Golden Rose Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1899 N Raymond Ave, Pasadena, California 91103
- CMS Provider Number
- 055862
- Inspections on file
- 85
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Golden Rose Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a right elbow skin tear had a physician order for daily wound care, but nursing staff failed to consistently provide and document the ordered treatment on multiple days, and there was a lapse in having an active wound care order for a period of time. Review of the TAR and notes showed missing initials and entries for the ordered treatments, and staff confirmed that no treatment order was in place during part of the wound’s course, contrary to the facility’s wound management policy requiring necessary treatment and prompt physician guidance.
A resident with diabetes, protein-calorie malnutrition, and high Braden risk, fully dependent for mobility and enrolled in a turning/repositioning program, was not repositioned every two hours as required by the care plan and facility policy. Surveyors observed the resident lying on the same side for several hours, while the responsible party and roommate reported no repositioning during that time. A CNA stated she typically changed/repositioned the resident only around the start and near the end of the shift, and facility leadership confirmed residents were supposed to be repositioned q2h to prevent skin issues and pressure injuries.
A resident with paraplegia, a Stage 4 sacro-coccygeal pressure ulcer, bacteremia, immunodeficiency, and multidrug-resistant infection required ordered wound care to the sacral area. During an observed dressing change, a treatment nurse removed a soiled dressing and continued the wound care procedure without changing gloves or performing hand hygiene, despite facility PPE policy requiring single-use gloves and handwashing before and after glove removal. In interviews, the nurse and the DON confirmed that gloves should have been removed and hand hygiene performed before applying new gloves and continuing treatment.
A resident with multiple chronic conditions missed a scheduled dental cleaning because the Social Worker did not notify them of the appointment after receiving an email reminder. The resident was out on pass during the visit, and the facility's policy indicated the Social Worker was responsible for coordinating and communicating such appointments.
A resident with a history of G-tube dislodgement and severe cognitive impairment did not have a comprehensive, individualized care plan addressing her repeated behaviors of pulling at her G-tube. Despite multiple incidents and staff awareness of the issue, no specific interventions or interdisciplinary team meetings were documented to address the problem, leading to inconsistent care.
A resident with complex medical needs was transferred to a hospital, and although a 7-day bed hold was requested and confirmed, the facility assigned the resident's bed to another individual after only three days. When the hospital attempted to discharge the resident back, staff reported no available bed, resulting in the resident remaining hospitalized beyond the intended period.
A resident who was fully dependent on staff for personal care due to complex medical conditions was found with long, dirty fingernails and old nail polish, despite a care plan requiring regular nail maintenance. Staff interviews and observations confirmed that nail care was not provided as required by facility policy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility did not maintain a working call light system for three nursing stations over several days, as confirmed by maintenance records, staff interviews, and direct observation. Despite policy requirements for immediate repair and hourly safety checks, the system remained non-operational, with incomplete documentation and delayed repairs, leaving multiple rooms without a functional alerting device for resident assistance.
The facility did not ensure timely and appropriate access to call lights for five residents, including delays in answering call lights, placing call lights on the side of a contracted limb, not keeping call lights within reach for residents in bed or wheelchairs, and failing to provide a suitable call device for a resident with hand mittens. These actions did not align with care plans or facility policy, impacting residents with significant cognitive and physical impairments.
Two residents were affected when staff failed to provide bedside fluids for a resident with multiple medical conditions and did not follow the facility's significant weight loss policy for another resident with ESRD on dialysis. Observations confirmed the absence of water at the bedside despite care plan requirements, and staff interviews revealed that required assessments and notifications were not completed after significant weight loss, contrary to facility policy.
Surveyors found that kitchen staff failed to label open food items with required information and did not discard expired foods, as confirmed by the Dietary Supervisor. Multiple items, including beets, cottage cheese, ranch dressing, tortillas, and peanut butter, were either expired or lacked proper labeling, in violation of facility policy and FDA Food Code.
Four outdoor trash dumpsters were observed overfilled with trash bags stacked above the brim, making it impossible to close the lids. The Dietary Supervisor confirmed that the lids should be closed but could not do so due to the excess trash, acknowledging the need for proper disposal to prevent pest infestation. Review of facility policy and FDA guidelines indicated that garbage should be stored in covered containers, but this was not followed.
Staff failed to maintain resident dignity and privacy by feeding a resident while standing above their eye level and by entering two residents' rooms without knocking. The affected residents had severe cognitive impairment and required extensive assistance, and staff acknowledged these actions were not in line with facility policy.
Several residents experienced unsanitary room conditions, including visible trash and soiled areas, and were unable to access hot water for bathing and hygiene. Residents and staff reported that water temperatures in showers and sinks were consistently below policy requirements, resulting in discomfort and missed showers. Facility policies required a clean, homelike environment and suitable water temperatures, but these standards were not met.
Three residents did not receive proper pharmaceutical services, including one who missed multiple doses of Marinol due to pharmacy delivery delays and lack of timely physician notification, another who received several scheduled medications late, and a third who had medications left at the bedside after refusal, contrary to facility policy.
Staff failed to follow infection prevention and control protocols, including not changing gloves or performing hand hygiene between tasks such as incontinence care, tracheostomy care, and medication administration for multiple residents. Staff also exited resident rooms wearing PPE and handled contaminated items without proper doffing or hand hygiene, contrary to facility policy.
A resident with mental health diagnoses and moderate cognitive impairment did not receive a required PASARR Level II evaluation because facility staff did not respond to multiple attempts to schedule the assessment. The case was closed without completion of the evaluation, and the responsible staff member did not submit a new screening as required by facility policy.
Two residents did not have individualized care plans addressing their specific needs: one with severe cognitive impairment and total dependence lacked a care plan for incontinence, while another with end stage renal disease and significant weight loss had no care plan for fluid restriction or weight management. Nursing staff and the DON confirmed these omissions, despite facility policies requiring comprehensive, resident-centered care plans.
A resident with a history of sepsis, tracheostomy, and severe cognitive impairment was weaned off a ventilator and placed on continuous oxygen via tracheostomy, but the care plan was not updated to reflect this change. The DON confirmed the care plan still focused on ventilator dependence, despite physician orders and current therapy indicating oxygen use via tracheostomy.
A resident at very high risk for pressure ulcers, with significant physical and cognitive impairments, was found with a low air loss mattress set incorrectly for their weight, contrary to physician orders and facility policy. Additionally, no care plan was developed to address the resident's risk for pressure ulcers, as confirmed by the DON and record review.
A resident with right-sided weakness and muscle atrophy was not provided with the physician-ordered PRAFO boot for their right lower extremity, as required by their care plan. Instead, a soft heel protector was used for a week because the PRAFO boot could not be found, and staff did not notify nursing or rehabilitation or arrange for a replacement. This resulted in the resident not receiving the correct orthotic support as ordered.
A resident with end stage renal disease and on dialysis did not receive a physician-ordered fluid restriction due to staff failing to activate the order and communicate it to dietary services. As a result, the resident received unrestricted fluids for over two weeks, contrary to facility policy and medical orders.
A resident with PTSD and major depressive disorder did not have a trauma-informed care plan addressing her triggers, such as loud noises and being touched. Staff were unaware of her diagnosis and had not received training on trauma-informed care or PTSD. The resident was repeatedly exposed to loud music during facility activities, which she reported as a trigger, and was told to keep her door open despite discomfort. The facility's policy requiring identification of triggers and staff training was not followed.
A resident with severe cognitive impairment and multiple high-risk diagnoses did not receive a monthly medication regimen review by a licensed pharmacist for two consecutive months. The DON confirmed the omission, noting that the resident's medications were not included in the MRR, despite facility policy requiring monthly reviews for all residents.
A resident with multiple complex diagnoses was switched from Megestrol to Marinol for poor appetite, but the medication order incorrectly listed the indication as vomiting, which the resident was not experiencing. The DON confirmed that the order should have been clarified to reflect the correct indication, as required by facility policy, but this was not done, resulting in a deficiency related to unnecessary medication use.
A resident with severe malnutrition and muscle wasting did not have her food preferences assessed or honored after starting an oral diet. Despite expressing dissatisfaction with the meals and making specific requests, her preferences were not documented or communicated by staff, and the required dietary evaluation was not completed, contrary to facility policy.
A resident with multiple infections and severe cognitive impairment was administered meropenem IV for pneumonia, even though only one of the three required criteria for antibiotic therapy was met. The Infection Preventionist Nurse confirmed that all criteria should have been met and there was no documentation of physician notification prior to starting the antibiotic, contrary to facility policy.
Two residents who were dependent on staff for care, including one with a tracheostomy and another with severe cognitive impairment, were found with their call lights out of reach. Staff and policy confirmed that call lights should be accessible at all times, especially for nonverbal or immobile residents, but observations showed this was not consistently done.
A resident with severe cognitive impairment and multiple medical conditions, fully dependent on staff for ADLs, was not provided incontinence care according to facility policy. Observations and staff interviews confirmed the resident was routinely left in a urine-soaked brief and wet linens, despite policies requiring changes every 2 to 4 hours or as needed to maintain cleanliness and prevent skin issues.
Two residents did not receive necessary care when staff failed to reevaluate and treat wounds, and did not implement interventions after reports of pain and confusion. One resident with severe cognitive impairment and self-inflicted wounds was not reassessed or provided with an updated care plan when treatments were ineffective. Another resident with cognitive impairment and a history of shoulder injury did not receive appropriate assessment or monitoring after complaints of pain and confusion, and the care plan was not updated.
A facility failed to keep its medication error rate below 5%, with four late medication administrations out of 33 observed opportunities. A resident with severe cognitive impairment and multiple chronic conditions did not receive four scheduled medications within the required time window, as a nurse administered them more than an hour after the scheduled time, contrary to facility policy.
The facility did not consistently post accurate and current Nurse Staffing Information in a prominent location, as required by policy. On several occasions, the posted information was outdated and did not match the actual staffing assignments and sign-in sheets for various shifts in both subacute and SNF units. Leadership confirmed that the postings should reflect the true number of direct care staff present each day.
A resident with a stage 4 pressure ulcer and paraplegia did not have wound care treatments documented for a 14-day period, despite physician orders and facility policy requiring daily treatment and documentation. The treatment nurse confirmed that care was provided but not recorded, and the DON acknowledged the lapse in documentation.
A resident with a documented DNR order and advance directive specifying no life-prolonging measures was given CPR by staff after being found on the floor, despite the facility having acknowledged and documented the resident's wishes. The DON confirmed that this action was contrary to both the physician's order and the facility's policy.
Staff failed to report allegations of physical and verbal abuse involving two residents by a family member within the required 2-hour timeframe to the State Survey Agency and ombudsman. The incidents included hair-pulling, yelling, and pushing, with both residents experiencing emotional distress. Despite staff awareness and internal reporting, the DON did not notify authorities as required by policy.
A resident with significant medical needs and cognitive impairment was unable to summon staff for incontinence care due to a disconnected call light cord. Staff confirmed the call light was not working, and facility policy requires call systems to be functional and accessible to residents.
A respiratory therapist left therapy notes containing sensitive health information for several residents unattended on top of a therapy cart in a hallway, making the information visible to anyone passing by. Staff interviews confirmed this was a breach of HIPAA and facility policy, as medical records should be kept secure and confidential at all times.
Three residents with complex medical conditions did not receive their scheduled 9 AM medications within the required 60-minute window due to delays by an LVN, technical issues with the electronic MAR, and missing medication supplies. Nursing staff confirmed the late administration and the facility's policy requiring timely medication administration.
A resident with a history of breast cancer, who required significant assistance with daily activities, reported being treated roughly by a CNA during care, including having her legs thrown onto the bed and a pillow tossed at her face. This interaction left the resident feeling humiliated and emotionally distressed, in violation of facility policy requiring respectful and dignified treatment of all residents.
A resident with a documented egg allergy was served meals containing egg-based products due to the failure to update and communicate allergy information on diet orders and tray tickets. Staff interviews revealed that dietary and nursing staff did not verify or modify meal preferences, resulting in the resident experiencing an allergic reaction and requiring medical attention.
A Kitchen Aid was observed opening a trash lid and then preparing food without performing hand hygiene. The staff member admitted to not washing hands after touching the trash, and the Administrator confirmed that proper hand hygiene is required before and during food preparation. Facility policies reviewed by surveyors emphasized the importance of hand hygiene in preventing infection.
A facility failed to provide adequate supervision and enforce policies, resulting in a resident consuming alcohol on the premises and multiple residents being left unsupervised in the smoking area. Despite a zero-tolerance policy for alcohol and a requirement for staff supervision during smoking sessions, residents were left without oversight, leading to safety risks. Additionally, the facility did not update care plans or enforce smoking policy compliance, allowing a resident to keep smoking materials in his room.
A facility failed to place a resident's advance directive in their medical chart, leading to CPR being administered against the resident's DNR wishes during a respiratory arrest. The directive was later found mixed with hospital records, highlighting a lapse in ensuring the resident's treatment preferences were accessible.
A facility failed to ensure a resident's POLST was complete with a physician's signature, leading to a conflict in honoring the resident's DNR wishes during a respiratory arrest. The resident, who required assistance for daily activities, had a POLST indicating DNR and comfort-focused treatment, but it was unsigned, resulting in CPR being administered. Interviews revealed a lack of responsibility in ensuring the POLST's completion, and the physician was unaware of the DNR status.
A facility failed to create a care plan for a resident at risk of elopement, despite the resident's fluctuating decision-making capacity and expressed desire to leave. The resident, with diagnoses including seizures and diabetes, ambulated out of the facility without supervision. The DON acknowledged the risk during an IDT meeting, but no care plan was developed, contrary to facility policies.
A resident with a history of falls experienced an unwitnessed fall, and the facility failed to complete the required neurological assessments as per policy. The resident's neurological assessment flowsheet showed multiple missed checks, which were confirmed by nursing staff. The facility's policy required a 72-hour neuro check following such incidents to monitor for potential head injuries or changes in condition.
A facility failed to document and report irregularities in a resident's medication regimen review, specifically concerning Lorazepam. The resident's orders lacked a diagnosis and specific target behavior, and the consulting pharmacist did not identify or report these issues during the monthly review. This oversight prevented necessary discussions with the resident's psychiatrist and posed a risk of unnecessary medication administration.
A resident was prescribed Lorazepam without a specific diagnosis or target behavior in the physician's order, and the PRN order was not discontinued after 14 days as required. The facility also failed to monitor for adverse reactions or the occurrence of target behaviors, contrary to its policy on Psychotherapeutic Drug Management.
Two residents in an LTC facility did not receive proper pressure ulcer care. One resident's wound care treatments were inconsistently administered, and their care plan lacked specific management strategies. Another resident's low air loss mattress was incorrectly set, and they were not repositioned every two hours, increasing the risk of worsening pressure ulcers. Staff interviews confirmed these deficiencies.
Failure to Provide and Document Continuous Wound Care for Elbow Skin Tear
Penalty
Summary
The facility failed to obtain and provide continuous wound treatment for a resident’s right elbow skin tear in accordance with physician orders and facility policy. The resident, who had severe cognitive impairment and was dependent for all ADLs, had a physician’s order dated 1/7/2026 for daily wound care to the right elbow skin tear, including cleansing with normal saline, patting dry, applying Xeroform, and covering with a dry dressing for 30 days. Review of the Treatment Administration Record (TAR) and progress notes showed that wound treatments were not documented as provided on 1/19/2026, 1/27/2026, and from 2/6/2026 to 2/14/2026. Treatment Nurse 1 confirmed that there were no initials on the TAR and no progress note documentation indicating that the ordered wound care was performed on those dates. Further review revealed that there was no active treatment order for the right elbow wound between 2/6/2026 and 2/14/2026, despite the ongoing need for care. Registered Nurse 2 confirmed the absence of a treatment order during that period and stated that staff, including LVNs, treatment nurses, and RNs, are responsible for monitoring wound treatment, communicating with the physician, and clarifying continuation of wound care. The facility’s wound management policy, revised 11/1/2017, stated that residents with wounds are to receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers, and that the attending physician will be notified promptly to advise on appropriate treatment. Staff interviews indicated that continuous treatment and documentation are necessary to assess wound progress and that if wound treatment is not documented, it is considered not to have occurred.
Failure to Reposition High-Risk Resident Every Two Hours
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention care by not turning and repositioning a high‑risk resident every two hours as required by the resident’s care plan and the facility’s positioning policy. The resident had diagnoses including diabetes mellitus and protein‑calorie malnutrition, was assessed as high risk for pressure injuries on a Braden Scale assessment, and the MDS documented dependence for all mobility and ADLs, as well as participation in a turning and repositioning program. The resident’s care plan, revised 7/14/2024, directed staff to turn and reposition the resident every two hours and as needed. The facility’s Positioning and Body Alignment policy, reviewed 1/1/2026, required position changes every two hours. On the survey date, the resident was observed at 10:40 AM lying on her right side. At 11:12 AM and again at 1:20 PM, the resident was still on her right side, and the responsible party and roommate reported that staff had not changed or repositioned the resident since 10:40 AM. The responsible party stated CNAs typically turned the resident only twice during the morning shift, around 8:00 AM and 2:00 PM. CNA 1 later reported she had changed/repositioned the resident at 8:00 AM and 2:00 PM, acknowledging this was not consistent with the every‑two‑hour requirement. The DSD and DON both stated residents should be repositioned every two hours, and the continence management guideline indicated pad/brief changes every 2–4 hours, while the DON noted the policy did not clearly state “every 2 hours and as needed” for changes. This combination of observations, staff statements, and record review showed the resident was not turned every two hours as required, creating the potential for skin tears and pressure injuries.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to wound care for one resident. The resident had multiple serious medical conditions, including paraplegia, a Stage 4 sacro-coccygeal pressure ulcer, bacteremia, immunodeficiency, and resistance to multiple antimicrobial drugs. The resident’s MDS showed severe cognitive impairment and dependence on staff for activities of daily living, and physician orders directed daily and as-needed wound care to the sacro-coccyx pressure injury, including cleansing with normal saline, patting dry, applying collagen powder and Thera honey, and covering with a foam dressing. During a wound care observation, the treatment nurse removed the resident’s soiled dressing and then continued the wound care procedure without changing gloves or performing hand hygiene, contrary to the facility’s Personal Protective Equipment policy. In interviews, the treatment nurse acknowledged she should have performed hand hygiene and donned a new pair of gloves after removing the dirty dressing and before continuing wound care. The DON also stated that gloves were intended for one-time use during removal of the soiled dressing and that the nurse should have removed the gloves, washed hands, and applied new gloves before proceeding, consistent with the written policy that gloves are single-use and that hands are to be washed before and after glove removal. The report stated these failures had the potential to increase the risk of infection for the resident and spread microorganisms to staff and other residents.
Failure to Notify Resident of Scheduled Dental Appointment
Penalty
Summary
The facility failed to notify a resident of a scheduled routine dental cleaning appointment, resulting in the resident missing the appointment and not receiving the planned oral hygiene care. The resident, who had diagnoses including paraplegia, type 2 diabetes, morbid obesity, and COPD, was assessed to have intact cognition and required partial assistance with oral hygiene. The dental appointment was scheduled and communicated to the facility's Social Worker (SW) via email, but the SW did not check the email until late in the day and did not inform the resident of the upcoming appointment. As a result, the resident was out on pass during the scheduled dental visit and missed the appointment. Interviews confirmed that the SW was responsible for notifying residents of dental appointments and that the facility's policy required the SW to coordinate dental services. The administrator acknowledged that the SW is expected to be aware of and communicate upcoming appointments to residents, and that missing such appointments can affect the quality of care.
Failure to Develop Comprehensive Care Plan for G-Tube Dislodgement
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident with a history of gastrostomy tube (G-tube) dislodgement. Despite multiple documented incidents of the resident pulling or dislodging her G-tube, there was no care plan addressing this issue from the time of admission through several months of care. The resident had diagnoses including type 2 diabetes mellitus, gastrostomy malfunction, and unspecified dementia, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. Multiple SBAR documents and staff interviews confirmed repeated episodes of G-tube dislodgement and behaviors such as pulling at the tube or linens, especially during care activities like dressing changes. Staff interviews revealed that the resident had a strong grip and would often grab her G-tube, requiring additional staff assistance during care to prevent dislodgement. Despite these ongoing issues, several staff members, including licensed nurses and the MDS nurse, were unaware of any care plan specifically addressing G-tube dislodgement or the resident's behavior of pulling at the tube. The care plan for G-tube dislodgement was not created until months after the initial incidents, and even then, it did not include interventions tailored to the resident's specific behaviors. Record review and interviews with the Registered Nurse Supervisor confirmed that no interdisciplinary team (IDT) meetings had been conducted to address the resident's frequent G-tube dislodgement, and the care plan lacked resident-centered interventions. The facility's own policy required comprehensive, individualized care plans to be developed and updated as needed, but this was not followed in the resident's case, resulting in inconsistent implementation of care.
Failure to Honor Bed Hold Policy for Hospitalized Resident
Penalty
Summary
The facility failed to follow its own bed hold policy for a resident who was transferred to a general acute care hospital (GACH) due to tachycardia and hypertension. The resident, who had significant medical needs including respiratory failure, ventilator dependence, and a persistent vegetative state, had a signed bed hold consent indicating a 7-day bed hold was requested and confirmed. Facility records and staff interviews confirmed that the resident's bed was held for only three days before being assigned to a new resident, despite a physician's order and facility policy requiring a 7-day hold. When the hospital notified the facility that the resident was ready for return within the 7-day period, staff reported that the bed was no longer available, as it had already been given to another resident. This resulted in the resident being unable to return to the facility as planned and remaining in the hospital for additional days. Facility staff, including the administrator, acknowledged that the bed should have been reserved for the full 7 days as per policy and the signed consent.
Failure to Provide Adequate Nail Care and Personal Hygiene
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for all activities of daily living due to multiple medical conditions including chronic respiratory failure, tracheostomy, muscle wasting, diabetes, and psychosis, was not provided with adequate nail care. The resident's care plan specifically required staff to check, trim, and clean nails on bath days and as necessary, and to report any changes to the nurse. However, during an observation, the resident was found with long, dirty fingernails, some stained brown, and old, partially removed nail polish. The resident indicated through nonverbal cues that staff had not attempted to provide nail care, and staff interviews confirmed that the resident's nails were not properly maintained. Interviews with facility staff, including a CNA, the Director of Rehabilitation, and the DON, revealed that CNAs were responsible for nail care and that the resident's nails should have been cleaned, trimmed, and old polish removed. Staff acknowledged that the resident's nails were not in compliance with facility policy, which requires nail care to keep nails clean and trimmed. The failure to provide this care was directly observed and confirmed through staff interviews and record review.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Maintain Functional Call Light System Across Multiple Nursing Stations
Penalty
Summary
The facility failed to maintain a functional call light system for three nursing stations over a period of seven days. According to maintenance records and staff interviews, the call light system at Stations 1, 2, and 3 became non-operational and remained so despite multiple unsuccessful troubleshooting attempts by the Maintenance Director and external technicians. Observations confirmed that the call light system was not working in all three stations during this period. The maintenance logbook did not show evidence of required testing of the nurse call system during the outage. The transformer for the system was found to be damaged and disconnected, and only partial repairs were made by the end of the period, with several rooms still lacking a functional call light system. Staff interviews, including those with the Maintenance Director, Environmental Health Consultant, Administrator, Director of Staff Development, Registered Nurse Supervisors, and the Director of Nursing, confirmed that the call light system was not operational and emphasized the importance of the system for resident safety and timely care. The facility's policy required immediate reporting and replacement of defective call lights, as well as hourly safety checks and documentation until the system was restored. However, the policy was not followed, as the system remained non-functional for an extended period and the required documentation and immediate repairs were not completed.
Failure to Accommodate Resident Needs for Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs and preferences of five residents by not ensuring timely and appropriate access to call lights and specialized call devices. In one instance, a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, had a care plan requiring the call light to be within reach. However, observations showed that the resident's call light was not answered promptly, with a delay of at least seven minutes during an episode of coughing and distress. The facility's policy required call lights to be answered within five minutes, and the DON confirmed that such a delay was unacceptable, especially in emergencies. Another resident with a contracture in the right arm and severe cognitive impairment was found with the call light placed on the contracted side, making it inaccessible. The RN confirmed that the call light should have been placed on the resident's strong side to allow activation if assistance was needed. Additional observations revealed that two other residents did not have their call lights within reach. One of these residents, who was dependent in most activities of daily living and had severe cognitive impairment, was found yelling for help because the call light was on a roommate's bed. The other resident, who required moderate assistance and was cognitively intact, was left in a wheelchair without the call light within reach and was unable to call for help. A fifth resident, who had a tracheostomy, gastrostomy, and was dependent in all activities of daily living, was observed with bilateral hand mittens to prevent removal of medical devices. Despite a care plan indicating the need for an adequate call light, the resident was provided with a push-button call light, which was not appropriate due to the mittens. The respiratory therapist and RN both confirmed that a touch pad call light was needed for this resident. Facility policies required call systems to be accessible and within reach, but these requirements were not met for the residents involved.
Failure to Provide Fluids and Follow Weight Loss Protocols
Penalty
Summary
The facility failed to ensure proper hydration and nutrition for two residents, resulting in deficiencies related to both fluid and nutritional management. For one resident with multiple complex medical conditions, including metabolic encephalopathy, type 2 diabetes, acute kidney failure, hypotension, and a stage 4 pressure injury, staff did not provide a water pitcher or fluids at the bedside as required. Multiple observations over two days confirmed the absence of water at the bedside, despite care plan interventions and signage instructing staff to keep the resident hydrated. Interviews with staff, including CNAs, the Director of Staff Development, and the DON, confirmed that there were no fluid restrictions and that water should have been available at all times. Staff acknowledged that the lack of water could lead to dehydration and related complications, and facility policy required water containers to be provided and maintained daily. For another resident with end stage renal disease and dependence on dialysis, the facility did not follow its significant weight loss policy after the resident experienced a weight loss of nearly 7% in one month. The resident's medical record did not show evidence of a change of condition assessment, notification of the physician or registered dietician, a nutritional assessment, or weekly weights as required by facility policy. Interviews with nursing and dietary staff confirmed that these steps were not taken, and the failure was attributed to a lack of communication and awareness among staff. The facility's policy required prompt notification and assessment in cases of significant weight loss, but these procedures were not followed for this resident. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The failures to provide fluids and to follow weight loss protocols were not isolated incidents but were confirmed by multiple staff members and documented in facility policies. The lack of adherence to established care plans and policies placed the residents at risk for dehydration and continued weight loss, as noted in the findings.
Failure to Label and Discard Expired Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices in accordance with its own policy and professional standards. During an inspection of the kitchen, multiple food items were found either unlabeled or past their use by dates. Specifically, a clear container of beets and four bags of corn tortillas were found with expired use by dates, while an opened tub of cottage cheese, a gallon container of buttermilk ranch dressing, and a four-pound jar of peanut butter were either expired or lacked required labeling such as the food item name, open date, or use by date. The Dietary Supervisor confirmed that these items were opened and should have been labeled and discarded if expired, as per facility policy. A review of the facility's policy and the 2022 FDA Food Code confirmed that all food items must be labeled and dated, and expired foods must be discarded. The Dietary Supervisor acknowledged that the failure to label and discard expired foods was not in accordance with policy and could result in serving expired food to residents. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Improper Disposal and Containment of Garbage
Penalty
Summary
During an observation with the Dietary Supervisor, four outdoor trash dumpsters were found overfilled with trash bags stacked above the brim, preventing the lids from being closed. The Dietary Supervisor confirmed that the lids should be closed and was unable to close them due to the excess trash. In a follow-up interview, the Dietary Supervisor acknowledged the need for proper trash disposal to prevent pest infestation and contamination. Review of the FDA Food Code and the facility's own policy confirmed that garbage and refuse should be stored in covered containers to minimize odors and prevent attracting pests, but these procedures were not followed as observed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor residents' rights to dignity, respect, and privacy for three residents. In one instance, a certified nursing assistant (CNA) was observed feeding a resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy, dementia, and Parkinson's disease, while standing above the resident's eye level. The CNA acknowledged that she should have been seated at the resident's eye level during feeding, as per facility policy and the resident's care plan, which required extensive assistance with eating. Additionally, a licensed vocational nurse (LVN) was observed entering the rooms of two different residents, both with severe cognitive impairment and dependent on staff for all activities of daily living, without knocking on their doors. The LVN admitted that staff are required to knock before entering to provide privacy and maintain residents' dignity. Another registered nurse confirmed the importance of this practice, emphasizing that privacy and dignity must be maintained even if the resident is not alert. A review of the facility's policy on resident rights confirmed that each resident must be treated with respect and dignity, and their individuality must be recognized. The observed actions by staff were inconsistent with this policy, resulting in a failure to maintain privacy and dignity for the affected residents.
Failure to Maintain Cleanliness and Adequate Hot Water for Resident Care
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for several residents, as evidenced by direct observations and resident interviews. In one instance, a resident with severe cognitive impairment and high dependence for activities of daily living was found in a room with visible trash, including crushed crackers, a used plastic glove, dried brown smears by the commode, and brown clumps under the bed. Both the DON and an LVN confirmed that such conditions were unsanitary and not conducive to residents' well-being, and that housekeeping should have been notified immediately to address the issue. Additionally, multiple residents reported a lack of hot water in their rooms and shower areas, which persisted for at least a week. Residents described being unable to shower or perform personal hygiene tasks comfortably due to the absence of hot water, with some stating they had to use cold water for bathing and incontinence care. Observations confirmed that water temperatures in various rooms and showers were significantly below the facility's policy requirements, with readings as low as 71.6 to 85 degrees Fahrenheit, far below the expected minimum of 110 degrees Fahrenheit. Facility policies reviewed indicated a requirement to provide a safe, clean, and homelike environment, including maintaining water temperatures suitable for residents' needs. Despite these policies, the facility did not ensure that resident rooms were kept clean or that water temperatures were adequate for daily living activities, directly impacting the comfort and hygiene of several residents with varying degrees of cognitive and physical impairment.
Failure to Provide Timely and Safe Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents by not ensuring timely administration and proper handling of medications as ordered by physicians. For one resident with severe cognitive impairment and poor appetite, the facility did not administer Marinol as ordered for eight days due to the medication not being available and waiting for pharmacy delivery. Nursing staff did not notify the physician within 24 hours of the medication's unavailability, as required by facility policy, resulting in 15 missed doses. Another resident, also with severe cognitive impairment and dependent on staff for daily activities, did not receive scheduled medications at the prescribed times. The medications, which included apixaban, spironolactone, finasteride, and bethanechol, were administered more than an hour after the scheduled time. The nurse acknowledged that the late administration could affect the resident's health, and the facility's policy allows for a one-hour window before or after the scheduled time, which was not adhered to in this case. A third resident, who had intact cognitive skills but required assistance with daily activities, was found with a medication cup containing two pills left on the bedside table after refusing to take them. The resident had not requested to self-administer medications, and facility policy prohibits leaving medications at the bedside. Staff interviews confirmed that medications should not be left unattended and should be properly documented and disposed of if refused.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Multiple staff members failed to adhere to standard infection prevention and control practices during direct care of several residents. Certified Nursing Assistant 4 (CNA 4) did not change gloves or perform hand hygiene after providing incontinence care to two residents, subsequently touching their bed sheets, bed remotes, and bodies with contaminated gloves. CNA 4 acknowledged during interview that gloves should have been changed and hand hygiene performed to prevent the spread of infection. The Infection Preventionist Nurse (IPN) confirmed that gloves soiled with urine and feces must be removed and hand hygiene performed before touching other surfaces or the resident. The Respiratory Therapist Director (RTD) was observed providing tracheostomy care to a resident and, without changing gloves or performing hand hygiene, touched the resident's personal items such as a cell phone and television remote. RTD then used the same gloves to prepare a sterile drape and handle a speaking valve, actions which he admitted could spread infection to the resident. The IPN stated that gloves should have been changed and hand hygiene performed after contact with personal items to prevent transmission of microorganisms to the tracheostomy area. Additional deficiencies included CNA 5 exiting a resident's room while still wearing PPE and handling dirty linen in the hallway, which she acknowledged was inappropriate due to the risk of spreading infection. Licensed Vocational Nurse 4 (LVN 4) was observed on two occasions failing to change gloves and perform hand hygiene between tasks during medication administration and gastrostomy tube care for two residents. LVN 4 admitted that gloves should have been changed to reduce the risk of introducing bacteria. The facility's policies and procedures require glove changes and hand hygiene after contact with blood, body fluids, and environmental surfaces, and specify that gloves are single-use only.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) Level II evaluation was completed for a resident with diagnoses including anxiety disorder, unspecified psychosis, and end stage renal disease. The resident's admission record and Minimum Data Set (MDS) indicated moderate cognitive impairment and the use of antipsychotic and antianxiety medications. Documentation showed that a PASARR Level I screening determined a Level II Mental Health Evaluation was necessary, and the facility was notified that an evaluator would contact them to schedule the assessment. However, the Level II evaluation was not completed because facility staff were unresponsive to multiple attempts by the evaluator to arrange the assessment within the required timeframe. As a result, the case was closed, and the facility was informed that a new Level I screening would be needed to reopen the case. The staff member responsible for PASARR follow-ups was unaware that the case had been closed and did not submit a new screening, contrary to facility policy, which requires completion of the PASARR Level II prior to admission and incorporation of its recommendations into the resident's care plan.
Failure to Develop Individualized Care Plans for Incontinence, Fluid Restriction, and Weight Loss
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans with measurable objectives, timeframes, and interventions for two of eighteen sampled residents. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, including toileting, there was no care plan addressing bowel and bladder incontinence, despite direct observation of staff providing incontinence care. Both the registered nurse and the director of nursing confirmed that a care plan for incontinence was missing and acknowledged its importance for ensuring continuity of care. Another resident, diagnosed with end stage renal disease and dependent on dialysis, experienced a significant weight loss of nearly 7% in one month and had a physician order for a strict fluid restriction. Despite these critical needs, there was no care plan in place to address the resident's fluid restriction or significant weight loss. The absence of these care plans was confirmed during interviews and record reviews with nursing staff and the director of nursing, who stated that care plans are essential for communicating interventions and ensuring staff follow prescribed care. Facility policies and procedures reviewed during the survey required the interdisciplinary team to ensure care plans documented renal conditions, necessary precautions, and individualized goals for managing significant weight changes. The policies also mandated that each resident have a comprehensive, person-centered care plan based on assessed needs, but these requirements were not met for the two residents identified.
Failure to Update Care Plan After Change in Respiratory Status
Penalty
Summary
The facility failed to revise the care plan for one resident to reflect a significant change in respiratory status following the discontinuation of ventilator support and the initiation of oxygen therapy via tracheostomy. The resident, who had a history of sepsis, urinary tract infection, ESBL, tracheostomy, and gastrostomy, was originally admitted and later readmitted with these diagnoses. Physician orders indicated the resident was to receive four liters per minute of humidified oxygen via tracheostomy, and the Minimum Data Set documented severe cognitive impairment and high levels of dependence for daily activities. Despite the resident being weaned off the ventilator in the hospital and currently receiving oxygen via tracheostomy, the care plan continued to focus on ventilator dependence and was not updated to reflect the current respiratory needs. This was confirmed during interviews and record reviews, where the DON acknowledged the care plan required revision to ensure appropriate care and staff implementation. The facility's policy required care plans to be updated with changes in resident status, but this was not done in this case.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers for a resident identified as being at very high risk. Specifically, the resident, who had a history of hemiplegia, hemiparesis, muscle wasting, and was dependent on staff for most activities of daily living, was found to have a low air loss (LAL) mattress set at 350 pounds, despite their actual weight being 144.4 pounds. This incorrect setting was not in accordance with the physician's order, which required the mattress to be set according to the resident's weight and monitored daily. Staff interviews confirmed that an improperly set mattress could be too hard and increase the risk of pressure ulcer development. Additionally, the resident's medical record did not contain a care plan addressing their risk for pressure ulcer development, despite assessments indicating a very high risk and facility policy requiring individualized care plans for such risks. The Director of Nursing confirmed the absence of a care plan and acknowledged that one should have been in place to guide staff interventions. Facility policies reviewed also emphasized the need for appropriate support surfaces and comprehensive care planning for residents at risk of skin breakdown, which were not followed in this case.
Failure to Provide Prescribed Foot Orthosis for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when a resident with a history of muscle wasting, atrophy, and right-sided weakness following a hemorrhagic stroke was not provided with the prescribed Pressure Relief Ankle Foot Orthosis (PRAFO) boot for their right lower extremity. The physician's order and care plan specified the use of the PRAFO boot for two hours, three times a week, to support, align, and protect the resident's right foot. However, during multiple observations and interviews, it was confirmed that the resident did not have the PRAFO boot available or in use, and instead, a soft heel protector was used for an entire week because the PRAFO boot could not be located. The Restorative Nursing Assistant (RNA) did not notify nursing or rehabilitation staff about the missing device or arrange for a replacement, and acknowledged that the evaluation of the resident's use of the PRAFO boot was inaccurate due to the substitution. The lack of the correct orthotic device was confirmed through record review, staff interviews, and direct observation. The Director of Nursing (DON) stated that the appropriate steps were not taken to locate or replace the PRAFO boot, and the facility's policy indicated that splints are used to prevent contractures and protect joint alignment. The manufacturer's guide for the PRAFO boot also emphasized its role in supporting and positioning the lower leg, ankle, and foot, and minimizing pressure areas. The failure to provide the prescribed orthosis as ordered constituted a deficiency in care for the resident.
Failure to Implement Physician-Ordered Fluid Restriction for Dialysis Resident
Penalty
Summary
Facility staff failed to implement a physician-ordered fluid restriction for a resident dependent on renal dialysis. The resident, who had end stage renal disease and moderately impaired cognitive skills, was admitted with a fluid restriction order of 1000ml per day, divided between dietary and nursing. Despite this order being placed on 5/19/2025, the restriction was not initiated or communicated to dietary staff until 6/4/2025. During this period, the resident continued to receive meals and fluids without any restriction, as evidenced by observations and review of dietary tray cards, which did not reflect the fluid restriction order. Interviews with nursing and dietary staff revealed a lack of awareness and communication regarding the fluid restriction order. The order was not activated in the resident's electronic chart, resulting in both nursing and dietary departments failing to enforce the restriction. The facility's policies required that fluid restrictions for dialysis residents be implemented as ordered and reflected on dietary records, but these procedures were not followed, leading to the resident not receiving the prescribed care.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD) and major depressive disorder. The resident's admission record and social service assessment documented PTSD with specific triggers, including being touched, loud noises, and yelling. Despite this, the resident reported never having a care plan discussion regarding PTSD, and staff interviews revealed a lack of awareness about the resident's diagnosis and triggers. The resident also stated that loud music played in the hallway triggered her PTSD and caused migraine headaches, and she was told by a social worker to keep her door open during these activities, despite her discomfort. Observations confirmed that loud music was played daily in the hallway as part of a facility activity, which the resident identified as a trigger. Staff members, including a CNA and LVN, were unaware of the resident's PTSD or had not received training on trauma-informed care or PTSD. The Director of Nursing confirmed that no comprehensive care plan addressing the resident's PTSD and its triggers had been developed, and acknowledged that the daily activity could trigger the resident's symptoms. A review of the facility's policy on trauma-informed care indicated that staff should identify triggers and implement adjustments to reduce trauma-related distress, and that training should be provided to employees. However, the policy was not followed, as staff had not received the required training and no trauma-informed care plan was in place for the resident, resulting in ongoing exposure to known PTSD triggers.
Failure to Complete Monthly Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly Medication Regimen Review (MRR) for one of five residents for the months of February and March 2025. Specifically, the medication regimen for a resident with diagnoses including encephalopathy, schizophrenia, and major depressive disorder was not reviewed during these months, as evidenced by the absence of documentation in the MRR records. The resident was noted to have severely impaired cognitive skills and was dependent on staff for multiple activities of daily living. The resident was also prescribed high-risk medications, including antipsychotics, antianxiety agents, antidepressants, and an anticoagulant. During interviews and record reviews, the DON confirmed that all residents should be included in the monthly MRR and acknowledged that the resident's medications were not reviewed for the specified months. The DON stated that the consultant pharmacist typically sends the MRR via email, but she did not verify that all residents were included, resulting in the omission. The facility's policy required monthly pharmacist review of each resident's medication regimen to identify irregularities and clinically significant risks, but this process was not followed for the resident in question.
Failure to Clarify Medication Indication for Marinol
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not clarifying the order indication for Marinol. The resident, who had diagnoses including encephalopathy, schizophrenia, and recurrent major depressive disorder, was initially prescribed Megestrol for poor appetite. Following a medication regimen review, Megestrol was discontinued due to associated risks, and Marinol was started. However, the order for Marinol was written for 'vomiting,' even though the resident was not experiencing vomiting, and the intended use was for poor appetite. During interviews and record reviews, it was confirmed that the Director of Nursing (DON) recognized the discrepancy in the medication order and acknowledged that the licensed nurse should have clarified the indication with the physician. The facility’s policy required that medication orders include the condition or diagnosis for which the medication is ordered, but this was not followed. As a result, the staff were not properly informed of the correct indication for Marinol, leading to a deficiency in medication management for the resident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of a resident who was admitted with severe protein calorie malnutrition and muscle wasting. The resident's admission record and subsequent medical documentation did not include an updated Nutritional Quarterly Progress Evaluation reflecting her food preferences after she was started on an oral diet. Despite the resident expressing her dissatisfaction with the meals and specifically requesting certain breakfast items, there was no evidence that her preferences were assessed or honored by the dietary staff. The dietary director confirmed that no updated evaluation had been completed, and the facility's policy required the use of a dietary questionnaire to determine food preferences for residents on oral diets. Interviews with the resident, the dietary director, the DON, and an LVN revealed that staff were aware of the importance of honoring food preferences to prevent weight loss and ensure resident satisfaction. However, the staff did not communicate the resident's preferences to the dietician, speech therapist, or physician, nor did they take steps to ensure her choices were incorporated into her meal plan. The facility's policy and procedure required the dietary department to provide meals consistent with resident preferences, but this was not followed in the case of this resident.
Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to follow its antibiotic stewardship program protocols for prescribing antibiotics to a resident prior to the administration of antibiotic therapy. Specifically, a review of the resident's records showed that the resident was prescribed and administered meropenem IV for pneumonia, despite only meeting one of the three required criteria for antibiotic therapy as documented on the surveillance data collection form. There was no documentation that the physician was notified about the resident not meeting all required criteria before the antibiotic was started. The resident involved had a history of pneumonia, sepsis, urinary tract infection, and ESBL resistance, and was severely cognitively impaired and dependent on staff for daily activities. The Infection Preventionist Nurse confirmed during interview and record review that all three criteria must be met for antibiotic therapy to be initiated, and acknowledged the lack of documentation regarding physician notification. The facility's policy required the Infection Preventionist Nurse to review infection control surveillance forms to determine if the infection met the associated criteria, which was not followed in this case.
Call Light System Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for two residents who were dependent on staff for assistance with activities of daily living. For one resident with a tracheostomy, aphonia, and moderate cognitive impairment, the call pad was observed hanging by the side of the bed, out of the resident's reach while she was sleeping. Staff interviews confirmed that residents in the subacute unit, many of whom are non-verbal and require the call pad to alert staff for help, should always have the call pad within reach. Facility policy also requires that call cords be placed within the resident's reach to enable prompt communication with nursing staff. Another resident, who had severe cognitive impairment, dysphagia, dementia, and was dependent for mobility and personal care, was observed with the call light on the floor, out of reach. Staff interviews confirmed that the call light should have been clipped to the bed and accessible, as it is the resident's first line of help. The Director of Nursing and other staff acknowledged the importance of ensuring call lights are within reach, especially for residents who are nonverbal or unable to walk, to allow them to request assistance when needed.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on assistance for activities of daily living (ADLs) did not receive adequate incontinence care in accordance with the facility's policy. The resident, who had significant medical conditions including anemia, gastrostomy, tracheostomy, and toxic encephalopathy, was noted to be severely cognitively impaired and fully dependent on staff for personal care tasks such as toileting hygiene and dressing. Observations and interviews revealed that the resident was routinely changed only twice per shift, despite the facility's policy requiring incontinence pad or brief changes every 2 to 4 hours or as needed to keep the resident clean and dry. Multiple observations confirmed that the resident was frequently found with a brief full of urine, and both the gown and bed linens were wet with urine at the time of care. Staff interviews corroborated that this was a recurring issue, with the resident's brief and linens consistently wet during scheduled changes. The Director of Nursing acknowledged that the resident required more frequent changes than were being provided to maintain skin integrity and cleanliness, as outlined in the facility's continence management and perineal care policies.
Failure to Provide Timely Wound Care and Interventions for Pain and Confusion
Penalty
Summary
The facility failed to provide necessary care and treatment for two residents by not reevaluating and treating wounds and not implementing interventions after reports of pain and confusion. For one resident with severe cognitive impairment and multiple mental health diagnoses, the care plan indicated that skin tears should be treated per protocol and the physician notified. Despite ongoing observations of the resident scratching herself, resulting in bleeding wounds on her arms and legs, there was no evidence of reevaluation or notification to the physician when treatments proved ineffective. The resident's care plan also lacked documentation for a prescribed ointment, and both the registered nurse and the director of nursing acknowledged that a care plan should have been in place to ensure continuity of care. For another resident with severe cognitive impairment and multiple medical conditions, including a history of shoulder dislocation and chronic respiratory issues, the facility did not provide appropriate interventions after the resident and family reported pain and episodes of confusion. Nursing notes indicated that the family expressed concerns about a possible fall and ongoing pain, but there was no documentation of a change of condition assessment, physician notification, or implementation of monitoring protocols such as neuro checks or 72-hour monitoring. Staff interviews confirmed that these steps were not taken, and the care plan was not updated to reflect the resident's current status. Facility policies required notification of the physician and the interdisciplinary team, assessment and documentation of changes in condition, and updates to care plans when there is a significant change in a resident's status. In both cases, these procedures were not followed, resulting in a lack of timely and appropriate care for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 12.12%. During a medication pass observation, four medication errors were identified out of 33 opportunities. Specifically, a resident with multiple diagnoses, including chronic obstructive pulmonary disease, chronic respiratory failure, atrial fibrillation, and urinary retention, did not receive four scheduled medications—apixaban, spironolactone, finasteride, and bethanechol—at the prescribed time. These medications were scheduled for administration at 9 AM but were instead given between 10:18 AM and 10:24 AM, outside the facility's policy window of one hour before or after the scheduled time. The resident in question was severely cognitively impaired and dependent on staff for all activities of daily living. The nurse administering the medications acknowledged that the medications were given late and described the potential impact of delayed administration for each medication. Facility policy required medications to be administered within a specific time frame, and the observed deviation from this policy led to the identified deficiency.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing Information was accurate and updated daily, as required by its policy and procedure. Observations revealed that the staffing information displayed in the front lobby was not current on multiple occasions, with postings showing outdated dates. Specifically, on several days, the posted information did not reflect the actual number of staff present for various shifts in both the subacute and skilled nursing facility units. Record reviews confirmed discrepancies between the posted staffing information and the actual Nursing Staffing Assignment and Sign-in Sheets for those dates and shifts. Interviews with the Director of Staff Development (DSD), Director of Nursing (DON), and Administrator confirmed that the posted information should accurately represent the number of staff working each day to inform residents, visitors, and staff. The facility's policy, revised in October 2022, requires daily posting of the total number and actual hours worked by licensed and unlicensed nursing staff in a prominent location. The failure to maintain accurate and timely postings had the potential to leave residents and visitors uninformed about the actual staffing levels providing direct care.
Failure to Document Wound Care Treatment for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to accurately document wound care treatment for one resident with a stage 4 pressure ulcer. The resident, who had a history of paraplegia, neuromuscular bladder dysfunction, and a stage 4 pressure ulcer on the right buttock, was admitted and readmitted to the facility with these diagnoses. Physician orders indicated daily wound care treatment for the pressure ulcer, and the treatment was to be documented in the resident's medical record. However, from 5/14/2025 to 5/27/2025, there was no documentation in the medical record to confirm that the wound care treatment was provided, despite the treatment nurse stating that the care was given during this period. Record reviews showed that the last documented wound care was on 5/13/2025, and subsequent treatment records were missing for the following 14 days. The facility's policy required that all treatments be documented upon completion, but this was not followed. Both the treatment nurse and the Director of Nursing confirmed that the required documentation was not completed, resulting in a lack of proof that the prescribed wound care was administered during the specified period.
Failure to Honor Advance Directive and DNR Order
Penalty
Summary
Facility staff failed to honor a resident's advance directive and physician's Do Not Resuscitate (DNR) order. The resident, who had diagnoses including cerebral infarction, endocarditis, hypertensive heart disease, and ulcerative colitis, was documented as having intact cognitive skills and had executed an advance directive indicating a wish not to prolong life. The resident's medical record included a DNR order, and the facility had acknowledged receipt of the advance directive. Despite these clear instructions, the resident received cardiopulmonary resuscitation (CPR) after being found on the floor by staff. Interviews with the family member and the Director of Nursing confirmed that CPR was administered against the resident's documented wishes and medical orders. The facility's policies required adherence to advance directives and DNR orders, but these were not followed in this instance. The Director of Nursing acknowledged that CPR should not have been performed, as it was contrary to both the resident's advance directive and the physician's order.
Failure to Timely Report Allegations of Abuse Involving Two Residents
Penalty
Summary
The facility failed to report allegations of physical and verbal abuse involving two residents within the required 2-hour timeframe to the State Survey Agency and the state ombudsman, as mandated by the facility's abuse policy. The incidents involved a family member (FM) who was observed by a Certified Nursing Assistant (CNA) and another resident engaging in abusive behavior towards a resident, including pulling the resident's hair, pushing her head down, and yelling at her. The CNA reported the incident to the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS), who in turn informed the Director of Nursing (DON). However, no immediate report was made to the appropriate authorities as required by policy. Resident 1, who had a history of acute respiratory failure, anxiety disorder, and hypertension, was cognitively impaired and required significant assistance with daily activities. The abuse incident occurred while the resident was brushing her teeth and vomiting, during which the family member became angry, pulled her hair, and pushed her head down while yelling. The CNA intervened and later contacted the police when she did not receive a response from the facility administrator. The police arrived, and the resident was placed on monitoring for emotional distress. Interviews with staff confirmed that the incident was not reported to the Department of Public Health (CDPH) within the required timeframe, and the DON acknowledged forgetting to make the report. A second resident, who had a history of falls and fractures, also reported being verbally abused by the same family member, who yelled at her and told her to "shut up" multiple times. This resident expressed anxiety and distress related to the family member's presence. The facility's policy clearly states that all allegations of abuse, including those involving family members, must be reported immediately, but this protocol was not followed in these cases. The failure to report these incidents as required constituted a deficiency in the facility's abuse prevention and reporting practices.
Failure to Ensure Functioning Call Light System for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a functioning call light system for one of four sampled residents. The resident, who had diagnoses including respiratory failure, tracheostomy, and muscle wasting, was assessed as having moderately impaired cognitive skills and was dependent on staff for all personal care activities. On the date of the incident, the resident was observed attempting to use the call light to request assistance for incontinence care, but no staff responded. Upon investigation, it was found that the call light cord was partially disconnected from the wall, rendering it nonfunctional. The resident expressed a need for assistance due to discomfort in the perineal area. Staff interviews confirmed that the call light was not properly connected, preventing it from alerting staff to the resident's needs. Facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, acknowledged the importance of ensuring call lights are plugged in, working, and within reach, especially for residents who cannot communicate verbally. Review of facility policy indicated that a working call system should be available to enable residents to alert nursing staff promptly from their beds.
Unattended Medical Records Expose Resident Information
Penalty
Summary
Facility staff failed to protect the medical records of six residents when a respiratory therapist left therapy notes containing sensitive information unattended on top of a therapy cart in a hallway. The unattended document included residents' names, room numbers, medications, oxygen requirements, diagnoses, and vital signs such as oxygen saturation, heart rate, respiratory rate, and breath sounds. This cart was located in a public area where other staff, residents, and visitors frequently passed by, making the information easily accessible to unauthorized individuals. Observations confirmed that the paper with residents' information was left open and unattended on the therapy cart. A licensed vocational nurse acknowledged that anyone walking by could see the residents' medical information and identified this as a violation of HIPAA regulations. The nurse further stated that staff are aware they should not leave papers with residents' information exposed, and that this was a breach of privacy. Interviews with another respiratory therapist and the director of nursing confirmed that the proper procedure is to keep such documents secured inside a locked drawer of the therapy cart, not left out in the open. Both staff members emphasized the importance of maintaining confidentiality and privacy of residents' health information. A review of the facility's policy and procedure also indicated that staff should not divulge clinical information in public areas and must keep medical records secure and confidential.
Failure to Administer Medications Within Prescribed Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents when a Licensed Vocational Nurse (LVN) did not administer scheduled medications within 60 minutes of the prescribed 9 AM time. This was observed for three residents with complex medical histories, including Huntington's disease, dementia, diabetes mellitus, chronic obstructive pulmonary disease, and schizophrenia. The facility's policy required medications to be administered within 60 minutes of the scheduled time, except for those ordered before, with, or after meals. For one resident with Huntington's disease, dementia, and anxiety disorder, the medication administration was observed at 10:02 AM, over an hour past the scheduled time. The LVN prepared and administered several medications, including Buspirone, Cholecalciferol, Tetrabenazine, Zoloft, and Zyprexa, after the scheduled window. Another resident with diabetes, autistic disorder, and dementia had multiple 9 AM medications, such as Aspirin, Cholecalciferol, Finasteride, Gabapentin, Glipizide, and others, not administered by 10:30 AM. The LVN was unable to locate one of the medications (chewable aspirin) during the medication pass. A third resident with COPD, schizophrenia, and major depressive disorder also did not receive their 9 AM medications by 10:18 AM, as indicated by blank documentation on the medication administration record. The LVN reported technical issues with the electronic medication administration record (MAR) as the reason for the delay. Interviews with nursing staff and the Director of Nursing confirmed that medications were administered late and emphasized the importance of timely administration as per physician orders and facility policy.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during the provision of care. The resident, who had a diagnosis of left breast cancer and required varying levels of assistance for activities of daily living, reported that the CNA threw her legs onto the bed and roughly tossed a pillow at her face while assisting with perineal hygiene. The resident described feeling humiliated and emotionally distressed as a result of this interaction. She did not report the incident immediately due to shock but later informed social services after reflecting on the potential for similar treatment of others. The resident's care plan indicated a risk for emotional distress and skin issues related to rough handling during care. Interviews with facility staff, including the DON and Administrator, confirmed awareness of the incident and acknowledged that the CNA was an agency staff member. The facility's policy required all employees to treat residents with kindness, respect, and dignity, and to honor residents' rights, regardless of diagnosis or condition. The actions of the CNA were inconsistent with these expectations and resulted in the resident experiencing emotional harm.
Failure to Communicate and Accommodate Resident Food Allergy
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to eggs was not properly accommodated during meal service. The resident's admission and allergy records clearly indicated an egg allergy, but this information was not reflected on the resident's diet order or meal tray ticket. As a result, the resident was served potato salad containing mayonnaise, an egg-based product, during lunch. After consuming a portion of the meal, the resident experienced symptoms consistent with an allergic reaction, including throat itchiness, shortness of breath, and throat constriction, prompting her to seek assistance from nursing staff. Interviews with facility staff revealed that the dietary kitchen assistant, who was in charge at the time, did not have access to or the ability to modify resident meal preferences or allergy information. The kitchen staff relied solely on the tray card for guidance, which did not list the egg allergy. The certified nursing assistant who served the meal did not verify the ingredients with the kitchen staff before serving the tray. Additionally, the following morning, the resident's breakfast tray again lacked an indication of the egg allergy on the preference card, despite the allergy being documented in the resident's records. The facility's policies required that resident allergies be reflected on tray cards and that food service staff be aware of such allergies. However, the failure to update and communicate the resident's egg allergy on the tray ticket and to verify meal ingredients led to the resident being served food containing eggs on multiple occasions. This lapse in communication and adherence to policy resulted in the resident experiencing an allergic reaction and requiring medical intervention.
Failure to Perform Hand Hygiene Prior to Food Preparation
Penalty
Summary
A Kitchen Aid (KA) was observed in the kitchen opening the trash lid and then proceeding to cut zucchini squash on a cutting board without performing hand hygiene. This action was directly witnessed by surveyors during a kitchen observation. When interviewed, the KA acknowledged not performing hand hygiene after touching the trash lid and stated that staff are required to perform hand hygiene before handling food to prevent the spread of infections. The Administrator (ADM) confirmed during an interview that kitchen staff should thoroughly perform hand hygiene with soap and water before, during, and after food preparation. A review of the facility's policies indicated that hand hygiene is considered the primary means to prevent the spread of infection and is required to ensure a safe and sanitary environment. The facility's Infection Prevention and Control Program also mandates maintaining practices to prevent the development and transmission of disease and infection.
Failure to Supervise and Enforce Policies Leads to Resident Safety Risks
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for three residents, leading to multiple incidents of non-compliance with facility policies. Resident 1 was able to obtain and consume alcohol on facility grounds, despite the facility's zero-tolerance policy for alcohol without a physician's order. This incident occurred on 3/9/2025, when Resident 1 was observed drinking vodka in the parking lot, which was reported by other residents and confirmed by the Maintenance Assistant. The Director of Nursing acknowledged that Resident 1 did not have a physician's order to consume alcohol, and the consumption was contraindicated due to the resident's medication regimen. Additionally, the facility failed to supervise Residents 1, 2, and 3 while they were outside by the parking lot and in the smoking area on multiple occasions. On 3/9/2025 and 3/12/2025, these residents were left unsupervised, which allowed Resident 1 to consume alcohol and potentially engage in other unsafe behaviors. Interviews with various staff members, including the Housekeeping staff and Kitchen Staff, confirmed that there was no staff present to monitor the residents during these times, contrary to the facility's policy that requires supervision during smoking sessions. The facility also did not implement its policy and procedure regarding smoking compliance and failed to update Resident 1's care plan to reflect necessary interventions. Despite Resident 1's history of non-compliance with the smoking policy, including keeping smoking materials in a locked drawer in his room, the facility did not enforce the policy that required smoking materials to be kept in a secure place by staff. The interdisciplinary team meetings intended to address Resident 1's smoking violations were not conducted as planned, and the care plan was not updated to ensure the resident's safety.
Failure to Implement Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directives was placed in the resident's chart alongside the Physician Orders for Life-Sustaining Treatment (POLST). This oversight led to a conflict in carrying out the resident's wishes for medical treatment when the resident went into respiratory arrest with no pulse detected. Despite having an advance directive indicating a Do Not Resuscitate (DNR) order, the facility staff provided CPR to the resident due to the absence of the directive in the medical records. The resident, who had intact cognitive skills for daily decision-making, was admitted with diagnoses of acute embolism and thrombosis of the right internal jugular vein and paroxysmal atrial fibrillation. The resident's family member confirmed that a notarized copy of the advance directive was provided to the facility, but it was not included in the resident's medical records. The Director of Nursing and Social Services Director acknowledged the absence of the advance directive in the chart, which should have been available to guide staff during emergencies. The directive was later found mixed with the resident's hospital records after the surveyor's exit.
Incomplete POLST Leads to Conflict in Resident's DNR Wishes
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders for Life-Sustaining Treatment (POLST) was complete with the necessary physician's signature, which is required to confirm the resident's do not resuscitate (DNR) status. This deficiency was identified for one of the two sampled residents, who had a POLST indicating DNR, comfort-focused treatment, and no artificial means of nutrition. However, the POLST was left unsigned by the physician, leading to a conflict in carrying out the resident's wishes when they went into respiratory arrest with no pulse detected, and CPR was administered by facility staff. The resident involved had an intact cognitive ability for daily decision-making and was dependent on assistance for various activities of daily living. The incident occurred when the resident went into respiratory arrest, and the facility staff initiated CPR, contrary to the resident's documented wishes. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the responsibility for ensuring the POLST was complete, including obtaining the physician's signature, was not fulfilled. The resident's physician was unaware of the DNR status due to the lack of a signature, which is necessary for the POLST to be a legally effective document that guides the facility's actions during emergencies.
Failure to Develop Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan for a resident at risk of elopement. The resident, who was admitted with diagnoses including seizures, diabetes, and muscle wasting, was noted to have fluctuating capacity to understand and make decisions. Despite being independent in cognitive skills for daily decision-making, the resident expressed a desire to be discharged home and was able to ambulate independently. The facility's Director of Nursing acknowledged that the resident was at risk for elopement during an IDT meeting, yet no care plan addressing this risk was developed. The facility's policies and procedures require the identification of residents at risk for elopement and the documentation of preventive interventions in the resident's medical record. However, the resident's risk for elopement was not documented, and no care plan was created to address this risk. This oversight was highlighted when the resident ambulated out of the facility, indicating a failure to implement the facility's policies and procedures effectively.
Failure to Complete Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure a neurological assessment was completed for a resident who experienced an unwitnessed fall, as per the facility's policy and procedure. The resident, who was admitted with a history of falling, anxiety, and muscle wasting, was found sitting on the floor next to her bed. The facility's policy required a 72-hour neuro check following such incidents, but the documentation showed that multiple scheduled assessments were missed. The neurological assessment flowsheet for the resident indicated that the last documented neuro check was conducted shortly after the fall, with subsequent scheduled checks left blank. Interviews with the Quality Assurance Nurse and Licensed Vocational Nurse confirmed that the flowsheet had incomplete documentation, with a total of ten missed assessments. The nurses acknowledged the importance of following the neuro check schedule to monitor for any changes in the resident's condition following the fall. Further interviews with the nursing staff revealed that the neuro check was not endorsed to the incoming nurse, and the scheduled assessments were not conducted. The facility's policy required neuro checks to be performed following an unwitnessed fall to detect any potential head injuries or changes in the resident's level of consciousness. The failure to complete these assessments as scheduled was verified by the nursing staff, who emphasized the importance of timely care and treatment to ensure resident safety.
Failure to Document and Report Medication Irregularities
Penalty
Summary
The facility failed to properly document and report irregularities in the medication regimen review for a resident, specifically concerning the use of Lorazepam. The resident, who was admitted with diagnoses including anxiety and muscle wasting, had orders for Lorazepam that were incomplete, lacking a diagnosis and specific target behavior. This oversight was identified during a review of the resident's records, which showed that the orders did not include necessary monitoring instructions for the medication's use and potential adverse reactions. The consulting pharmacist did not identify or report these irregularities during the monthly drug regimen review conducted at the end of November. The pharmacist missed the opportunity to clarify the Lorazepam order with the prescribing physician, which should have included the resident's diagnosis and specific behaviors to monitor. This omission meant that there was no recommendation made to the attending physician regarding the need for monitoring specific behaviors and potential adverse reactions associated with Lorazepam use. Interviews with facility staff, including a registered nurse and a quality assurance nurse, confirmed that the lack of documentation and reporting by the pharmacist prevented necessary discussions with the resident's psychiatrist. The facility's policy on psychotherapeutic drug management requires the pharmacist to review and make recommendations, but this was not adhered to in this case, leading to a potential risk of unnecessary medication administration and harm to the resident.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs, specifically Lorazepam, as per the facility's policy and procedure on Psychotherapeutic Drug Management. The resident, who was admitted with a history of falling, anxiety, and muscle wasting, was prescribed Lorazepam without a specific indication for a diagnosis in the physician's order. Additionally, the order lacked a specific target behavior, such as restlessness or attempts to get up from bed without assistance, which are manifestations of the resident's anxiety. The resident's Lorazepam PRN order was not discontinued after 14 days from the start date, as required by the facility's policy. There was no documentation from the resident's physician to justify extending the PRN order beyond this period. The Quality Assurance Nurse confirmed that the Lorazepam order was incomplete and emphasized the importance of having a complete physician order to ensure the correct medication is administered for the correct indication. Furthermore, the facility did not have an order to monitor or document any adverse reactions to the anti-anxiety therapy, nor was there an order to monitor the occurrence of target behaviors for the use of Lorazepam. The Registered Nurse highlighted the necessity of including specific target behaviors in the physician's order to guide licensed nurses on when to administer the medication and to monitor its effectiveness. The facility's policy requires that psychotropic medication orders include a diagnosis and indications for the disorder being treated, and PRN orders for such drugs are limited to 14 days unless extended with documented rationale.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment and care plans. Resident 1, who was admitted with severe cognitive impairment and multiple unstageable pressure ulcers and deep tissue injuries (DTIs), did not receive consistent wound care treatment as ordered by the physician. The Treatment Administration Record (TAR) for Resident 1 showed missing wound care treatments on several dates, indicating that the prescribed care was not administered. Additionally, Resident 1's care plan did not include specific management strategies for the existing pressure ulcers and DTIs, contrary to the facility's policy. Resident 2, who was admitted with muscle wasting and atrophy, had a stage 2 and a stage 3 pressure ulcer upon admission. The facility failed to set the low air loss (LAL) mattress according to Resident 2's weight, which was significantly lower than the mattress setting. This incorrect setting could increase pressure on the resident's back, potentially worsening the pressure ulcers. Furthermore, Resident 2 was not turned and repositioned every two hours as required, which is crucial for preventing further skin breakdown and promoting healing. Interviews with the nursing staff, including a Registered Nurse (RN) and a Certified Nursing Assistant (CNA), confirmed these deficiencies. The RN acknowledged that the LAL mattress was not set correctly and that Resident 2 was not turned as needed. The CNA noted that Resident 2 could not be kept turned without a turn wedge, which was not used. The Director of Nursing (DON) also confirmed the incorrect mattress setting and the lack of proper turning, acknowledging that these practices defeated the purpose of the LAL mattress and could lead to further skin breakdown.
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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