Golden Haven Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 409 W. Glenoaks Blvd., Glendale, California 91202
- CMS Provider Number
- 056317
- Inspections on file
- 38
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Golden Haven Care Center during CMS and state inspections, most recent first.
A resident who required maximal assistance for transfers due to cognitive and physical impairments was transferred by a responsible party using a Hoyer lift without staff assistance. Although staff identified and discussed this safety concern with the family, the care plan was not updated to address the unauthorized use of the lift or its storage in the resident's room, contrary to facility policy requiring individualized care planning.
A resident with moderate cognitive impairment, communication challenges, and a history of impaired vision and fall risk was found without a functioning call light, which was observed on the floor and not within reach. Staff confirmed the call light was non-functional and had not been reported as defective, despite facility policy requiring immediate action and alternative safety measures when the primary call system fails.
A resident receiving Quetiapine for paranoid delusions was not properly monitored for the effectiveness of the medication or adverse reactions, as required by the facility's policy. Despite a care plan indicating the need for monitoring, there was no documented evidence of such actions, placing the resident at risk of unnecessary medication use and potential side effects.
A resident with COPD exacerbation and a history of pneumonia experienced severe respiratory distress with oxygen saturation dropping to 72%. The facility failed to monitor and adjust oxygen therapy as per physician orders, and the LVN did not document or report the resident's condition to the physician. Emergency services were not notified immediately, and the resident's refusal to go to the hospital was not communicated to the physician. These deficiencies resulted in the resident's death after unsuccessful CPR.
The facility failed to update the medical records of three residents to reflect their wishes regarding advance directives and POLST. A resident's records did not show evidence that the option of an advance directive was informed or offered, and another resident's POLST form lacked a physician's signature. Additionally, a third resident's POLST form was missing a physician's signature, and the advance directive was incomplete. Staff acknowledged these deficiencies, and the facility's policies and procedures for ensuring complete documentation were not followed.
A resident with COPD and a history of pneumonia experienced severe respiratory distress with an oxygen saturation of 72%. Despite the resident's refusal to be transferred to the hospital, the facility failed to notify the physician or call 911, as required by their policies. The resident was later found unresponsive and pronounced dead after unsuccessful CPR efforts.
Two residents with indwelling catheters were not provided appropriate care, as sediments in their urine were not documented or reported to a physician. Despite care plans requiring monitoring for UTI symptoms, the facility failed to assess and flush the catheters as needed. Observations confirmed sediments in the tubing, but these were not documented, and the physician was not notified, leading to a deficiency in care.
The facility did not post nurse staffing information in a highly visible and prominent place accessible to residents, staff, and visitors. Observations revealed the absence of staffing information in the front lobby and nursing stations. The Director of Staff Development and the Director of Nursing confirmed the information was not posted in visible areas, contrary to the facility's policies.
The facility failed to properly store and manage medications, resulting in expired Tylenol suppositories, Ondansetron HCL tablets, and N95 masks being found in storage areas. An opened Lidocaine cream lacked an open date label. Staff interviews revealed lapses in routine checks and adherence to facility policy, contributing to these deficiencies.
A resident with COPD and other conditions experienced respiratory distress and died after the facility failed to monitor, document, and respond to their condition. The facility did not follow physician orders or notify emergency services, and the incident was not investigated as part of the QAPI program.
A resident experienced a 20-minute delay in receiving his meal tray compared to others at the same table, violating facility policy that requires simultaneous service. Staff interviews revealed a lack of awareness about the delay, and the Registered Dietitian confirmed that such delays are unacceptable. The facility's policies emphasize the importance of serving meals at the same time to promote dignity.
The facility failed to ensure that call lights were within reach for two residents, both with severe cognitive impairments and dependent on staff for daily activities. One resident's call light was frequently out of reach due to movement, while another was unable to access the call light due to being seated in a Geriatric chair with a lap table. Staff interviews confirmed the oversight, and the facility's policy requires call cords to be within reach.
A resident with Alzheimer's and diabetes was placed in a Geri chair with a lap table that they could not remove, effectively restraining them without a physician's order or consent. Staff admitted it was for convenience, despite the resident's ability to walk with assistance. The facility's policy against restraints for convenience was not followed.
A facility failed to complete a required PASARR Level II evaluation for a resident with mental health diagnoses, including depression, anxiety, and psychosis. Despite receiving medications for these conditions, the necessary evaluation was not documented, as confirmed by staff interviews. The facility's policy mandates a Level II evaluation following a positive Level I screen, which was not adhered to, risking the resident's care.
The facility failed to create comprehensive care plans for two residents, one with thrombocythemia on antiplatelet therapy and another exhibiting challenging behaviors. The absence of care plans led to potential health risks due to inconsistent monitoring and interventions, as confirmed by interviews with the DON and LVN.
A resident with multiple medical conditions, including diabetes and amputations, did not receive required dermatology and podiatry consultations for nail care, leading to severe infection and pain. Facility staff failed to document or address the resident's nail condition, violating care protocols.
A resident with Alzheimer's and epilepsy, admitted with intact skin, developed a Stage 3 pressure injury due to inadequate preventive care. Despite being high-risk and fully dependent on staff for repositioning and incontinence care, the resident's pressure injury healed but later reopened. The facility failed to adhere to its pressure ulcer prevention policy, leading to the development and recurrence of the injury.
A resident with a G-tube and a history of dementia and anxiety repeatedly pulled out her G-tube, leading to multiple hospitalizations. The facility's care plans were not adequately revised to address the behavior, and interventions such as mitten restraints and an abdominal binder were ineffective. Staff interviews revealed inconsistent supervision and monitoring, and the facility failed to conduct IDT meetings to explore alternative interventions.
A resident with COPD and pneumonia experienced respiratory distress, with oxygen levels dropping to 72%. Despite administering a breathing treatment, an LVN failed to notify the physician or escalate the situation, leading to the resident's death. The facility's policies and procedures for emergency response were not followed, as confirmed by interviews with the DON and the resident's primary physician.
A resident with epilepsy and intellectual disabilities exhibited agitation and yelling, leading to an incident where a CNA attempted to redirect the resident physically, increasing agitation. The CNA did not seek assistance, and the intervention violated the resident's rights. Staff interviews highlighted the need for verbal de-escalation techniques and respecting the resident's wishes, as per facility policy.
A facility failed to document the justification for the continued use of Ativan PRN beyond the 14-day limit for a resident with severe cognitive impairment and epilepsy. The resident was prescribed Ativan for seizures and anxiety, but the facility did not adhere to its policy requiring PRN orders for psychotropic drugs to be limited to 14 days unless extended by documented physician rationale.
Two residents in an LTC facility did not receive their prescribed medications, resulting in a 7.14% medication error rate. One resident with vitamin D deficiency did not receive their Vitamin D3 via G-tube due to an LVN mistakenly marking it as administered. Another resident with metabolic encephalopathy did not receive their multivitamin because it was not listed in the computer system. The facility's policy requires medications to be administered per physician's orders.
A resident with cognitive impairment and early dementia did not receive drinks consistent with their preferences, despite clear instructions on their tray card. The resident repeatedly informed staff of their dietary restrictions, yet milk was still provided. The Certified Dietary Manager acknowledged the error, and the Registered Dietitian emphasized the importance of honoring residents' preferences.
A resident with Diabetes Mellitus Type 2 was admitted to an LTC facility without proper orders for blood sugar monitoring and insulin administration. The facility staff failed to review hospital discharge records and verify diabetes care orders with the attending physician. This oversight led to the resident's severe health deterioration, resulting in an emergency hospital transfer and subsequent death due to Diabetic Ketoacidosis.
A resident with Diabetes Mellitus was admitted to a facility without proper review of their medical history and necessary diabetes management, including insulin and blood sugar monitoring. The facility failed to implement its admission assessment policy, leading to a lack of necessary diabetes care. The resident experienced a severe change in condition and died from diabetic ketoacidosis.
A resident with diabetes was not properly monitored or administered insulin during their stay at the facility, despite having a care plan that required such actions. The resident's condition deteriorated, leading to an emergency hospital transfer and subsequent death from diabetic ketoacidosis. The facility failed to adhere to its policies requiring physician oversight and monitoring of blood sugar levels.
A resident with Diabetes Mellitus Type 2 was admitted to a facility with a plan to continue insulin medication, but the insulin was discontinued without justification, and blood sugar levels were not monitored. The pharmacy consultant failed to review the resident's medication regimen thoroughly, leading to a lack of necessary diabetes management. This oversight resulted in the resident developing Diabetic Ketoacidosis and subsequently passing away after being transferred to a hospital.
The facility failed to report a COVID-19 outbreak involving five residents to the CDPH within the required 24-hour period, only notifying the local health department. This oversight prevented timely investigation and intervention. The affected residents had various medical conditions and decision-making capacities. Interviews revealed a lack of understanding of reporting procedures by the Infection Preventionist and miscommunication with the Director of Nursing.
A resident with a history of seizures and cognitive impairments experienced multiple falls due to the facility's failure to implement seizure precautions and update care plans. Despite being at high risk for falls, necessary safety measures like side rails and floor mats were not consistently used, leading to a severe fall with head injury and seizure activity.
A resident with a history of seizures, dementia, and Parkinson's disease was admitted to an LTC facility without a comprehensive care plan addressing these conditions. Despite known risks, the facility did not implement interventions to prevent injury during seizures or address the resident's cognitive impairments and noncompliance. This oversight led to the resident falling during a seizure, resulting in a major head injury. Interviews with staff and record reviews confirmed the absence of a care plan, violating the facility's care planning policy.
The facility failed to ensure that licensed nursing staff did not administer expired insulin to six residents. Insulin for multiple residents was found to be expired during an inspection of medication carts, and it was confirmed that the expired insulin had been administered on several occasions. Additionally, Resident 14's Basaglar insulin was not administered according to the manufacturer's specifications, leading to multiple doses being given after the insulin had expired. The facility's policy is to discard insulin 28 days after it is opened, but this was not followed, increasing the risk of side effects for the residents.
The facility failed to ensure expired and discontinued medications were discarded and disposed of properly. Expired insulin was not removed for 10 residents, medications for a discharged resident were not removed from active supply, and a discontinued medication was not disposed of with a witness or documented. These failures increased the risk of ineffective treatment and medication errors.
The facility failed to post accurate daily nurse staffing information, as required by its policy. Observations and interviews revealed that the staffing information was outdated, which could lead to misinformation and a sense of insecurity among residents and visitors.
Failure to Update Care Plan After Safety Concern with Mechanical Lift Use
Penalty
Summary
The facility failed to develop a resident-centered care plan after identifying a safety concern involving a resident who required substantial to maximal assistance for transfers and activities of daily living due to muscle wasting, abnormal posture, and moderately impaired cognitive skills. The resident's responsible party was observed using a Hoyer lift to transfer the resident from bed to chair without staff assistance, despite the resident's lack of capacity to understand and make decisions. The care plan in place addressed general fall risk and included interventions such as frequent safety reminders and education for the resident, family, and caregivers, but did not specifically address the issue of unauthorized use of the Hoyer lift by the responsible party or the storage of the lift in the resident's room. Interdisciplinary team meeting notes documented that staff had discussed the safety concern with the resident's family after observing the unauthorized transfer. However, the care plan was not updated to reflect this specific risk or to provide clear instructions regarding the use and storage of the Hoyer lift. The Director of Nursing confirmed that a care plan for non-compliance or lack of knowledge was not initiated, and the facility's policy required comprehensive, individualized care planning based on assessed needs and changes in condition or behavior.
Failure to Provide Functioning Call Light for Resident with Communication and Fall Risk
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, communication difficulties, and a history of impaired vision and fall risk was not provided with a functioning call light. The resident's care plans specifically required that a call light be within reach to ensure safety and facilitate communication with staff. During observation, the call light was found on the floor and not within the resident's reach. Both a CNA and an RN confirmed that the call light was non-functional, with the button stuck and unable to be pressed, and no light or sound was produced when tested. The resident reported that the call light did not work, and staff interviews confirmed the importance of a working call system for residents to request assistance. The maintenance supervisor stated that weekly inspections were conducted and that no issues had been reported for this resident's call light during the last check. However, there was no documentation or notification of the malfunction prior to the surveyor's observation. Facility policy required immediate reporting and replacement of defective call lights, as well as alternative systems and hourly safety checks if the primary system was inoperable, but these measures were not documented as being implemented for this resident.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring of a resident who was receiving Quetiapine for paranoid delusions associated with schizophrenia. The resident, who had moderately impaired cognition and lacked the capacity to make decisions, was admitted with diagnoses including schizophrenia, mood disorders, and dementia. Despite a physician's order for Quetiapine to address paranoid delusions, the facility did not document monitoring of these specific behaviors in the Medication Administration Report or nursing progress notes for January and February 2025. The care plan for the resident indicated that behavior should be monitored for effectiveness every shift, and adverse reactions to Quetiapine should be observed. However, interviews with an LVN and the DON revealed that there was no documented evidence of such monitoring. The facility's policy required daily monitoring of psychotropic drug use and target behaviors, but this was not adhered to, leading to a risk of unnecessary medication use and potential side effects for the resident.
Failure to Provide Adequate Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide necessary respiratory care and implement interventions for a resident diagnosed with chronic obstructive pulmonary disease (COPD) exacerbation and a history of pneumonia. The resident experienced severe respiratory distress, with oxygen saturation dropping to 72% while receiving oxygen via nasal cannula at 2 liters per minute. Despite the resident's condition, the facility did not monitor and evaluate the effectiveness of the oxygen provided, nor did they follow physician orders to adjust the oxygen therapy to maintain oxygen blood levels at 92%. The Licensed Vocational Nurse (LVN) on duty did not document the resident's respiratory distress or report the change in condition to the physician, as required by the facility's policy and procedure. The LVN also failed to notify emergency services immediately when the resident exhibited signs of respiratory distress and refused to go to the hospital. The resident's refusal to be transferred to the hospital was not communicated to the physician, and no alternative interventions were discussed or documented. As a result of these deficiencies, the resident did not receive immediate respiratory care and interventions, leading to their death after unsuccessful CPR was administered. The California Department of Public Health identified an Immediate Jeopardy situation due to the facility's failure to notify the physician and provide necessary respiratory care and monitoring for the resident.
Removal Plan
- The Director of Nursing (DON) conducted a full house audit to identify all residents with a diagnosis of COPD, those on continuous and PRN oxygen. The audit identified 10 residents with COPD and 18 residents receiving oxygen therapy. The DON reviewed the care plans and physician's orders for these residents to ensure appropriate interventions such as following MD orders, oxygen therapy orders, repositioning of patients, checking oxygen saturation, assessment of signs and symptoms of hypoxia respiratory failure for effectiveness of the intervention and monitoring for signs and symptoms of respiratory distress, verifying respiratory status using objective data such as oxygen saturation were in place. The DON will also review the communication to the Primary Care MD, if no response, the medical director and or emergency services will be called immediately. No additional residents were found to be at immediate risk.
- A one to one in-service regarding MD notification, Medical Director notification, and emergency services was provided to the Night Shift Licensed Nurse assigned to Resident 77 by the facility's DON. The Licensed Nurse was also suspended pending the facility's investigation.
- The Pharmacy Consultant initiated Medication Regimen Reviews for all residents receiving Oxygen Therapy and with COPD/SOB.
- The facility conducted a root cause analysis (RCA) which included interviews with involved staff. The RCA revealed the following contributing factors: Lack of staff education on monitoring and reporting changes in respiratory status, and inadequate communication between nursing staff and physicians regarding significant changes in condition.
- The Certified Nursing Assistant (CNA) assigned to Resident 77 during the night shift was provided a one-to-one in-service regarding Emergency Care Policy and Procedure.
- The Director of Nursing/ Staff Development Coordinator (DSD) started to provide in-services to all Licensed Nursing staff for all shifts including CNAs, LVNS, RNs on Emergency Medical Response: A. Monitoring and reporting changes in respiratory status B. Following physician orders for oxygen titration and maintaining target oxygen saturation levels, and C. Facility policy and procedure for responding to respiratory distress, including immediate notification of the primary physician, emergency services, and medical director.
- The DON reviewed the facility's policy and procedure for responding to respiratory distress to ensure clarity and consistency with current standards of practice.
- The DON created a monitoring tool related to COPD and Oxygen Therapy to ensure clarity and consistency with current standards of practice.
Deficiencies in Advance Directive and POLST Documentation
Penalty
Summary
The facility failed to ensure that the medical records of three residents were updated to reflect their wishes regarding advance directives and Physician Orders for Life-Sustaining Treatment (POLST). Resident 19's records did not show evidence that the option of an advance directive was informed or offered to the resident or their responsible party (RP). Additionally, Resident 20's POLST form lacked a physician's signature, and there was no documentation indicating that the advance directive option was explained to the resident or their RP. Resident 1's POLST form was also missing a physician's signature, and the advance directive was not filled out completely. The facility's staff, including a registered nurse (RN), the Social Services Director (SSD), and the Medical Records Director (MRD), acknowledged these deficiencies during interviews. The RN stated that the POLST should be signed by a physician within 72 hours of admission, and the SSD admitted to forgetting to check the completeness of the POLST and advance directive forms. The facility's policies and procedures require that a completed and signed POLST form be a legal physician order and that the advance directive be explained to the resident or their RP. However, these procedures were not followed, leading to incomplete documentation and a lack of clarity regarding the residents' wishes for life-sustaining treatment and resuscitation.
Failure to Notify Physician and Emergency Services for Resident in Respiratory Distress
Penalty
Summary
The facility failed to adhere to its Policies and Procedures regarding Change of Condition Notification for a resident with chronic obstructive pulmonary disease exacerbation and a history of pneumonia. The resident exhibited signs of respiratory distress, including labored breathing and an oxygen saturation level of 72%, which is significantly below the normal range. Despite these critical symptoms, the facility did not notify the physician or emergency services immediately, as required by their protocols. The resident, who was alert and capable of making decisions, refused to be transferred to the hospital despite experiencing severe respiratory distress. The Licensed Vocational Nurse (LVN) on duty administered a breathing treatment, which temporarily improved the resident's condition, but did not reach out to the physician or call 911. The LVN believed the resident's condition had improved sufficiently and was also occupied with other residents, which contributed to the lack of immediate action. The facility's failure to notify the physician or emergency services resulted in the resident not receiving timely medical intervention. The resident was later found unresponsive, and despite CPR efforts, was pronounced dead by paramedics. The facility's policies clearly outlined the steps to be taken in such emergencies, including notifying the physician and calling 911, but these were not followed, leading to the resident's death.
Failure to Monitor and Document Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling catheters, leading to a deficiency in care. Resident 65, who was admitted with metabolic encephalopathy and acute kidney failure, had severely impaired cognition and was dependent on assistance for all activities of daily living. The resident's care plan required monitoring for signs of urinary tract infections (UTIs), including sediments in the urine. However, the Treatment Administration Record (TAR) for December 2024 did not document the presence of sediments, and the catheter was not flushed as needed, despite observations of sediments in the tubing. Similarly, Resident 36, admitted with encephalopathy and an overactive bladder, also had severely impaired cognition and required dependent assistance for all activities. The resident's care plan included monitoring for UTI symptoms, but the TAR for December 2024 failed to document sediments in the urine, and the catheter was not flushed as required. Observations confirmed the presence of sediments in the catheter tubing, which were not reported or documented, and the physician was not notified of these findings. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed a lack of awareness and documentation regarding the sediments in the residents' catheters. The facility's policies and procedures required notification of the physician for any abnormal findings, such as sediments, but this was not followed. The failure to assess, document, and report the sediments in the urine could lead to complications, including UTIs, which were not addressed in a timely manner.
Failure to Post Nurse Staffing Information in Visible Location
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a highly visible and prominent place that was readily accessible to residents, staff, and visitors daily. During observations on December 3, 2024, at 8:30 AM in the front lobby and at 9:00 AM in Nursing Stations 1, 2, and 3, there was no nurse staffing information posted. This was confirmed during a concurrent observation and interview on December 6, 2024, at 6:50 PM with the Director of Staff Development (DSD), who acknowledged that the staffing information was posted next to the facility's shadow box frame by the main entrance, which was not easily visible to residents and visitors. The Director of Nursing (DON) also confirmed during an interview on December 6, 2024, at 7:30 PM that the nurse staffing information was not posted in a highly visible area such as the nursing station or by the front lobby. The facility's policies and procedures, revised on October 24, 2022, indicated that nurse staffing data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. The failure to comply with this policy had the potential to prevent residents and visitors from accessing the facility's staffing information to ensure safe and sufficient staffing levels.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and manage medications and biologicals, leading to the presence of expired and unlabeled items in the medication storage areas. During an observation, thirteen expired Tylenol suppositories were found on a shelf in the Medication Storage Room in Station 1, with expiration dates ranging from June to December 2024. Additionally, a container of Ondansetron HCL oral tablets, prescribed to a resident for nausea and vomiting, was found expired on Medication Cart 2. Furthermore, nine expired N95 face masks and an opened Lidocaine cream without an open date label were also found on the same cart. Interviews with staff revealed that the licensed nurses were responsible for removing expired medications but did so only when they had time. The Director of Nursing stated that licensed nurses should routinely check expiration dates every shift and that a system was in place for weekly audits, which failed to identify the expired items. The facility's policy required medications to be stored safely and securely, with opened medications labeled with an open date, but these procedures were not followed, leading to the deficiencies observed.
Failure to Investigate Respiratory Distress Leading to Resident's Death
Penalty
Summary
The facility failed to develop a system to systematically identify adverse events, monitor, investigate, analyze root causes, and evaluate its Quality Assurance and Performance Improvement Program (QAPI) related to respiratory care for one of the sampled residents. This deficiency was highlighted by the case of a resident who experienced a change in condition leading to death, which was not investigated to determine if it was due to the facility's failure to notify the physician and emergency services, follow oxygen orders, monitor, and document the resident's condition, and respond appropriately to severe respiratory distress. The resident, who had been admitted with diagnoses including COPD with exacerbation, pneumonia, and hypertensive heart disease, experienced shortness of breath, labored breathing, and an oxygen saturation of 72% while on oxygen via nasal cannula at 2 LPM. The facility did not follow physician orders to adjust the resident's oxygen levels, failed to monitor and document the resident's respiratory distress, and did not notify the physician or emergency services when the resident exhibited signs of respiratory distress. The facility's QAPI program did not include adverse events, and the cause of death was not investigated to determine if quality deficiencies existed.
Resident Meal Service Delay
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 48, received his meal tray at the same time as other residents seated at the same table. During an observation in the dining room, it was noted that Resident 48 had to wait an additional 20 minutes for his meal tray while others were already eating. This delay was confirmed by Resident 48, who expressed feelings of being hurt due to consistently being the last to receive his meal. The facility's policy requires that all residents at the same table be served simultaneously, which was not adhered to in this instance. Interviews with staff, including the Activity Director and Dietary Supervisor, revealed a lack of awareness and understanding of why Resident 48's meal was delayed. The Registered Dietitian also confirmed that it was unacceptable for residents to wait longer than 2-5 minutes for their meals. The facility's meal service policy, dated 2023, and the privacy and dignity policy, dated 2017, both emphasize the importance of serving meals simultaneously to promote independence and dignity. Despite these policies, the facility's meal delivery process, which involves delivering trays based on room numbers, contributed to the delay experienced by Resident 48.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a critical component for residents to alert staff when they need assistance. Resident 45, who was admitted with severe cognitive impairment and was dependent on assistance for daily activities, had a care plan that required the call light to be within reach to prevent falls. However, during an observation, the call light was found hanging on the bedside, out of reach. Interviews with staff, including an LVN and a CNA, revealed that the call light frequently fell due to the resident's movements, and it was the responsibility of the nursing staff to ensure it was accessible. The Director of Nursing emphasized the importance of the call light being within reach to prevent potential harm. Similarly, Resident 46, who had Alzheimer's disease and severe cognitive impairment, was observed seated in a Geriatric chair with a lap table, making it impossible for the resident to reach the call light. The care plan for this resident also required the call light to be within reach to prevent falls or injuries. Interviews with a CNA and an LVN highlighted that the resident was unable to use the call light due to the restrictive setup, and the call light should be placed within reach to allow the resident to call for assistance. The facility's policy on the call system mandates that call cords be within the resident's reach, which was not adhered to in these cases.
Resident Restrained Without Proper Authorization
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed in the case of a resident who was placed in a Geri chair with a lap table that the resident could not easily remove. The resident, who was admitted with diagnoses including Alzheimer's disease and diabetes mellitus, was observed from 11 AM to 2:35 PM in the Geri chair with the lap table attached. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for assistance with daily activities, but did not document the use of restraints. There was no physician's order for the use of the Geri chair with a lap table, and the resident was unable to remove the lap table independently, effectively making it a restraint. Interviews with staff revealed that the resident was typically seated in the Geri chair with the lap table from 11 AM to 2 PM, which restricted the resident's movement and limited their freedom to move and ambulate. The CNA stated that it was easier to care for the resident in this manner, despite the resident's ability to walk with assistance. The Director of Nursing confirmed the lack of a physician's order, consent, or documentation for the use of the Geri chair with a lap table, and acknowledged that the inability of the resident to remove the lap table constituted a restraint. The facility's policy indicated that restraints should only be used for medical symptoms and not for convenience, yet this policy was not followed in this instance.
Incomplete PASARR Evaluation for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the completion of a Preadmission Screening and Annual Resident Review (PASARR) for a resident with mental health diagnoses, including depression, anxiety, and psychosis. The resident was admitted with these conditions and was receiving antipsychotic, antidepressant, and antianxiety medications. Despite a Department of Health Care Services letter indicating the need for a Level II mental health evaluation, there was no record of this evaluation in the resident's chart or electronic health record. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASARR process. The Director of Nursing stated that the California State DHCS manages the scheduling and execution of PASARR evaluations, while the Admission Coordinator acknowledged the facility's responsibility to ensure the completion of the PASARR assessment. The facility's policy requires that a positive Level I screen necessitates a Level II evaluation before admission, but this was not completed for the resident, placing them at risk of not receiving necessary care and services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential health risks. Resident 54, who had a history of thrombocythemia and was receiving antiplatelet therapy, did not have a care plan to monitor for signs and symptoms of bleeding. Despite the presence of orders to monitor for bleeding every shift, the care plan was not created, which could result in inconsistent monitoring and care. Interviews with the LVN and DON confirmed the absence of a care plan and highlighted the importance of having one to ensure consistent and person-centered care. Resident 16, who exhibited behaviors such as agitation, screaming, and attempting to hit staff, also lacked a care plan to address these behaviors. The resident had been admitted with diagnoses including epilepsy and intellectual disabilities, and a psychiatric consult had been ordered due to the challenging behaviors. However, no care plan was developed to manage these behaviors, which could lead to inconsistent responses from staff and increased risk of harm. Interviews with the DON and LVN emphasized the necessity of care plans for managing challenging behaviors and ensuring effective interventions. The facility's policies and procedures on care planning, revised in 2022, indicated that care plans should include measurable objectives and timetables to address residents' medical, nursing, mental, and psychosocial needs. The lack of care plans for both residents indicates a failure to adhere to these policies, potentially compromising the residents' well-being and the consistency of care provided by the staff.
Failure to Provide Nail Care Leads to Infection
Penalty
Summary
The facility failed to provide appropriate care and services for a resident, identified as Resident 54, who was admitted with several medical conditions including orthopedic aftercare following surgical amputation, Type 2 Diabetes Mellitus with diabetic neuropathy, bilateral glaucoma, and acquired absence of both legs above the knee. The resident's care plan included orders for dermatology and podiatry consultations every two months and as needed for mycotic and hypertrophic nails. However, there was no documented evidence that these consultations were conducted, and the resident's nails were not properly managed, leading to severe infection and pain. Observations and interviews revealed that Resident 54's fingernails were thickened, dry, brittle, and broken, with some nails falling off and causing pain. Despite the resident's condition, there was no record of nail care or treatments in the resident's medical records. Interviews with staff, including CNAs and LVNs, indicated a lack of awareness and action regarding the resident's nail condition. The staff failed to notify the physician or document any change of condition, and there were no nursing progress notes or care plans addressing the issue. The facility's policies and procedures required high-risk residents with nail issues to be referred to a podiatrist, and any significant change in a resident's condition should be reported to the physician. However, these protocols were not followed for Resident 54, resulting in untreated fungal infections and overgrown nails. The lack of timely intervention and communication with healthcare providers contributed to the resident's deteriorating condition, which could have led to hospitalization.
Failure to Prevent and Manage Pressure Injury in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development and recurrence of a Stage 3 pressure injury in a resident who was admitted with intact skin. The resident, who had Alzheimer's disease and epilepsy, was identified as high risk for pressure injuries due to being bedbound and having very limited mobility. Despite this, the resident developed a deep tissue pressure injury on the sacrum, which progressed to a Stage 3 pressure injury. The facility's records indicated that the pressure injury healed but later reopened, suggesting inadequate preventive measures were in place. The resident was fully dependent on staff for repositioning and incontinence care, as they were unable to communicate when wet or soiled. The Treatment Nurse noted that there were instances when the resident was found with soiled incontinent briefs that had not been changed overnight, which could have contributed to the delay in healing and reopening of the pressure injury. The facility's policy on pressure ulcer prevention required identifying residents at risk and providing appropriate care, but this was not effectively implemented for this resident. The facility's failure to adhere to its own policy and provide necessary care, such as regular repositioning and timely incontinence care, led to the development and recurrence of the pressure injury. The Treatment Nurse acknowledged that the wound was avoidable with proper care and that the resident's condition required diligent staff intervention to prevent such occurrences.
Inadequate Management of G-tube in Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure that a resident with a Gastrostomy Tube (G-tube) received appropriate treatment and services to prevent complications such as peritonitis and perforation. The resident, who had a history of muscle wasting, dementia, and major depressive disorder with severe psychotic symptoms, repeatedly pulled out her G-tube due to confusion and anxiety. This resulted in seven hospitalizations for G-tube dislodgement, with the potential for trauma and infection at the G-tube stoma, as well as dehydration and malnutrition. The facility's documentation and care plans for the resident were inconsistent and lacked detailed information about the G-tube site location. Despite the resident's behavior of pulling out the G-tube, the care plans were not adequately revised to include effective interventions. The facility attempted to use bilateral hand mitten restraints and an abdominal binder, but these measures were insufficient as the resident was able to remove them and continue dislodging the G-tube. The facility did not conduct Interdisciplinary Team (IDT) meetings after each incident to determine the cause of the behavior and explore alternative interventions. Interviews with facility staff revealed a lack of consistent supervision and monitoring of the resident. The Director of Nursing acknowledged the need for more frequent supervision to prevent G-tube dislodgement. The facility's policies and procedures required daily inspection of the G-tube site for signs of irritation or infection, but there was no evidence that these inspections were consistently documented or that the care plans were updated with new interventions after each incident.
Inadequate Response to Respiratory Distress Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) had the appropriate competencies and skills to provide adequate nursing care to a resident experiencing respiratory distress due to Chronic Obstructive Pulmonary Disease (COPD) and pneumonia. The resident, who had a Physician Orders for Life-Sustaining Treatment (POLST) indicating a wish for Cardiopulmonary Resuscitation (CPR), experienced a significant drop in oxygen levels to 72%. Despite administering a breathing treatment, the LVN did not notify the physician or escalate the situation appropriately, leading to the resident's condition declining and resulting in death. The LVN, upon noticing the resident's labored breathing and low oxygen levels, offered to transfer the resident to a hospital, but the resident declined. The LVN administered a breathing treatment, which temporarily improved the resident's oxygen levels, but failed to continuously monitor the resident or notify the physician of the critical situation. The LVN also instructed a Certified Nurse Assistant (CNA) to monitor the resident, but did not follow up with the necessary medical interventions or communication with the physician. Interviews with facility staff, including the Director of Nursing (DON) and the resident's primary physician, revealed that the LVN did not follow the facility's policies and procedures for handling such emergencies. The DON stated that the LVN should have notified the physician and continuously monitored the resident's condition. The primary physician confirmed that he was not informed of the resident's condition until after the resident had passed away, indicating a failure in communication and adherence to clinical standards of practice.
Failure to Implement Appropriate Behavior Management for a Resident
Penalty
Summary
The facility failed to implement appropriate behavior management and interventions for a resident, identified as Resident 16, who exhibited behaviors of agitation, yelling, and attempts to hit staff. The resident, who was admitted with diagnoses including epilepsy and intellectual disabilities, was observed walking in the hallway without pants, exposing her private area. A Certified Nurse Assistant (CNA 7) attempted to redirect the resident back to her room by holding her shoulders, despite the resident's verbal protests to be left alone. This physical intervention increased the resident's agitation, leading to the resident scratching the CNA. Interviews with staff revealed that CNA 7 did not seek assistance from other staff members, believing the task needed to be handled alone. The CNA's actions were intended to protect the resident's dignity and privacy but resulted in increased agitation. The Licensed Vocational Nurse (LVN 2) and the Director of Nursing (DON) indicated that the CNA should have used verbal and non-verbal de-escalation techniques and respected the resident's wishes not to be touched. The DON emphasized that physical intervention should only occur when necessary and after efforts to calm the resident verbally have been made. The facility's policy on behavior management requires staff to assess behavioral symptoms and implement non-drug interventions before initiating psychotherapeutic medications. The policy also emphasizes the importance of person-centered care that maximizes the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. The failure to adhere to these guidelines resulted in a deficiency in providing necessary behavioral health care and services to Resident 16.
Failure to Document Justification for Extended Use of Ativan PRN
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not documenting the justification for the continued use of Ativan PRN beyond the 14-day limit. The resident, who was admitted with diagnoses including seizures/epilepsy and intellectual disabilities, was prescribed Ativan to be administered as needed for seizures and anxiety related to epilepsy. However, the facility did not adhere to its policy that requires PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician documents a rationale for extending the order. The resident's cognitive skills for daily decision-making were severely impaired, necessitating supervision and extensive assistance from staff for activities of daily living. Despite this, the Director of Nursing acknowledged that the physician's order for Ativan PRN was not limited to 14 days and indicated plans to contact the physician for verification and possible reevaluation. The facility's policy requires that if a PRN order is to be extended beyond 14 days, the attending physician must document their rationale and indicate the duration for the PRN order, which was not done in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as prescribed to two residents, resulting in a medication error rate of 7.14%. Resident 45, who was admitted with a diagnosis of vitamin D deficiency and had severely impaired cognition, did not receive their prescribed Vitamin D3 oral tablet via G-tube. During a medication administration observation, the LVN responsible for administering the medication mistakenly checked off the Vitamin D3 as administered in the electronic Medication Administration Record (e-MAR) without actually giving it to the resident. Similarly, Resident 61, who was admitted with metabolic encephalopathy and had intact cognition, did not receive their prescribed multivitamin oral tablet. The LVN failed to administer the multivitamin because it did not appear in the computer system when checking the scheduled medications for the resident. The facility's policy requires medications to be administered by a licensed nurse per the physician's order, but this was not followed in these instances.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide a resident with drinks that accommodated their preferences, which had the potential to result in decreased fluid intake and lead to dehydration. The resident, who has moderately impaired cognition and early dementia, expressed dissatisfaction with receiving milk despite repeatedly informing staff of their dietary preferences, which included no cheese, milk, pork, or beef. The resident's tray card clearly indicated these preferences, yet milk was still provided. The Certified Dietary Manager acknowledged the error upon reviewing the tray card but did not provide an explanation for why milk was included. The Registered Dietitian confirmed that residents' hydration needs and preferences should be honored. The facility's policy stated that meals should be consistent with residents' preferences as indicated on the tray card, but this was not adhered to in the case of the resident in question.
Failure in Diabetes Management Leads to Resident's Death
Penalty
Summary
The facility failed to ensure proper diabetes management for a resident with a diagnosis of Diabetes Mellitus Type 2 upon admission. The attending physician did not include necessary orders for blood sugar monitoring and insulin administration, which are critical for managing diabetes. The licensed staff did not review the resident's hospital discharge records to verify and implement appropriate diabetes care orders, nor did they confirm these orders with the attending physician upon the resident's admission to the facility. The resident, who had a history of diabetes, encephalopathy, dementia, and hypertension, was admitted to the facility without the necessary orders for diabetes management. The facility's records showed that an order for Insulin Lispro was discontinued without valid justification, and there was no evidence of blood sugar monitoring or insulin administration during the resident's stay. The resident's care plan included monitoring for signs of hyperglycemia and hypoglycemia, but there was no documentation that this was done. As a result of these deficiencies, the resident experienced a severe deterioration in health, leading to an emergency transfer to a hospital where they were diagnosed with Diabetic Ketoacidosis and subsequently passed away. The facility's failure to ensure continuity of diabetes care and proper medication management directly contributed to the resident's critical condition and eventual death.
Failure to Provide Adequate Diabetes Management
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Diabetes Mellitus (DM) received appropriate treatment and services in accordance with professional standards of practice, the care plan, physician orders, and the facility's policies and procedures. The resident, who had a history of DM, was admitted to the facility without a proper review of their medical history and discharge orders from the previous acute care hospital, which indicated the need for insulin and blood sugar monitoring. The facility did not verify with the physician whether these treatments should continue, leading to a lack of necessary diabetes management. The facility also failed to implement its policy and procedure for admission assessment, as a licensed nurse did not complete a drug regimen review upon the resident's admission. This oversight resulted in the failure to identify clinically significant medication issues, such as the need for insulin and blood sugar monitoring. Additionally, the facility did not follow its diabetic care policy or the resident's care plan, which required monitoring for signs and symptoms of hypoglycemia and hyperglycemia. The interdisciplinary team, including the Director of Nursing, was not aware of or did not review the resident's care plan to ensure it was being followed. As a result of these failures, the resident experienced a change in condition, including an altered level of consciousness, oxygen desaturation, and a critically high blood sugar level. The resident was transferred to a general acute care hospital, where they were diagnosed with diabetic ketoacidosis and subsequently died. The facility's pharmacist consultant also did not provide documented recommendations for managing the resident's diabetes, further contributing to the lack of appropriate care and monitoring.
Failure to Monitor and Manage Diabetes in Resident
Penalty
Summary
The facility failed to ensure that the attending physician assessed and evaluated the total program of care for a resident with diabetes. The resident's blood sugar was not monitored, and insulin medication was not administered during their stay at the facility. This oversight occurred despite the resident having a documented diagnosis of diabetes mellitus and a care plan that required monitoring and reporting of blood sugar levels. The resident was admitted to the facility with a history of diabetes mellitus, encephalopathy, dementia, and hypertension. Upon admission, the resident's care plan included monitoring for signs of hyperglycemia and hypoglycemia. However, the Minimum Data Set did not reflect the resident's diabetes diagnosis, and there was no order for insulin or blood sugar monitoring. The physician's orders for insulin were discontinued without documented clarification, and the interdisciplinary team did not discuss the resident's diabetes management. As a result of these failures, the resident experienced a severe deterioration in health, leading to an emergency transfer to a hospital with a blood sugar level of 500 mg/dL. The resident was diagnosed with diabetic ketoacidosis and subsequently passed away two days after hospital admission. The facility's policies required physician oversight and monitoring of blood sugar levels, which were not adhered to in this case.
Failure to Monitor and Administer Insulin Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that the pharmacy consultant thoroughly reviewed and reported irregularities in the medication regimen of a resident diagnosed with Diabetes Mellitus Type 2. The resident was admitted to the facility with a plan to continue insulin medication to manage blood sugar levels. However, the insulin was discontinued without clear justification, and there was no monitoring of the resident's blood sugar levels. This oversight led to the resident not receiving necessary insulin and blood sugar monitoring, which are critical for managing diabetes. The resident's medical records from the facility and the General Acute Care Hospital (GACH) indicated a lack of documented evidence that insulin was administered or that blood sugar levels were monitored. The Medication Administration Record (MAR) and the Medication Regimen Review (MRR) did not reflect any recommendations or actions taken to address the resident's diabetes management. The pharmacy consultant admitted to only reviewing current medications and not considering discontinued medications or the resident's diagnoses, which contributed to the oversight. As a result of these failures, the resident experienced a severe medical emergency, with a blood sugar level of 500, leading to a diagnosis of Diabetic Ketoacidosis (DKA) and subsequent transfer to a hospital. Despite receiving emergency treatment, the resident's condition deteriorated, resulting in death. The facility's policies and procedures for drug regimen review were not adequately followed, leading to a critical lapse in care for the resident.
Failure to Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) within the required 24-hour timeframe. Five residents tested positive for COVID-19, but the facility only reported the outbreak to the local health department, not the CDPH. This failure to report prevented the CDPH from conducting a timely on-site investigation to ensure proper precautions were being taken to protect residents and staff. The report details the medical conditions and decision-making capacities of the affected residents. Resident 1, who tested positive on January 15, 2024, had hemiplegia and hemiparesis following a cerebral infarction and lacked decision-making capacity. Resident 2, also testing positive on the same date, had chronic obstructive pulmonary disease and similarly lacked decision-making capacity. Resident 3, who had muscle wasting and atrophy, was capable of making decisions and tested positive on January 15, 2024. Resident 4, who was readmitted with COVID-19, lacked decision-making capacity and was transferred to a general acute care hospital (GACH) where they tested positive. Resident 5, with a femur fracture, left the facility against medical advice after testing positive. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed a lack of communication and understanding of reporting procedures. The IP admitted to not knowing how to contact the CDPH and only reported to the local health officer. The DON was under the impression that the CDPH had been notified. The facility's policy on communicable disease outbreaks required reporting to both the CDPH and local health officer, which was not followed in this instance.
Failure to Implement Seizure Precautions and Fall Management
Penalty
Summary
The facility failed to prevent a high-risk resident from falling and sustaining injuries due to inadequate care planning and supervision. The resident, who had a history of seizures, Parkinson's disease, and cognitive impairments, was admitted to the facility without a care plan for seizure monitoring and precautions. Despite a physician's order for bilateral side rails and the facility's policy requiring seizure precautions, these measures were not implemented upon admission. The resident experienced multiple falls, including incidents on March 7 and March 18, which resulted in injuries. The facility did not conduct an Interdisciplinary Team (IDT) Falls Committee meeting within 72 hours of these falls to update the care plan and implement necessary interventions. This lack of timely assessment and intervention contributed to a subsequent fall on May 2, where the resident was found on the floor with a head injury and seizure activity, requiring emergency hospital transfer. Interviews with facility staff revealed that the resident was known to be at high risk for falls due to forgetfulness and confusion, yet appropriate safety measures such as floor mats and side rails were not consistently used. The facility's policies on fall management and seizure precautions were not followed, and there was no documented evidence of care plans addressing the resident's non-compliance and dementia. The failure to reassess and adjust interventions after each fall incident further exacerbated the risk of injury.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, leading to a significant health deficiency. The resident, who had a history of head injury, cardiac arrest, seizures, Parkinson's disease, and dementia, was admitted to the facility without a care plan addressing these conditions. Despite the resident's known history of seizures and dementia, the facility did not establish appropriate interventions to prevent major injury during seizure activity or address the resident's cognitive impairments and noncompliance with care instructions. Interviews with facility staff, including CNAs and RNs, revealed that the resident was known to be confused, forgetful, and noncompliant with instructions to call for help before getting up. The staff acknowledged that a care plan should have been developed upon admission to address the resident's seizure history and noncompliant behaviors, but no such plan was in place. The lack of a care plan resulted in the resident experiencing a fall during a seizure, leading to a major laceration and bleeding on the head. The facility's own care planning policy, revised in October 2022, mandates the development of a comprehensive person-centered care plan for each resident based on their assessed needs. However, the facility failed to adhere to this policy, as evidenced by the absence of a care plan for the resident's seizures, dementia, and noncompliance. This oversight was confirmed through record reviews and interviews with the Infection Prevention Nurse and the Director of Nursing, who both acknowledged the lack of appropriate care planning for the resident.
Expired Insulin Administration
Penalty
Summary
The facility failed to ensure that licensed nursing staff did not administer expired insulin to six out of ten residents. During an inspection of two medication carts, it was found that insulin for Residents 5, 6, 7, 8, 12, and 14 was expired. Licensed Vocational Nurse (LVN) 3 confirmed that insulin has an expiration date of 28 days once opened, and administering expired insulin could result in ineffective blood sugar control. Resident 14's Basaglar insulin was also not administered according to the manufacturer's specifications, which require it to be injected once daily at the same time every day. Instead, it was administered as a sliding scale insulin, leading to multiple doses being given after the insulin had expired. Resident 14's medical records indicated that the resident did not have the capacity to understand and make decisions, and the expired insulin was administered on several occasions in April 2024, as documented in the Medication Administration Record (MAR). Similarly, Resident 12 was administered expired Insulin Lispro on multiple occasions between April 17 and April 22, 2024, despite the insulin being expired since April 16, 2024. LVN 3 confirmed that the expired insulin was still in the medication cart and had been administered to the resident. Resident 12's medical records also indicated that the resident did not have the capacity to understand and make decisions. The inspection of Medication Cart 1 on Station 1 revealed that insulin for Residents 5, 6, 7, and 8 was also expired and available for use. LVN 1 confirmed that the insulin was expired and should not have been administered. Resident 7's Novolog insulin, Resident 8's Humalog insulin, Resident 6's Insulin Lispro, and Resident 5's Insulin Glargine were all found to be expired and had been administered to the residents on multiple occasions. The Director of Nursing (DON) confirmed that the facility's policy is to discard insulin 28 days after it is opened, and administering expired insulin increases the risk of side effects such as uncontrolled blood glucose, acidosis, hospitalization, coma, and death. The facility's policy and procedure for medication storage indicated that all expired medications should be removed from the active supply and destroyed, and that insulin should be used within 28 days of being opened.
Failure to Properly Discard and Dispose of Medications
Penalty
Summary
The facility failed to ensure expired and discontinued medications were discarded and disposed of properly according to the facility's policy and procedure. During an inspection of two medication carts, it was found that expired insulin was not removed and discarded for 10 out of 12 residents. Specifically, insulin vials and pens were either not labeled with an open date, stored improperly, or available for use beyond their expiration date. This included insulin for Residents 1, 5, 6, 7, 8, 9, 11, 12, 13, and 14. The Licensed Vocational Nurses (LVNs) acknowledged the discrepancies and confirmed that expired insulin could be ineffective in controlling blood sugar levels, posing a risk to the residents' health. The facility also failed to remove and securely store medications for Resident 10 after the resident was discharged. During an inspection, multiple bubble packs of medications labeled for Resident 10 were found mixed with current residents' medications in a medication cart. The Director of Nursing (DON) confirmed that these medications should have been removed immediately upon the resident's transfer and placed in a designated location in the medication storage room. The medications included treatments for conditions such as epilepsy, high cholesterol, and heartburn. Additionally, the facility did not properly dispose of a discontinued medication for Resident 15. The LVN was observed discarding Eliquis 2.5 mg tablets without a witness and without documenting the disposal, contrary to the facility's policy. The DON stated that all medication destruction must be documented and witnessed by a second nurse. The failure to follow proper disposal procedures for discontinued medications increased the risk of inadvertent administration, misuse, and medication errors.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. This information was not posted in a prominent location readily accessible to residents and visitors for viewing, as required by the facility's policy and procedure. The deficiency was identified during an observation on 4/23/24, where the facility's projected daily nursing staffing was found to be outdated. The census at that time was 86 residents. Interviews with the Director of Staff Development consultant and the Director of Nursing confirmed that the daily staffing should be updated daily and that the failure to do so could lead to misinformation and a sense of insecurity regarding adequate staffing among residents and visitors. A review of the facility's policy and procedure titled Nursing Department-Staffing, Scheduling & Postings, revised on 10/24/2022, indicated that the facility is required to post the nursing staffing data daily at the beginning of each shift. The Director of Nursing acknowledged that the daily nursing staffing posting observed on the wall at the nurses' station was not updated, which could create a sense of insecurity for adequate staffing among visitors and family members. The Director of Staff Development consultant also emphasized the importance of keeping staffing assignments updated to provide accurate information for everyone involved.
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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