.
- The Administrator reported the incident to the California Department of Public Health and Ombudsman.
- The Administrator reported initiation of sexual abuse allegation investigation to the Medical Director.
- A change of condition documentation for sexual abuse allegation was completed by a licensed nurse on Resident 1 notifying his primary physician and responsible parties.
- A head-to-toe body assessment was conducted by a licensed nurse with no new skin discoloration or impairments noted.
- Resident 1 was placed on every shift monitoring for a change of condition related to sexual abuse allegation.
- Plan of care was updated by licensed nurses to provide resident with 2 CNAs when providing care.
- Resident 1 was placed under a one-to-one supervision and monitoring utilizing the one-to-one observation daily monitoring form to document supervision and monitoring.
- Resident 1 was seen by primary physician with no new orders.
- The Psychiatrist assessed and evaluated Resident 1 and was found with no signs of agitation. Succeeding psychiatrist visits would be scheduled monthly for 3 months and as needed.
- The Social Services Director conducted visits to Resident 1 to provide psychosocial support.
- Resident 1's plan of care was reviewed and updated by a licensed nurse to reflect current needs and monitoring.
- A Quality Assurance Performance Improvement plan was developed surrounding Abuse Management and was discussed by the Administrator, Director of Nursing, and Medical Director.
- CNA 1 was terminated by the Administrator and reported to the CNA licensing body for gross misconduct.
- Director of Nursing, Activities Director, and EC 1 met and discussed recent alleged abuse event.
- The IDT members conducted an interview and observation to all other residents utilizing the Sexual Screening Assessment tool.
- The Director of Staff Development provided the initial in-service education to Department Manager, nursing staff regarding Abuse prohibition and Management.
- A total of actively employed facility staff were provided an in-service. The Inservice re-education would continue until 100% was achieved.
- The Director of Staff Development and/or designee would facilitate background checks and at least two reference checks prior to hire and quarterly background checks thereafter.
- The Director of Staff Development and/or designee would conduct abuse training to facility staff upon hire and quarterly thereafter.
- The Sexual Screening Assessment tool would be utilized by licensed nurses for incidents involving sexual abuse allegations.
- The IDT would conduct an abuse risk assessment during the scheduled quarterly care conference meetings.
- The Sexual Capacity Assessment tool for residents would be completed as part of the admission assessments for new admissions and/or re-admissions.
- The Department Managers and other staff assigned would continue to complete daily Resident Care Room Rounds.
- Licensed nurses would conduct verbal endorsement daily at the start of each shift with licensed nurses and CNAs.
- The Administrator and/or Designee would conduct random observation rounds weekly.
- Social Service and/or Designee, would conduct a resident council meeting twice within the next 30 days.
- The Administrator and/or designee would discuss any pattern of findings related to any alleged abuse investigation with the Medical Director and QAA committee monthly.
Failure to Manage Psychotropic Medication
Penalty
Summary
The facility failed to manage a resident's psychotropic medication, Depakote, in accordance with its policies and procedures. The resident was administered Depakote for seizures from 12/11/2024 to 12/18/2024, despite not having a seizure disorder or diagnosis. The diagnosis for Depakote use was later changed to mood swings without adequate clinical assessment or a comprehensive review of the resident's condition. Additionally, the facility did not develop a comprehensive care plan for the administration of Depakote, which should have included guidelines for medication management and monitoring for side effects. The facility's licensed nurses did not adequately monitor or document the efficacy and adverse consequences of Depakote from 12/11/2024 to 12/28/2024. The resident was observed to be quiet, drowsy, sedated, and with poor oral intake, but these symptoms were not properly addressed. The resident's responsible party repeatedly requested the discontinuation of Depakote due to these symptoms, but the facility staff did not evaluate the resident or communicate these concerns to the psychiatrist in a timely manner. Furthermore, the facility failed to arrange a follow-up visit with the psychiatrist to reevaluate the resident's psychotropic medication as ordered by the attending physician. The resident was not reassessed by a psychiatrist from 12/11/2024 to 12/28/2024, and there was no documented evidence of monitoring for side effects or laboratory tests for Depakote levels. These failures resulted in a delay in managing the resident's adverse consequences, leading to hospitalization with diagnoses including lower gastrointestinal bleed, hypernatremia, and dehydration.
Failure to Implement Effective Infection Control Measures During GI Outbreak
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent and control the spread of gastrointestinal (GI) infections among residents and staff. This deficiency was observed in 26 of 106 sampled residents and 16 of 150 facility staff who presented with GI illness symptoms over a 14-day period. The facility did not place affected residents on transmission-based precautions, nor did it prohibit symptomatic staff from working until they were symptom-free for at least 48 hours. Additionally, the facility failed to collect stool specimens from affected residents to identify the infection source. The facility did not ensure that residents with symptoms of vomiting and diarrhea were placed on transmission-based precautions. Staff members, including CNAs, who exhibited active symptoms of diarrhea and vomiting, were not prohibited from providing care to residents, increasing the risk of further infection spread. The facility also failed to investigate the outbreak to identify individual cases and trends, which would have allowed for appropriate preventative interventions. The Infection Preventionist (IP) nurse did not start the facility's surveillance tracking tool to monitor the outbreak effectively, and the local health department was not notified in a timely manner. Furthermore, the facility did not ensure that staff followed proper hand hygiene procedures, which had the potential to cross-contaminate food and beverages, such as ice served to residents. There was no properly installed handwashing sink near the ice dispensing room, and staff were observed not washing their hands before handling ice. These practices placed residents and staff at risk for complications from GI infections, including dehydration, hospitalization, and possible death. Laboratory results confirmed Norovirus 2 in two residents, highlighting the severity of the outbreak.
Removal Plan
- Notification to the local health department that an outbreak investigation had been initiated.
- The facility's IP nurse completed and updated the cumulative line listing of Residents with GI symptoms.
- The facility will send the updated line listing/contract tracing to the local health department daily until further notice from the Public Health Department.
- The facility has posted a Notice to all visitors of a declared outbreak for the investigation of GI related illness on all facility entrances.
- All visitors are subject to registration before entering the premises and are required to complete a questionnaire screening.
- The DON and the IP nurse completed an evaluation and assessment of all residents to ensure no other residents have been identified with GI symptoms.
- Symptomatic Residents identified had action plans initiated including change of condition completion, developed care plans, notification to each resident's attending physician, and environmental cleaning and sanitation.
- Nursing personnel are conducting clinical assessments of all symptomatic Residents to manage symptoms and prevent fluid deficits and discomfort.
- The contracted Registered Dietitian Resources made a service visit to assess active cases and monitor affected Residents.
- Current symptomatic nursing employees had been removed from work schedules pending resolution of symptoms.
- An educational in-service training was initiated and completed by the Regional IP-Director of Staff Development Resource with all Dietary on foodborne illness prevention, handwashing, and appropriate dress code.
- An all-staff educational in-service was initiated for all Nursing and Non-Nursing personnel to address identification, prevention, and management of GI related illness.
- The Nursing Department will continue to complete shift huddle/handoff to identify any changes of condition related to GI symptoms.
- For the facility's Ice Process: The Dietary and Nursing personnel will complete handwashing hygiene with soap and water before handling ice.
- Food service workers were in-serviced by the Regional IP-DSD Resource on foodborne illness and hand hygiene.
- The food service workers were screened prior to commencement of duties to ensure they are free of gastrointestinal symptoms.
- The IP nurse included Environmental services personnel within the offered in-service and have been directed to increase disinfection of high touch surfaces.
- Laundry personnel will continue to monitor linen handling, washing, and drying to ensure proper processing temperatures and sanitizing is maintained.
- The IP and the DON will continue to monitor the above measures in collaboration with the local health department.
- The facility regional consultant provided an in-service for the facility leaders regarding reportable diseases and conditions.
- The facility regional consultant provided a one-on-one in-service to the facility IP nurse regarding proper identification of health illnesses that constitute a reportable condition.
QAPI Committee Fails to Address GI Illness Outbreak
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to systematically identify and address an outbreak of gastrointestinal (GI) illness among residents and staff. The committee did not implement or evaluate preventative measures in response to the outbreak, which affected 26 residents and 16 staff members. The outbreak, characterized by symptoms such as vomiting and diarrhea, persisted over a 14-day period without adequate intervention or follow-up from the QAPI committee. The QAPI committee also failed to ensure that appropriate transmission-based precautions were implemented for affected individuals. Despite the presence of symptoms in both residents and staff, the committee did not take necessary actions to mitigate the spread of the illness. Additionally, the facility did not notify the local health department in a timely manner, delaying the response to the outbreak and potentially exacerbating the situation. Interviews with facility staff, including the Administrator and Director of Nursing, revealed that the QAPI meetings were not conducted as required, and the increasing number of GI illness cases was not brought to the committee's attention. The facility's policy on QAPI, which outlines the need for a data-driven approach to quality improvement, was not adhered to, resulting in a lack of coordinated efforts to address the outbreak effectively.
Failure to Develop Comprehensive Care Plan for Resident with Anxiety
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented for a resident diagnosed with anxiety disorder. The resident, who was admitted with diagnoses including bipolar disorder, anxiety disorder, and malignant neoplasm of the kidney, did not have a care plan addressing their anxiety. This oversight was identified during a review of the resident's care plan, which was based on their history and physical, diagnosis, and progress notes. The MDS Nurse confirmed that all diagnoses should have corresponding care plans to guide staff in providing appropriate care. The Director of Nurses acknowledged the absence of a care plan for the resident's anxiety and emphasized the importance of having one to ensure proper care. The facility's policy on comprehensive, person-centered care plans, revised in March 2022, mandates the development and implementation of care plans with measurable objectives and timetables to meet residents' needs. The lack of a care plan for the resident's anxiety disorder was a deviation from this policy, potentially leading to inadequate and incomplete care for the resident.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering medications as ordered by the physician on three separate occasions. The resident, who was admitted with diagnoses including diabetes mellitus and hypertension, did not receive their prescribed medications on specific dates in November 2024. This failure was identified through a review of the resident's Medication Administration Record (MAR), which lacked documentation indicating that the medications were administered on those dates. The resident's MAR for November 2024 showed that medications due at 9 AM on 11/4, 11/5, and 11/12 were not documented as given. The medications included treatments for high blood pressure, diabetes, and other conditions. The Director of Nursing confirmed that the absence of documentation meant the medications were not administered, as per the facility's standard practice. The Licensed Vocational Nurse responsible for administering the medications admitted to forgetting to document the administration, acknowledging that if it was not documented, it was not done. The facility's policy on medication administration documentation, revised in 2022, requires that all medications administered be documented immediately after being given. This policy was not followed, leading to the deficiency. The lack of documentation and administration of medications could have potentially impacted the resident's health, given their medical conditions, although the report does not specify any direct consequences that occurred as a result.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident, who was transferred to a General Acute Care Hospital (GACH) due to a change in condition, was provided with written information regarding the facility's bed-hold policies and was permitted to be readmitted back to the facility on the first available bed. The resident, who had been admitted to the Skilled Nursing Facility (SNF) with diagnoses including metabolic encephalopathy, unspecified psychosis, and Type 2 diabetes, was transferred to the GACH via 911 emergency services due to altered mental status. Despite being medically stable for discharge back to the SNF, the resident was not readmitted and had to remain in the GACH for an additional six days before being transferred to another facility. The facility's failure to place the resident on a bed hold and provide the family with written information about the bed-hold policies was a significant oversight. The facility's Administrator (ADM) decided not to place the resident on bed hold, believing the resident required a higher level of care and that the GACH could assist in finding a new placement. This decision was made without conducting an interdisciplinary team (IDT) meeting or involving the resident's family in discharge care planning. The facility's Director of Nursing (DON) confirmed that the resident was not placed on bed hold, and the family was not notified about the seven-day bed hold policy. Interviews with facility staff and the GACH Social Service Director revealed that the ADM had requested psychiatric and medical clearances before considering the resident's readmission. Despite receiving the necessary clearances, the ADM did not proceed with the readmission, citing the need for additional paperwork. The facility's actions were contrary to their policy and the California Standard Admission Agreement, which required them to offer the next available appropriate bed if the bed-hold notification procedure was not followed.
Failure to Complete Annual Competency Assessments for Nursing Staff
Penalty
Summary
The facility failed to ensure that two licensed nurses, an RN and an LVN, completed their annual competency assessment and evaluation as required by the facility's policy and procedure. The RN was hired on January 16, 2023, and the LVN on March 27, 2023. Both had initial skills checklists signed by the employee and the DON on their respective hire dates. However, there was no documented evidence of a skills competency evaluation being completed for either nurse since their hiring. During an interview and record review with the DON, it was confirmed that the facility had not conducted a skills competency evaluation for the current year. The DON explained that the facility typically holds a Skills Competency and Evaluation fair annually to ensure all nursing staff are assessed simultaneously. The absence of this evaluation placed residents at risk of receiving care that did not meet the standard of practice, potentially affecting their quality of life and care. The facility's policy emphasized the importance of competency in identifying, documenting, and reporting resident changes of condition, which is monitored by nursing leadership.
Food Storage and Egg Handling Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure guidelines to prevent food contamination and the spread of foodborne illness in the kitchen. During an observation, multiple opened dry food items in the kitchen's dry goods storage area were found to be improperly stored. These items, including pasta bags, gelatin powder, and gravy bags, were wrapped in transparent plastic wrap without labels indicating the date they were opened or their expiration dates. The Dietary Supervisor confirmed that the facility's policy requires opened food items to be stored in sealable plastic bags and labeled with the product name, opened date, and expiration date to prevent food contamination and the use of expired food items. Additionally, the facility was found to be using unpasteurized eggs as ingredients in foods served to residents, which is against their policy. Two boxes of eggs in the kitchen's walk-in refrigerator did not have labels indicating they were pasteurized. The Dietary Supervisor acknowledged that the facility only orders pasteurized eggs, but due to an out-of-stock situation, they received a substitute that was not pasteurized. The facility's policy mandates the use of pasteurized eggs for certain preparations to prevent foodborne illnesses. The Registered Nurse confirmed that using unpasteurized eggs could potentially make residents sick.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with multiple wounds and a Foley catheter. This deficiency was observed when a Certified Nursing Assistant (CNA) provided care to the resident without wearing the required personal protective equipment (PPE), specifically an isolation gown. The resident, who was admitted with diagnoses including a urinary tract infection and pressure ulcers, was identified as requiring EBP due to the presence of wounds. The CNA admitted to forgetting to wear the gown, which is necessary to prevent the spread of infections. The facility's policy, revised in April 2024, mandates the use of gowns and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices. Despite this, the CNA was observed providing a bed bath without the appropriate PPE. Interviews with the CNA, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) confirmed the requirement for EBP and the importance of using PPE to prevent infection transmission. The failure to adhere to these precautions placed the resident and others at risk of infection spread.
Resident Dignity Compromised During Transport
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified and respectful manner, as required by their policy on dignity. During an observation, a certified nursing assistant (CNA) was seen transporting a resident in a shower chair through the hallway without adequately covering the resident's body, resulting in the resident's buttocks being exposed. This incident occurred despite the facility's policy that emphasizes the importance of maintaining resident privacy and dignity during personal care and treatment procedures. The resident involved had been admitted to the facility with diagnoses including Parkinson's disease, depression, and hypothyroidism, and was capable of understanding and making decisions. The CNA involved was unaware of the exposure and acknowledged the importance of covering the resident to protect their privacy. Interviews with the Director of Staff Development and the Director of Nursing highlighted the significance of ensuring residents are fully covered during transportation to uphold their dignity, especially in public areas like hallways.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to accurately assess a resident, identified as Resident 90, for the ability to safely self-administer medications. The resident had 17 bottles of medications stored at her bedside, which were not prescribed or ordered by a physician for self-administration. The facility did not conduct an IDT meeting to evaluate the resident's cognitive and physical abilities to self-administer these medications. Additionally, there was no review of whether any of the medications were expired, discontinued, or recalled, nor was there documentation of the times when the resident self-administered her medications. Resident 90 was admitted with diagnoses including a leg fracture and malignant neoplasms of the kidney and bone. Her medical records indicated fluctuating capacity to understand and make decisions, yet her Minimum Data Set (MDS) showed intact cognition. Despite this, there was no evidence in her medical records that the facility assessed her safety in self-administering medications or monitored her for any side effects. Observations revealed multiple bottles of herbal medications and oils at her bedside, which she consumed without consulting facility staff. Interviews with facility staff, including a registered nurse (RN), pharmacist (PH), and the director of nursing (DON), confirmed the lack of assessment and monitoring for Resident 90's self-administration of medications. The facility's policies required an assessment by the IDT and a physician's order for self-administration, which were not followed. The medications were not reviewed by the pharmacist, and there was no documentation in the Medication Administration Record (MAR) regarding the resident's self-administration or any associated side effects.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents by not ensuring their call lights were within reach, which could lead to delayed care and potential accidents. Resident 83, who has severe cognitive impairment and is dependent on assistance for daily activities, was observed with their call light on the floor, out of reach. This resident's care plan specifically required the call light to be within reach due to their risk of falls and impaired visual function. During an observation, a registered nurse confirmed the call light was not accessible and acknowledged the risk of accidents if call lights are not within reach. Similarly, Resident 314, who has intact cognition but requires supervision and moderate assistance for various activities, was also found with their call light on the floor, out of reach. The resident's care plan highlighted the need for the call light to be accessible due to their risk of falls related to limited mobility. A licensed vocational nurse confirmed the call light should be within reach to prevent potential falls. The Director of Nursing reiterated the importance of keeping call lights within reach to avoid delays in response and potential accidents. The facility's policy mandates that call lights be accessible and calls for assistance be answered promptly.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the medical records for two residents. Resident 53, who was admitted with diagnoses including metabolic encephalopathy, end-stage renal disease, and lobar pneumonia, had an advance healthcare directive (AHCD) noted in a multidisciplinary care conference. However, the AHCD acknowledgment form indicated that Resident 53 did not have an advance directive, and there was no follow-up from the facility staff to obtain it. The Social Services Director confirmed that a copy of the advance directive was requested but not followed up on, highlighting the importance of having it readily available in case of emergencies. Similarly, Resident 21, admitted with diagnoses including end-stage renal disease and pneumonia, had an acknowledgment form indicating no advance directive, but another document showed that an advance directive was completed. Despite this, a copy was not available in the medical records. The Social Services Director was unaware of the status of Resident 21's advance directive and did not follow up with the family. The Director of Nursing emphasized the importance of having a copy of the advance directive to ensure the resident's wishes are known and respected during emergencies. The facility's policy required obtaining and including a copy of the advance directive in the resident's medical record upon admission.
Failure to Notify Physician and Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and resident representative of a significant weight loss for a resident, identified as Resident 21, who experienced a 23-pound weight loss over 15 days. This deficiency was identified through interviews and record reviews. The resident, who was admitted with diagnoses including Parkinson's disease, cognitive communication deficit, and heart failure, was noted to have moderate cognitive impairment and was on a mechanically altered and therapeutic diet. Despite these conditions, the facility did not complete a Change of Condition (COC) or update the Comprehensive Care Plan to address the weight loss. The resident's weight was recorded as 148 pounds on one date and 125 pounds 15 days later, indicating a 15.54% weight loss. The Nutrition Assessment noted the resident's weight loss and identified nutritional risks such as variable oral intake, disease process, and psychotropic medications. However, the facility did not document a COC or update the care plan to address these changes. The Nutrition Progress Notes indicated the resident was eating well and recommended monitoring weight changes and providing snacks for weight management. Interviews with facility staff, including the Director of Nursing (DON), confirmed that there was no COC or Care Plan completed for the resident's weight loss, which should have been done according to the facility's policies. The facility's policies required documentation of changes in the resident's condition and notification of the physician for significant changes, which were not followed in this case.
Inadequate Discharge Planning and Unsafe AMA Discharges
Penalty
Summary
The facility initiated discharges for two residents without adequate reason or proper documentation, leading to unsafe discharges against medical advice (AMA). Resident 320 was informed by the Social Services Director that she did not meet the criteria to stay at the facility and was given the option to pay out of pocket or sign an AMA form. The facility failed to provide adequate discharge planning, did not inform Resident 320 of her right to appeal, and did not provide necessary post-discharge resources such as medications or home health services. The resident was not aware of her rights and felt compelled to leave due to financial constraints. Resident 111, who had moderately impaired cognition, was not allowed to return to the facility after going out on pass. The facility informed her that she could not come back despite her desire to return. The facility did not provide adequate discharge planning, resulting in an unsafe discharge AMA. The facility's records did not indicate any previous issues with Resident 111's compliance with the out-on-pass policy, and there was no documented evidence of discharge paperwork or prescriptions for her medications. The facility's policies and procedures were not followed, as evidenced by the lack of proper documentation and communication regarding the residents' rights and options. The facility failed to ensure that residents were informed of their rights to appeal and did not provide necessary support for residents who were discharged AMA. The facility's actions led to potential negative health effects for the residents due to the lack of medications and home health services.
Failure to Revise Pain Management Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 38, who continued to experience daily pain despite receiving pain medication. The resident was initially admitted in 2018 and readmitted in 2023 with diagnoses including chronic congestive heart failure, hypothyroidism, and anemia. The Minimum Data Set (MDS) assessment indicated that the resident had intact cognition and experienced occasional pain, with a numeric pain rating of nine out of ten. The resident's pain care plan, last updated in March 2024, included interventions such as evaluating for breakthrough pain and implementing nonpharmacological interventions. However, the care plan was not revised to address the resident's ongoing pain complaints. Interviews with the Director of Nursing (DON) and the MDS Coordinator (MDSC) revealed that the care plan should have been updated to reflect the resident's continued pain and to identify alternative interventions. The DON acknowledged that although the medication was helping, the facility should have explored different ways to alleviate the resident's pain. The MDSC confirmed that the care plan had not been revised since March 2024, which could lead to the resident experiencing worsening pain. The facility's policy on comprehensive, person-centered care plans emphasized the need for ongoing assessments and revisions as residents' conditions changed.
Failure to Assist Resident with Vision Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident 72, in obtaining necessary vision services after his prescription glasses were broken by a Certified Nursing Assistant (CNA). Despite Resident 72's repeated notifications to multiple facility staff about the broken glasses, no timely action was taken to address the issue. The resident's care plan indicated a risk for injuries related to impaired visual function, and the need for corrective lenses was documented in his Minimum Data Set. However, the Social Service Assistant (SSA) did not contact the facility's optometrist promptly, waiting instead for a routine visit, and did not document any communication regarding the broken glasses. The Director of Nursing (DON) became aware of the issue a week before the survey and instructed Social Services to assist the resident, but was unaware that the glasses had been broken for over a month. The facility lacked a specific policy for ancillary eyeglasses services, although it was their practice to arrange appointments and obtain necessary assistive devices promptly. This inaction led to the resident having to manage with broken glasses and non-prescription reading glasses, potentially affecting his quality of life.
Failure to Administer Oxygen Therapy with Proper Parameters
Penalty
Summary
The facility failed to administer oxygen therapy according to a physician's order and without clear parameters for when to administer oxygen for a resident. The resident, who was admitted with diagnoses including Type 2 Diabetes, chronic kidney disease, and heart failure, had an order for oxygen at 2 liters per minute. However, the care plan indicated oxygen should be administered at 2-3 liters per minute to maintain oxygen saturation above 92%. During an observation, a Licensed Vocational Nurse (LVN) administered oxygen at 3 liters per minute when the resident's oxygen saturation was at 89%, without a specific parameter in the order indicating when to administer oxygen. The LVN acknowledged the lack of parameters in the order and stated she would normally administer oxygen when the resident's saturation dropped below 90% or if the resident showed signs of shortness of breath. The Director of Nursing confirmed that all oxygen orders should include parameters to guide staff on when to administer oxygen. The facility's policy on oxygen administration requires verification of a physician's order and adherence to proper administration guidelines, which was not followed in this instance.
Failure to Conduct Medication Regimen Review for Self-Administered Medications
Penalty
Summary
The facility failed to conduct a Medication Regimen Review (MRR) for a resident who was self-administering 17 bottles of medications kept at her bedside, which were not prescribed by a physician. The resident, who had been admitted with diagnoses including a leg fracture and malignant neoplasm of the kidney and bone, was found to have fluctuating capacity to understand and make decisions. Despite this, the resident's Minimum Data Set indicated no cognitive impairment. The resident was consuming herbal medications and oils daily without any monitoring or documentation by the facility staff. During observations and interviews, it was revealed that the facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), were unaware of the resident's self-administration of these medications. The RN confirmed that the resident had multiple bottles of various herbal and oil-based medications, none of which had been reviewed or approved by the resident's physician. The facility's Pharmacist Consultant stated that without physician orders, she could not review the resident's bedside medications, which posed a risk for potential side effects. The Director of Nursing (DON) acknowledged that the facility should have verified the safety of the resident's self-administered medications with the pharmacist. The facility's Medication Regimen Review records for previous months did not address the resident's bedside medications, and the facility's policies required the inclusion of herbal or dietary supplements in medication histories. The failure to monitor and review the resident's self-administered medications led to a deficiency in ensuring the resident's safety and well-being.
Failure to Update Resident Representative Contact Information
Penalty
Summary
The facility failed to maintain complete and accurate documentation of medical records for a resident by not updating the contact phone number of the resident's representative in the Admission Record. The resident, who was admitted with diagnoses including palliative care, anemia, and end-stage renal disease, did not have the capacity to understand and make decisions. The Minimum Data Set indicated moderate cognitive impairment and that the resident was receiving hospice care. Despite the receptionist obtaining the new contact number on a later date, the Admission Record was not updated, leaving the facility without a means to contact the resident's representative. During an attempt to contact the resident's responsible party, the phone number listed was found to be out of service. Interviews with the Infection Preventionist and the Director of Nursing revealed that the contact information should have been updated to ensure the facility could reach the representative in case of an emergency. The facility's policy required nursing staff to review and update resident identification information as necessary, but this was not adhered to, potentially interrupting the provision of care and services for the resident.
Failure to Maintain Resident's Electric Wheelchair
Penalty
Summary
The facility failed to maintain the electric wheelchair of a resident, identified as Resident 40, in a safe and functional condition. The resident, who has been at the facility since 2018 and was readmitted in 2023, suffers from morbid obesity, anemia, and paraplegia, requiring the use of an electric wheelchair for mobility. Despite the resident's intact cognition and ability to make decisions, the electric wheelchair has been broken for two years, significantly impacting her ability to move around and engage in social and outdoor activities. The resident expressed frustration over the prolonged period without a functioning wheelchair, which has negatively affected her quality of life. The facility's care plan for Resident 40, dated September 2024, included interventions to check the wheelchair's functionality and monitor the resident's ability to perform daily activities. However, the care plan did not address the broken wheelchair or outline any goals or interventions for its repair. A repair assessment indicated that the wheelchair did not turn on and required new batteries and joystick hardware, but no repairs were completed. Interviews with the Social Services Assistant and the Director of Nursing revealed that the facility had been unable to fix the wheelchair, affecting the resident's quality of life and potentially impacting her mental and emotional state.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 33 out of 44 rooms, which included 31 rooms with a three-bed capacity and two rooms with a two-bed capacity. This deficiency was identified through observation, interviews, and record reviews. The rooms in question did not meet federal requirements, as they housed more than the allowed number of residents and measured less than the required space per bed. Despite the facility's request for a room waiver, the rooms were found to be non-compliant with the space requirements. During interviews, the Administrator acknowledged the issue and mentioned that there had been no complaints from residents, families, or staff regarding room sizes. Observations indicated that the rooms provided adequate space for residents to move freely and for the use of mobility aids such as wheelchairs, walkers, and canes. The facility's policy, dated May 2017, stated that bedrooms should accommodate no more than two residents and measure at least 80 square feet per resident in double rooms, which was not adhered to in the identified rooms.
Failure to Ensure Safe Discharge for Resident with COPD
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with fluctuating capacity to understand and make decisions, who required continuous oxygen due to COPD. The resident was discharged against medical advice without adequate preparation or orientation, resulting in a subsequent transfer to a hospital due to severe respiratory distress. The resident's oxygen saturation was critically low upon arrival at the hospital, and he had been without medications for three days, leading to an ICU admission. The resident had a history of leaving the facility daily without a physician's order for Out on Pass, despite the facility's knowledge of his condition and language barrier. The resident's care plan did not address his frequent departures or the lack of a physician's order, and there was no documented evidence of a discharge plan or interdisciplinary team meeting to address these issues. The facility's staff failed to use a translator to explain the AMA form to the resident, who did not fully understand English, leading to his unintentional discharge. The facility's policies and procedures for discharge planning and care plan development were not followed, as evidenced by the lack of a comprehensive, person-centered care plan and the absence of a documented discharge plan. The resident's frequent departures and the facility's failure to address these concerns contributed to the unsafe discharge, highlighting deficiencies in communication, care planning, and adherence to policies.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect three residents from non-consensual sexual contact by another resident diagnosed with Alzheimer's disease. This resident, identified as Resident 1, engaged in inappropriate sexual behaviors towards female residents, including grabbing arms and breasts, and swiping his palms across a resident's chest. These incidents were witnessed by staff and other residents, yet the facility did not implement adequate measures to prevent further occurrences. Resident 1 had a documented history of inappropriate sexual behavior, which was known to the facility staff. Despite this, the facility did not develop a comprehensive care plan to address these behaviors or implement effective monitoring and supervision. The care plans in place were insufficient, lacking specific interventions to manage Resident 1's behaviors and protect other residents. The facility's failure to act on the known risks posed by Resident 1's behavior resulted in repeated incidents of non-consensual contact. Interviews with staff and residents revealed that the facility's monitoring of Resident 1 was inconsistent and inadequate. Staff were aware of Resident 1's behaviors but did not have a clear protocol for supervision or documentation. The facility's inaction and lack of a structured response to Resident 1's behavior placed other residents at risk and failed to ensure their safety and well-being.
Failure to Safeguard Resident's Belongings
Penalty
Summary
The facility failed to protect a resident's personal belongings, resulting in the misappropriation of property. Upon admission, the resident's wallet, debit cards, cash, and watch were not documented on the Clothing and Possession Form. This lack of documentation persisted upon the resident's readmission, indicating a failure to accurately account for the resident's valuables. The resident, who had severe cognitive impairment, was unable to manage their belongings, further emphasizing the facility's responsibility to safeguard these items. The facility did not follow its policy and procedure for investigating incidents of theft or misappropriation. When the resident's family member reported the missing items after the resident's death, the facility did not conduct a thorough investigation or report the incident to the appropriate authorities. Interviews with staff revealed confusion and inconsistency regarding the responsibility for documenting and securing residents' valuables, with some staff members unsure of the procedures or the whereabouts of the missing items. The facility's failure to implement its policies resulted in the loss of the resident's valuables. The administrator acknowledged the oversight in securing the resident's belongings and the lack of proper documentation. The facility's policy required immediate investigation and reporting of such incidents, but these steps were not taken, leaving the resident's family without resolution and potentially placing other residents at risk for similar incidents.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property for a resident to the California Department of Public Health (CDPH) within the required timeframe. The incident involved a resident who was admitted with a diagnosis of malignant neoplasm of the lung and had severe cognitive impairment. After the resident passed away, a family member reported to the facility administrator that the resident's personal belongings, including a wallet, watch, debit card, and cash, were missing. Despite this report, the facility did not notify the CDPH, file a report with the police, or conduct an investigation to locate the missing items. The facility's policy and procedure on investigating incidents of theft and misappropriation of resident property, revised in August 2021, requires that such incidents be reported to appropriate authorities within 24 hours. Additionally, the policy on abuse investigation and reporting mandates immediate reporting of alleged violations involving abuse or serious bodily injury within two hours, and within 24 hours for other violations. The administrator acknowledged the failure to report the missing belongings and the lack of an investigation, which constitutes a deficiency in adhering to the facility's policies and regulatory requirements.
Failure to Provide Adequate Assistance and Fall Precautions
Penalty
Summary
The facility failed to provide adequate safety measures for a resident at high risk for injury, as outlined in their policy and procedure titled Falls and Fall Risk, Managing. The resident, who had severe cognitive impairment, hemiplegia, and was dependent on staff for activities of daily living (ADL), required assistance from two persons for care. However, during an incident, a Certified Nursing Assistant (CNA) attempted to assist the resident alone, resulting in the resident sliding off the bed and sustaining a left distal tibia-fibula fracture. The resident's care plan and assessments indicated a need for two-person assistance due to the resident's condition, which included contractures and inability to turn without help. Despite this, the CNA proceeded to assist the resident alone, prioritizing the resident's timely preparation for a dialysis appointment over the required assistance level. This action directly led to the resident's fall and subsequent injury. Additionally, the facility did not implement immediate fall precautions following the incident. The resident's bed was not consistently monitored for safety, and the necessary precautions were not documented until several days after the fall. This lack of timely intervention and adherence to the care plan increased the risk of further incidents and compromised the resident's safety.
Inadequate Incontinent Care and ADL Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate incontinent care and assistance with activities of daily living (ADL) for five out of six sampled residents, leading to significant distress and potential health risks. Residents reported waiting for extended periods, sometimes over two hours, to receive necessary care, such as being changed after incontinent episodes. This delay in care resulted in residents feeling frustrated, embarrassed, and neglected, with some expressing feelings of worthlessness and helplessness. The deficiency was exacerbated by staffing shortages, particularly during the afternoon and night shifts. Interviews with staff and residents revealed that the facility was consistently understaffed, with certified nursing assistants (CNAs) responsible for caring for an excessive number of residents. This shortage was attributed to CNAs calling off sick, resigning, or switching to part-time, and the facility's decision not to use registry staff to fill gaps. As a result, residents' care was compromised, leading to delays in providing essential services and increasing the risk of skin breakdown and falls. Specific incidents highlighted in the report include a resident waiting 3.5 hours to be changed after an incontinent episode, another resident's family member observing a two-hour delay in care, and multiple residents expressing distress over the lack of timely assistance. Staff interviews confirmed that the facility's staffing issues were ongoing, with CNAs and licensed nurses being sent home early, further impacting the quality of care provided to residents.
Inadequate Staffing Leads to Delayed Care and Increased Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed care and increased falls. Observations and interviews revealed that residents experienced significant delays in receiving assistance with activities of daily living (ADLs), such as incontinence care, due to inadequate staffing levels. For instance, one resident reported waiting 3.5 hours to be changed after an incontinent episode, leading to feelings of worthlessness and frustration. Another resident's family member confirmed that it took two hours for a CNA to assist with incontinence care, highlighting the persistent staffing issues during the afternoon and night shifts. The deficiency was further evidenced by the facility's fall records, which showed a total of 11 falls in July 2024, with three resulting in injuries. Interviews with staff, including CNAs and LVNs, corroborated the shortage of staff, particularly during the 3 PM to 11 PM and 11 PM to 7 AM shifts. Staff members reported that the lack of adequate staffing led to delays in responding to call lights and providing necessary care, increasing the risk of skin breakdown and resident dissatisfaction. The Director of Nursing and the Administrator acknowledged the staffing challenges, citing reasons such as CNAs calling off sick, resigning, or switching to part-time. Despite the facility's policy requiring sufficient and competent nursing staff to ensure resident safety and well-being, the staffing shortages compromised the quality of care provided. The facility's failure to maintain adequate staffing levels directly contributed to the increased number of falls and delayed care, as observed in the report.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for a resident, resulting in repeated falls. The resident, who was admitted with diagnoses including dementia and a high risk for falls, sustained two falls between March and July 2024. On July 10, 2024, the resident fell in the shower room, resulting in a head wound that required emergency medical attention and staples. The incident occurred when a CNA turned her back on the resident to retrieve a towel, leaving the resident unattended in a slippery shower room. Interviews with staff revealed that the resident was known to be unsteady and required constant supervision, especially during activities like showering. The facility's policy emphasized the need for supervision and not leaving high-risk residents unattended, which was not followed in this case. Additionally, the shower room floor was reported to be slippery, a hazard that had been previously communicated to the maintenance supervisor but not addressed. The facility's policies on hazardous areas and resident safety were not effectively implemented, contributing to the unsafe conditions that led to the resident's fall and injury.
Failure to Involve Resident's Representative in Admission Process
Penalty
Summary
The facility failed to ensure that the resident's representative was informed and involved in the admission process of a resident who lacked the capacity to understand and make decisions. The resident, diagnosed with unspecified dementia and moderate cognitive impairment, required assistance with daily tasks. Despite this, the facility had the resident sign important admission documents, including the MDS Transmission Notification, Consent to Treat, and Advanced Healthcare Directive Acknowledgement form, without the involvement of the resident's representative. The Social Service Assistant admitted that the admission paperwork was left blank because they had not been able to speak with the resident's representative. However, the Licensed Vocational Nurse (LVN) later had the resident sign the documents without reviewing the resident's cognitive status or consulting the representative. The LVN assumed the resident had the capacity to make medical decisions based on a previous admission and did not verify the current cognitive status before proceeding. The Director of Nursing confirmed that the facility's practice is to involve the resident's representative in decision-making when a resident is deemed unable to make or understand medical decisions. The facility's policy states that the decisions of the resident representative are treated as the decisions of the resident. The failure to adhere to this policy resulted in the resident signing documents without the necessary understanding or consent from the representative.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to implement its Abuse Prevention Program and Abuse Investigation and Reporting policies, resulting in a deficiency related to the protection of a resident during an abuse investigation. A resident, who was admitted with Parkinson's Disease and had intact cognition, reported an alleged abuse incident involving a CNA. The resident described the alleged abuser as a dark-skinned man wearing a baseball cap, who reportedly assaulted him during the night shift. Despite being informed of the allegation by the resident's family member, the LVN did not take immediate action to prevent the alleged abuser, CNA 1, from having further contact with the resident. Approximately 30 minutes after the allegation was reported, CNA 1, who matched the description provided by the resident, entered the resident's room to provide care. The LVN only intervened after being informed again by the family member that CNA 1 was the alleged abuser. The facility's policies required immediate separation of the resident from the alleged abuser and an initial investigation by the nursing staff. However, the LVN did not conduct an investigation or prevent further contact, as he believed it was the administrator's responsibility. The administrator later confirmed that the nursing staff should have conducted initial interviews and investigations to prevent reoccurrence, highlighting a failure in communication and adherence to the facility's abuse prevention policies.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident's responsible party, as required by their policy. The resident, who was admitted with conditions including hypertensive chronic kidney disease and moderate cognitive impairment, had a designated responsible party who requested access to the resident's medical records. The request was made verbally on April 11, 2024, and followed up with an email on April 16, 2024. Despite these requests, the facility did not provide the records within the 48-hour timeframe stipulated by their policy. Interviews with facility staff revealed that the responsible party's request was communicated to the Medical Records Director and other relevant staff members. However, there was a lack of follow-up and communication from the facility to the responsible party. The responsible party expressed frustration over the delay and lack of response, even after visiting the facility in person on April 23, 2024, to inquire about the records. The responsible party eventually received a form to fill out on April 29, 2024, but still did not receive the complete records requested. The facility's policy, dated November 2009, requires that residents or their representatives have access to records within 48 hours of a request, excluding weekends and holidays. The State Operations Manual also mandates that facilities provide access to personal and medical records within 24 hours of a request. The facility's failure to adhere to these guidelines resulted in a delay in providing the requested records, constituting a deficiency in their compliance with regulatory requirements.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes, and interventions for a resident with a right heel skin concern. The deficiency was identified when a Deep Tissue Injury (DTI) was found on the resident's right heel by a treatment nurse, but no care plan was developed to address this issue. Despite the presence of a DTI, there was no documented evidence of a care plan being created to manage the resident's right heel condition. Additionally, the facility did not timely develop care plan interventions for the resident's peripheral vascular disease (PVD), which was identified by a wound physician. The care plan for PVD was only developed 40 days after the condition was classified, indicating a significant delay in addressing the resident's needs. This delay in care planning could have impacted the resident's wound healing process and overall care. Furthermore, the facility failed to implement care plan interventions for the resident's identified concerns that affected wound healing, such as offloading and non-weight bearing of the right heel, use of a heel protector, and addressing the resident's poor compliance with offloading. Despite recommendations from wound specialists, these interventions were not documented in the care plan, potentially compromising the resident's treatment and recovery.
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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