Good Samaritan Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 1630 N. Edison Street, Stockton, California 95204
- CMS Provider Number
- 055039
- Inspections on file
- 19
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Good Samaritan Rehab And Care Center during CMS and state inspections, most recent first.
A resident with chronic pain syndrome, ESRD, PVD, multiple wounds, gangrene, and bilateral lower extremity amputations repeatedly reported severe pain, including 10/10 pain, yet staff administered PRN acetaminophen ordered only for mild pain and did not consistently notify the physician when pain remained uncontrolled. The ordered oxycodone-acetaminophen for severe pain was not available due to a delayed C-II prescription and pharmacy delivery issues, and staff were unable to obtain authorization to use the narcotic E-kit despite the resident’s ongoing severe pain. Nursing staff acknowledged administering pain medication inconsistent with the pain scale parameters, failing to obtain clear PRN orders for mild, moderate, and severe pain, and not promptly addressing the resident’s pain, while the DON confirmed there was no order for moderate pain medication and that pain management for this resident was a concern.
A resident who was fully dependent on staff for ADLs due to significant neurological impairment did not receive weekly showers for two months, as required by facility policy. Despite daily bed baths, staff interviews and record reviews confirmed the absence of weekly showers, and the DON acknowledged the policy was not followed.
The facility did not maintain confidentiality or proper organization of medical records when documents belonging to two residents, including intake/output forms and a physician's order for time of death, were found in another resident's file. This mix-up was confirmed by medical records staff, who stated that facility policy was not followed, potentially exposing private information and leading to inappropriate care actions.
Dietary aides were observed discarding meal tray tickets containing residents' personal and medical information into regular trash bins, rather than shredding them as required by facility policy. Both the Registered Dietician and DON acknowledged this as a breach of confidentiality, and the facility's policy specifies that such information must be destroyed to prevent unauthorized access.
Surveyors identified multiple deficiencies in food storage, preparation, and kitchen sanitation, including improper thawing of raw meat, storage of spoiled produce, incorrect dating and handling of leftovers, staff food stored with resident food, food and supplies placed on the floor, non-food and personal items in storage areas, dented cans ready for use, wet food service items stored without drying, and dirty kitchen equipment. These actions and inactions were confirmed by interviews with the CDM, RD, and kitchen staff, and were found to be inconsistent with facility policy and FDA Food Code requirements.
Surveyors found that a can opener was not properly cleaned, with visible food debris and metal shavings, and the dishwashing machine failed to reach the required sanitizing temperature, as confirmed by dietary staff and the RD. These deficiencies were not in line with FDA Food Code requirements for safe and sanitary food service equipment.
Roaches were found in and around a microwave used to reheat residents' food, with visible old food splatters and inadequate cleaning by housekeeping. Despite regular monthly pest control, staff confirmed the presence of roaches and acknowledged the infection control risk, and records showed prior reports of pest sightings and treatment.
A resident with a urinary catheter for urinary retention was observed with an uncovered catheter bag in their room. Both a CNA and an LN confirmed the lack of a privacy cover, acknowledging it should have been in place to maintain dignity. The DON and facility policy require catheter bags to be covered to protect resident privacy and dignity.
A resident with dementia, under the care of a court-appointed conservator, was prescribed and administered Risperidone and Valproic Acid without documented informed consent from the responsible party. Facility staff confirmed that consent forms were incomplete and lacked evidence of discussion with the conservator, despite facility policy requiring informed consent prior to psychotropic medication use.
Two residents were not properly supervised while smoking and had access to smoking materials against facility policy. One resident with cognitive impairment was left alone in the courtyard to smoke after staff lit his cigarette, despite his care plan requiring supervision. Another resident with respiratory conditions kept a lighter in his room and on his person, with staff providing inconsistent guidance about storage and supervision of smoking paraphernalia. These actions were not in accordance with the facility's smoking policies and placed residents at risk for accidental burns and injuries.
A nurse administered Amlodipine to a resident with a blood pressure below the physician-ordered hold parameter, despite documentation in the MAR and order summary indicating the medication should be withheld if systolic blood pressure was under 110. The DON confirmed that facility policy was not followed, and the nurse acknowledged the error.
Surveyors identified multiple deficiencies in medication and supply storage, including staff beverages and personal items in medication rooms, an unlocked medication refrigerator containing narcotics, expired and unlabeled medications in medication and treatment carts, and opened but undated multi-use wound care solutions. Nursing staff and the DON confirmed these practices did not follow facility policy.
A resident admitted with muscle weakness and repeated falls had physician orders for PT and OT evaluations and treatments, but did not receive these services as required. Both therapists confirmed they did not receive referrals, and the DON acknowledged that therapy services were unavailable during a transition period. The resident's care plans referenced the need for therapy, but no evaluations or treatments were provided.
A resident receiving care from an outside primary care provider did not have the provider's progress notes included in their medical record. Staff interviews revealed that the facility had not received or requested these notes, and the DON confirmed their absence, resulting in incomplete documentation of the resident's care and communication among the care team.
The facility did not provide evidence of an ongoing QAPI program, as required, and only produced QAPI documents that were created during the survey week after deficiencies were identified. Despite having written policies describing QAPI processes, there was no documentation showing active implementation or a current QAPI plan prior to the survey.
A Medical Records Assistant refilled a personal soda bottle from a resident water dispenser, allowing the bottle's mouth to touch the dispenser spout, contrary to facility policy. The DON confirmed that staff were instructed to avoid such contact to prevent contamination and infection, but this protocol was not followed.
A resident who developed a UTI and was prescribed antibiotics was not tracked according to the facility's Antibiotic Stewardship Program. The required stewardship guideline form was not initiated, the resident was not added to antibiotic tracking logs, and an antibiotic time-out was not performed or documented. The Infection Preventionist was unaware of the antibiotic prescription, and the facility's policy for monitoring and reassessment of antibiotic use was not followed.
Four rooms were found to be below the required minimum square footage per resident, with three triple-occupancy rooms and one double-occupancy room not meeting the 80 square feet per resident standard. Despite this, residents and staff reported no issues with care delivery or mobility within these rooms, and the Administrator confirmed no complaints had been received.
A resident with end-stage renal disease missed a scheduled dialysis session due to unavailable transportation, resulting in a four-day gap without treatment. The facility did not attempt alternative transportation options or notify the resident's family. Additionally, the facility failed to maintain up-to-date lab results from the dialysis center in the resident's medical record, as required by policy.
The facility failed to ensure safe handling of hazardous medications during storage and administration. LNs administered hazardous drugs like valproic acid and finasteride without using gloves or PPE, and MARs lacked handling instructions. Interviews revealed staff were unaware of special handling requirements, and the DON acknowledged the issue.
A resident with a history of left-side paralysis and a crushed left leg experienced unmanaged severe pain due to the facility's failure to notify the physician and obtain appropriate pain medication. Despite repeated complaints of severe pain, the resident was given ibuprofen, which was insufficient, instead of the prescribed Morphine Sulfate for severe pain, which was only administered at bedtime. The facility did not follow its policy for physician notification, resulting in prolonged unmanaged pain for the resident.
The facility failed to ensure prescribed medications were available and communicated unavailability to the medical doctor for two residents. Additionally, the facility did not follow safe pharmaceutical practices, including proper medication disposal and accountability of delivered medications.
The facility failed to ensure safe infection control practices with shared medical devices and did not have a water management program, putting residents at risk for infections. Additionally, a resident's room was found to be cluttered and unsanitary, further increasing the risk of infection.
The facility failed to ensure a resident's POLST form was fully completed and uploaded to their EHR. The form lacked essential identifying information, which could lead to incorrect life-sustaining measures being administered. Staff interviews confirmed the omission and the potential for a full code to be performed contrary to the resident's wishes.
The facility failed to ensure that two residents received care and services safely when they were unable to open a heavy and sticky bathroom door. Both residents reported difficulty and feelings of entrapment, with observations confirming the door's inaccessibility. The facility's policy on resident accommodation was not followed, impacting the residents' independence and dignity.
The facility failed to develop and implement care plans for psychotropic and high-risk medications for three residents, leading to inadequate monitoring of medication use and potential adverse effects. The deficiencies were confirmed by the DON and LNs during a review of the residents' medical records.
The facility failed to ensure a safe environment and adequate supervision for a resident with epilepsy and muscle weakness. The fall risk assessment was inaccurate, and interventions were not updated after multiple falls. Additionally, the resident eloped from the facility, and staff were unaware until contacted by the police. The care plan did not address the elopement risk, and facility policies were not followed.
The facility failed to follow the physician's orders for supplemental oxygen administration for a resident with COPD and asthma. The resident was observed receiving higher levels of oxygen than prescribed, and clinical records showed multiple instances of incorrect oxygen administration. Interviews with staff and the Director of Nursing confirmed that the facility's policy on oxygen therapy was not followed.
The facility failed to apply appropriate siderails for a resident who was ordered half siderails but was found with two full bed siderails in use. The resident's medical records indicated a high risk for falls and specified the use of half siderails for bed mobility and transfers. Both a licensed nurse and the DON confirmed the presence of full siderails and acknowledged the order for half siderails, with no proper assessment, care plan, or consent for full siderails.
The facility failed to monitor the adverse effects of high-risk medications in two residents. One resident was prescribed multiple blood thinners and a pain medication, while another was on aspirin and clopidogrel for stroke prevention. In both cases, there was no documented monitoring for adverse effects, which was acknowledged by the DON.
The facility failed to monitor psychotropic medication side effects and behaviors for a resident prescribed duloxetine and cariprazine for anxiety. The oversight was confirmed during a review of the resident's medical records, which showed no documented daily monitoring as required by the facility's policy.
The facility failed to review and update the Facility Assessment annually, with the last update occurring in January 2018. This was confirmed by the Administrator and DON during an interview and record review. The facility policy requires annual reviews and updates of the Facility Assessment.
Four rooms in the facility did not meet the required square footage per resident. Despite this, residents reported no concerns, and staff indicated they could perform their duties effectively. The Administrator confirmed the measurements and acknowledged the shortfall.
Failure to Provide Ordered and Appropriate Pain Management for a Resident With Severe Chronic Pain
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice for a resident with extensive medical conditions and chronic pain. The resident was admitted with chronic pain syndrome, acquired absence of limb, peripheral vascular disease, pressure ulcers, chronic cholecystitis, and end stage renal disease, and had multiple open sores, gangrene, and bilateral lower extremity amputations. Physician orders included acetaminophen 325 mg, two tablets every six hours as needed for mild pain, and oxycodone-acetaminophen 10-325 mg, one tablet twice daily for severe pain. The resident’s care plan indicated the resident was on pain medication therapy related to ESRD, PVD, and multiple wounds, with a goal that the resident would be free of discomfort, and interventions directing staff to administer analgesics as ordered, assess pain intensity, and request changes in the regimen if pain control was not adequate. From admission and during subsequent stays, the resident repeatedly reported severe pain that was not managed according to the physician’s orders or the resident’s reported pain levels. Nursing progress notes documented that on admission the resident expressed 10/10 pain, refused PRN acetaminophen stating it would not help, and was informed that oxycodone would arrive with the pharmacy delivery, but the ordered oxycodone was not available. On another date, the resident again expressed 10/10 pain, and the charge nurse administered PRN Tylenol despite the order specifying it for mild pain only. Later that same day, the resident was observed yelling and screaming in extreme pain rated 10/10; PRN Tylenol was given at 2100 with no relief, and the scheduled oxycodone dose due at that time was not available because the pharmacy had not delivered it. The on-call pharmacy contact declined to authorize use of the narcotic emergency kit, and the resident continued to report severe pain. Further documentation and interviews showed that the resident’s severe and moderate pain continued to be treated with a medication ordered only for mild pain, without appropriate physician notification or adjustment of orders. A nursing note indicated the pharmacy had mistakenly faxed the required C-II prescription form to the wrong physician, delaying oxycodone dispensing, and that the resident had been screaming in pain since admission. The pharmacist stated she could have authorized emergency kit use if a physician verbal order had been obtained. Review of the MAR with LN 3 showed that acetaminophen for mild pain was administered on multiple dates when the resident reported severe pain scores of 8–10, and LN 3 acknowledged this did not match the physician’s order and that the physician should have been contacted. Review with LN 2 showed acetaminophen for mild pain was given when the resident reported moderate pain scores of 5–6, and LN 2 acknowledged she should have reviewed the orders, reassessed pain, and contacted the physician for clear PRN orders for mild, moderate, and severe pain. The DON confirmed that there was no order for moderate pain medication, that nurses were expected to contact the physician when pain was not adequately controlled, and stated that pain management for this resident was a concern. Pharmacist interviews confirmed that a delay in receiving the completed C-II prescription and lack of communication from the facility contributed to the unavailability of the ordered narcotic, leaving the resident’s severe pain untreated. Facility policies required assessment for pain, review of physician orders, calling the physician if there was no pain medication order or if medication was ineffective, and monitoring and documenting effectiveness, which were not consistently followed in this case.
Failure to Provide Weekly Showers for Dependent Resident
Penalty
Summary
A facility failed to provide a dependent resident with weekly showers for a period of two months, despite the resident's need for assistance with all activities of daily living (ADLs) due to conditions including cerebral infarction, hemiplegia, and hemiparesis. The resident was admitted in 2018 and was documented as being dependent on staff for completion of ADLs. Interviews with the responsible party and staff, as well as review of clinical records and electronic medical records (EMR), confirmed that the resident did not receive a shower in May or June 2025, although daily bed baths were provided. The facility's policy required that bedridden residents receive daily bed baths and weekly showers, but this was not followed for the resident in question. Multiple staff members, including the Director of Staff Development, Licensed Nurse, Medical Records staff, and the DON, confirmed through interviews and record reviews that there was no documentation of showers being provided during the specified period. The DON acknowledged that the facility's policy was not followed and confirmed the absence of weekly showers for the resident. The deficiency was identified through interviews, record reviews, and confirmation that the facility's own bathing policy was not adhered to for this resident.
Failure to Maintain Confidentiality and Proper Organization of Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and proper organization of resident medical records, resulting in portions of two residents' medical records being found in another resident's file. Specifically, intake and output forms for one resident and a physician's order regarding the time of death and release of body for another resident were discovered in a third resident's medical record. This was confirmed during a concurrent interview and record review with the Medical Records staff, who acknowledged that the documents were mixed up and that facility policy was not followed. The affected residents had significant medical histories, including conditions such as cerebral infarction, hemiplegia, hemiparesis, respiratory failure, and diabetes mellitus. The facility's policy required that all medical records be complete, accurately documented, and stored to protect against unauthorized use, with each patient assigned a unique medical record number. The improper filing and mixing of documents created the potential for exposure of private and confidential information to unauthorized individuals and could have led to inappropriate care actions if orders were followed for the wrong resident.
Improper Disposal of Meal Tray Tickets Containing PHI
Penalty
Summary
The facility failed to protect residents' personal and medical information by improperly disposing of meal tray tickets that contained sensitive data. During observations in the kitchen, dietary aides were seen discarding meal tray tickets, which included residents' names, unit, room and bed numbers, diet orders, allergies, food notes, and other identifying information, into regular trash bins along with food scraps. This practice was confirmed by dietary staff as the standard method of disposal for these documents. Interviews with the Registered Dietician and the Director of Nursing revealed that both recognized the confidentiality issue associated with this practice. The Director of Nursing specifically stated that all meal tray tickets should be shredded after use to maintain privacy, and acknowledged that the current practice violated residents' privacy expectations. A review of the facility's policy confirmed that patient health information should be destroyed in a manner that renders it unreadable before disposal, which was not being followed in this case.
Widespread Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and kitchen maintenance that did not meet professional standards for food safety. Raw chicken was found thawing in a sink without running water, contrary to facility policy and FDA Food Code requirements, which specify that thawing under water must be done with running water at 70°F or lower. Over-ripe and spoiled produce, including eggplants with discoloration, bell peppers with mold, and tomatoes with black fuzzy substances, were found in the walk-in refrigerator and available for use. Additionally, containers of food were incorrectly dated or lacked use-by dates, and leftover food was kept beyond safe time frames without following the required cool down process or proper documentation. Staff food was stored in the same refrigerator as resident food, with raw tilapia intended for staff placed on top of cooked food and vegetables, increasing the risk of cross-contamination. Boxes of food, drinks, and supplies were found stored directly on the floor in the dry storage room, and non-food items such as chairs, a space heater, a fan, and personal lunch pails were also stored in this area. Dented cans were found in the dry storage area, ready to serve, despite facility policy requiring such items to be separated and returned to the vendor. Clean food service items, such as trays and steam table pans, were put away while still wet, and the oven was found dirty with layers of grease and food debris. Interviews with the Certified Dietary Manager (CDM), Registered Dietician (RD), and kitchen staff confirmed that these practices did not align with facility policies or food safety standards. The RD and CDM acknowledged that the observed conditions, such as improper thawing, storage of spoiled produce, lack of proper labeling and dating, and failure to follow cleaning schedules, were unacceptable and posed risks for foodborne illness. The facility's own documentation and the FDA Food Code were referenced throughout the findings, highlighting the discrepancies between expected and actual practices.
Failure to Maintain Safe and Sanitary Kitchen Equipment
Penalty
Summary
Surveyors observed that essential kitchen equipment was not maintained in safe operating condition. During a kitchen tour, a can opener was found with chipped paint, food debris, and a layer of metal shavings behind the blade. The condition of the can opener was confirmed by kitchen staff and the Registered Dietician (RD), who stated that the can opener should be cleaned regularly according to a cleaning schedule. The RD also noted that staff had been instructed to use a wire brush for cleaning, but the can opener was not maintained as expected, creating a risk of harboring pathogens. Additionally, the dishwashing machine was observed over three complete cycles and failed to reach the manufacturer-required minimum temperature of 120 degrees Fahrenheit, with the highest recorded temperature being 117 degrees. The Certified Dietary Manager (CDM) and RD confirmed that the machine was not operating at the required temperature, and the Maintenance Supervisor stated that the machine needed calibration. The FDA Food Code was referenced, indicating that both the can opener and dishwashing machine were not in compliance with standards for cleanliness and safe operation.
Failure to Prevent Roach Infestation in Food Preparation Area
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by the presence of roaches in the area where residents' food was reheated. During an observation with the Certified Dietary Manager, the microwave used for reheating outside food for residents was found to have layers of old food splatters, and the manager indicated that housekeeping was responsible for cleaning it. A subsequent observation revealed a roach walking in front of the microwave, and when the microwave was moved, multiple roaches were seen running away. The Housekeeping Supervisor confirmed that the microwave had not been cleaned as required and acknowledged the presence of roaches. The Maintenance Supervisor stated that the facility had regular monthly pest control services but confirmed the presence of roaches and recognized the infection control issue they posed. Record review showed that there had been previous reports of roaches in a resident's room, and treatment was provided. The Physical Plant Supervisor emphasized the importance of daily cleaning and pest control to prevent the spread of disease. These findings demonstrate a failure to ensure proper cleaning and pest control measures, resulting in a pest infestation in a food preparation area.
Failure to Maintain Privacy for Resident with Urinary Catheter
Penalty
Summary
A deficiency was identified when a resident's urinary catheter bag was observed without a privacy cover in the resident's room. During the observation, both a CNA and a licensed nurse confirmed that the catheter bag was not covered, and acknowledged that it should have been covered to maintain the resident's privacy and dignity. The licensed nurse further explained that the privacy cover is important because not all residents are comfortable with the catheter bag being visible, both inside and outside the room. The resident had a physician's order for a catheter to drainage bag due to urinary retention. The Director of Nursing confirmed that the facility's policy requires urinary catheter bags to be covered to preserve resident dignity. Facility policy also states that residents are to be treated with respect, kindness, and dignity, and that staff are to be educated and monitored for compliance with resident rights.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided with informed consent regarding the use of psychotropic medications, specifically Risperidone and Valproic Acid. The resident, who had a diagnosis of dementia and a court-appointed conservator as the responsible party, was prescribed and administered these medications without documented evidence that the risks, benefits, and alternatives were explained to the conservator. Review of the resident's records showed that the required informed consent forms were incomplete, undated, and only signed by the physician, with no indication of discussion or consent from the conservator. Interviews with facility staff, including a licensed nurse and the DON, confirmed that the forms lacked necessary details such as dates and documentation of with whom the consent was discussed. The facility's own policies require that residents or their surrogate decision makers be fully informed and provide consent prior to the use of psychotropic medications. Despite this, the medications were administered as ordered, as evidenced by the Medication Administration Record, without proper informed consent procedures being followed.
Failure to Supervise Smoking and Control Smoking Paraphernalia
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents who smoked, specifically for two residents. One resident, who had a diagnosis of metabolic encephalopathy resulting in confusion and memory loss, was observed smoking a cigarette in the facility courtyard without required supervision. The nursing assistant lit the cigarette for the resident and then left the resident alone in the courtyard, despite the resident's care plan and smoking assessment indicating that supervision was necessary due to cognitive and physical limitations. The nursing assistant confirmed that she was not permitted to supervise the resident and acknowledged the risk of harm from leaving the resident unsupervised. Another resident, with a history of acute respiratory failure and COPD, reported keeping a cigarette lighter in his room and in his pocket, making it accessible to other residents. This resident stated he received conflicting information about whether he needed to lock up his smoking materials and believed he could smoke outside whenever he wanted. Interviews with facility staff revealed inconsistencies in the enforcement of the smoking policy, with some staff stating that only residents assessed as independent smokers could keep lighters and cigarettes in their rooms, while others stated that lighters should not be kept in resident rooms for safety reasons. Facility policy required that residents who were physically or cognitively incapacitated be closely supervised while smoking and that smoking paraphernalia only be made available under safe conditions as determined by the interdisciplinary team. Despite these policies, both residents were allowed access to smoking materials and opportunities to smoke without the required supervision, contrary to their care plans and facility procedures. These failures placed the residents and others at risk for accidental burns and injuries.
Blood Pressure Medication Administered Outside Prescribed Parameters
Penalty
Summary
A licensed nurse administered an oral tablet of Amlodipine, a medication prescribed for hypertension, to a resident whose blood pressure reading was 102/57. The resident's physician order specified that the medication should be held if the systolic blood pressure was less than 110. Despite this hold parameter being documented in both the order summary and the medication administration record (MAR), the nurse proceeded with the administration. The nurse later confirmed awareness of the hold parameter and acknowledged that the medication should not have been given under these circumstances. The resident had a medical history including cerebral infarction and hypertension. The Director of Nursing confirmed that facility policy requires nurses to check blood pressure and hold parameters before administering such medications, and that the policy was not followed in this instance. The facility's policy and procedure on medication administration also requires medications to be given as prescribed and in accordance with written orders, which was not adhered to during this event.
Medication and Supply Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication and medical supply storage practices. Staff beverages and personal belongings were found stored in medication storage rooms at multiple nursing stations, which staff acknowledged posed an infection risk. Additionally, the medication refrigerator containing narcotics was not locked, and a narcotic locked box inside the refrigerator contained lorazepam, a controlled substance. Staff confirmed that the refrigerator should have been locked when narcotics were present to prevent unauthorized access. Further observations revealed expired medications and opened, unlabeled medications stored in the medication cart, including expired eye drops, oral calcium, docusate sodium capsules, an Albuterol Sulfate inhaler, and an opened, unlabeled bottle of Milk of Magnesia. In the treatment cart, surveyors found expired single-use wound care irrigation solutions that were opened but not dated, as well as expired wound care ointments, creams, and dressing materials. An opened sterile dressing was also found in the treatment cart and had not been discarded. Multi-use wound care solutions, such as povidone iodine ointment and Dakin's solution, were opened but not dated. Interviews with nursing staff and the Director of Nursing confirmed that these practices were not in accordance with facility policy, which requires medications and biologicals to be stored safely, securely, and properly, with expired or contaminated items immediately removed from inventory. The facility's policies also require that controlled substances be stored in locked compartments and that multi-dose containers be dated when opened. The observed deficiencies were acknowledged by staff and leadership as not meeting these standards.
Failure to Provide Ordered PT/OT Services Upon Admission
Penalty
Summary
A resident was admitted to the facility with diagnoses including generalized muscle weakness, repeated falls, and cognitive symptoms. Upon admission, there were physician orders for both physical therapy (PT) and occupational therapy (OT) evaluations and treatments. However, a review of the resident's medical record showed that neither PT nor OT evaluations or treatments were provided as ordered. The resident reported not receiving therapy services for balance problems, which were a primary reason for admission. Both the occupational therapist and physical therapist confirmed that they did not receive referrals for the resident, despite the presence of orders in the medical record. The facility's protocol required that rehabilitation services be initiated within 72 hours of the order, but this did not occur. Further interviews revealed that the facility did not have rehabilitation services available from early December through mid-January due to a transition period while negotiating a new contract for in-house rehabilitation services. The Director of Nursing confirmed that therapy orders were present upon admission and acknowledged that evaluations should have been completed within 24 hours. The resident's care plans and baseline care plan also referenced the need for PT and OT services, but these were not implemented. Facility policy stated that residents requiring rehabilitation services would be identified and evaluated, but this process was not followed for the resident in question.
Incomplete Medical Records for Resident Under Outside Provider Care
Penalty
Summary
The facility failed to maintain and obtain complete medical records for a resident who was under the care of an outside primary care provider. During observation, the resident was seen scratching her chest and upper extremities. Interviews with staff revealed that the resident's care and medications were managed by an external provider, but a review of the resident's medical record showed that progress notes from this provider were missing. The Director of Nursing confirmed that the outside provider had been managing the resident's care since August 2024, but their notes were not present in the facility's records. Further investigation found that the medical records staff had not received or requested the necessary documentation from the outside provider. The outside primary care provider stated that their progress notes served as communication for new orders, updates, and continuity of care. The Director of Nursing acknowledged that the absence of these notes in the resident's medical record would result in a lack of information regarding required measures or interventions for the resident.
Failure to Provide Evidence of Ongoing QAPI Program
Penalty
Summary
The facility failed to provide evidence of an ongoing Quality Assurance and Performance Improvement (QAPI) program or plan for its resident population. During the survey, the Administrator (ADM) was repeatedly asked to provide QAPI documents, including the plan and the names of committee members, as required by federal regulations. Despite these requests, the only QAPI-related documents produced were created during the week of the survey, after the survey team had already identified a deficiency related to expired medications. The ADM acknowledged that the QAPI plan presented was newly created in response to the survey findings, rather than being an established, ongoing program. Further review of facility policies and undated documents indicated that the facility had written policies describing the QAPI process and requirements, but there was no evidence that these policies were being actively implemented or that a QAPI plan was in place prior to the survey. The lack of a current, ongoing QAPI program meant the facility could not demonstrate systematic efforts to identify, report, investigate, analyze, and prioritize quality concerns as required.
Staff Failed to Prevent Contamination of Resident Water Dispenser
Penalty
Summary
A deficiency occurred when a Medical Records Assistant was observed refilling an empty plastic soda bottle from a resident water dispenser at a nurses' station, allowing the mouth of the bottle to touch the dispenser spout. The staff member confirmed this action and acknowledged that it was not acceptable, recognizing the risk of contaminating the dispenser and potentially spreading illness to residents who use the dispenser. Disposable cups were available for use, and staff were instructed to avoid contact between personal containers and the dispenser spout, but this protocol was not followed. The Director of Nursing confirmed that the facility's policy required water dispensers to be cleaned every 24 hours and that disposable cups were provided for drinking water. The DON also stated that staff should not allow personal containers to touch the dispenser spout when refilling. The facility's infection control policy aimed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection, but this policy was not adhered to in this instance.
Failure to Follow Antibiotic Stewardship Program for Resident on Antibiotics
Penalty
Summary
The facility failed to follow its Antibiotic Stewardship Program (ASP) for a resident who developed signs and symptoms of a urinary tract infection (UTI). When the resident complained of a burning sensation during urination, a urine analysis was ordered and later, an antibiotic (Ciprofloxacin) was prescribed for five days. However, the facility's required ANTIBIOTIC STEWARDSHIP GUIDELINE form was not initiated for this resident at the time of the initial complaint or diagnosis. The Infection Preventionist (IP) was not aware that the resident had been prescribed antibiotics and did not add the resident to the ANTIBIOTIC STARTS TRACKING log, the MONTHLY SURVEILLANCE REPORT FORM, or the ANTIBIOTIC LOG. Review of these tracking documents for the relevant month confirmed that the resident was not listed, despite being on antibiotic therapy. The IP stated that the nurse should have completed the required form and placed it in the designated binder for tracking, but this did not occur. Additionally, the facility did not conduct an antibiotic time-out for the resident, which is a reassessment of the antibiotic prescription 48-72 hours after initiation, as required by facility policy. The IP acknowledged that antibiotic time-outs were not being performed for any residents on antibiotics, and this process was not documented in the resident's record as required. The facility's policy specifies that antibiotic starts, days of therapy, antibiotic use, stewardship actions, and outcomes must be tracked, and a monthly ASP Tracking Report compiled, but these steps were not followed for the resident in question.
Resident Rooms Below Required Square Footage
Penalty
Summary
Four resident rooms (rooms 5, 18, 22, and 45) did not meet the required minimum square footage per resident, as observed and measured by the Maintenance Supervisor. Specifically, three of the rooms, each housing three residents, measured between 233.21 and 237.37 square feet, which is less than the required 240 square feet (80 square feet per resident). The fourth room, a two-bed room, measured 142.85 square feet, which is below the required 160 square feet (80 square feet per resident). These measurements were confirmed during direct observation and interviews with the Maintenance Supervisor. Residents occupying these rooms, as well as staff providing care, were interviewed and consistently reported no issues with space, care delivery, or mobility within the rooms. Residents stated they had enough room for their needs, including the use of wheelchairs and movement around the room. Staff, including licensed nurses and certified nursing assistants, also confirmed that the room sizes did not hinder their ability to provide care or perform daily tasks. The Administrator acknowledged the room sizes and stated there had been no complaints from residents or staff regarding space limitations.
Failure to Provide Timely Dialysis and Maintain Lab Records
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease, who was dependent on dialysis. The resident missed a scheduled dialysis session due to unavailable transportation, and a make-up session was not arranged promptly. Interviews with facility staff revealed that the resident missed a dialysis session on a Friday and did not receive treatment until the following Monday, resulting in a four-day gap without dialysis. The Nursing Secretary admitted to not attempting alternative transportation options or notifying the resident's family for assistance. The facility's contract and policy indicated responsibility for arranging transportation, which was not fulfilled. Additionally, the facility did not maintain up-to-date lab results from the dialysis center in the resident's medical record. The resident's monthly lab results were not available in the facility's records since May, despite being conducted at the dialysis center. The Director of Nursing confirmed that charge nurses were responsible for reviewing these labs, but the Primary Doctor only reviewed critical values. The facility's policy required documentation of laboratory tests in the resident's medical record, which was not adhered to, leading to a potential lapse in care coordination between the facility and the dialysis center.
Failure to Ensure Safe Handling of Hazardous Medications
Penalty
Summary
The facility failed to ensure safe practices in handling hazardous medications during storage and medication administration. During observations, Licensed Nurses (LNs) administered hazardous medications such as valproic acid and finasteride without using gloves or other personal protective equipment (PPE). The Medication Administration Records (MARs) for the residents did not contain any instructions on how to handle these hazardous drugs safely. This was observed with multiple residents, including Resident 33, Resident 55, Resident 8, and Resident 10, across different hallways and stations in the facility. Interviews with the LNs revealed a lack of awareness regarding the special handling requirements for hazardous medications. LN 4 and LN 5 both stated they were not aware of the need for gloves or other protective measures when handling these drugs. The pharmacy labels only indicated that the drugs should not be taken if pregnant, without providing specific handling instructions. The Director of Nursing (DON) acknowledged the shortcomings and mentioned that the facility was in the process of revising their policy to ensure safe handling of hazardous drugs. Review of drug information from Lexicomp and guidelines from the National Institute for Occupational Safety and Health (NIOSH) confirmed that valproic acid and finasteride should be handled with appropriate precautions, including the use of gloves. The lack of proper handling instructions and PPE use during medication administration poses a health risk to both staff and residents. The facility's failure to adhere to these guidelines led to the identified deficiencies in medication handling practices.
Failure to Manage Severe Pain for Resident
Penalty
Summary
The facility failed to manage the severe pain of a resident, identified as Resident 28, who had a history of left-side paralysis following a stroke and a crushed left leg from the Vietnam War. Despite repeated complaints of severe pain in the left leg and knee, the facility administered ibuprofen, which was only ordered for mild to moderate pain, instead of notifying the physician to obtain an appropriate medication for severe pain. This resulted in Resident 28 experiencing unmanaged severe pain for extended periods. Resident 28's clinical records showed consistent complaints of severe pain, with pain levels frequently recorded as 8 or 9 out of 10. The records indicated that the resident had an order for Morphine Sulfate for severe pain, but it was only to be administered at bedtime. During the daytime, the resident was given ibuprofen, which was insufficient for managing the severe pain. The licensed nurse acknowledged that the physician should have been contacted for a new medication order to address the severe pain during the day. Interviews with the physician and the Director of Nursing (DON) confirmed that the facility's policy and procedures for physician notification were not followed. The physician stated that Resident 28 could have benefited from around-the-clock pain medication, and the DON acknowledged that the licensed nurses should have called the physician for an additional pain medication order to cover severe pain during the day. The failure to notify the physician and manage the resident's severe pain appropriately was a significant deficiency in the care provided by the facility.
Medication Unavailability and Unsafe Pharmaceutical Practices
Penalty
Summary
The facility failed to ensure prescribed medication unavailability was communicated to the medical doctor and failed to ensure vital medications were available for administration for two residents. Resident 43, who has PTSD and Parkinson's Disease, did not receive her anxiety medication, Alprazolam, on multiple days in February 2024. Additionally, her pain medication, Tramadol, was not available for administration on several days in March 2024. The facility did not follow up adequately with the pharmacy or the medical director to ensure these medications were available, leading to gaps in her treatment. The pharmacist and physician both acknowledged issues in the process, but no alternative medications were provided during the unavailability period. The DON confirmed the lapses in medication administration and the lack of documented follow-up actions to resolve the issue promptly. The facility's policy on medication ordering and receiving was not adhered to, resulting in these deficiencies. Resident 80, who has a diabetic diagnosis, did not receive her insulin glargine on the mornings of March 1 and March 2, 2024, due to unavailability from the pharmacy. Despite the high blood sugar levels recorded, there was no documentation indicating that the medical doctor was contacted to address the issue. The DON acknowledged that the nursing staff could have used the emergency supply of insulin but did not do so. The facility's policy on medication administration and documentation was not followed, leading to this deficiency. The facility also failed to ensure safe pharmaceutical services with medication disposal, waste, and the accountability of delivered medications. The pharmaceutical waste bin was accessible by hand, and medications were not rendered unusable, posing a risk of drug diversion. Additionally, prescription drug disposition records were not co-signed and witnessed by licensed staff during destruction and disposal. Medication delivery receipts and manifests by the pharmacy provider were not consistently signed by licensed staff, compromising accountability and accuracy. The DON confirmed these lapses and acknowledged the missing witness signatures and the improper handling of the pharmaceutical waste bin. The facility's policies on medication disposal and controlled substance handling were not followed, leading to these deficiencies.
Infection Control Deficiencies and Lack of Water Management Program
Penalty
Summary
The facility failed to ensure safe infection control practices with the use of shared blood pressure devices and glucometers between residents. During multiple observations, Licensed Nurses (LNs) were seen using the same blood pressure device and glucometer on different residents without proper cleaning and sanitization. The LNs used alcohol wipes instead of the facility's approved disinfectant wipes, which were not effective against serious pathogens. Interviews with the LNs, Infection Preventionist (IP), and Director of Nursing (DON) confirmed that the staff did not follow the correct procedures for cleaning these devices, and the facility's policies were inconsistent and outdated. The facility also failed to develop and implement a water management program to reduce the risk of bacterial growth in the water system. The Administrator and IP admitted that there was no such program in place, which put residents at risk for waterborne illnesses. This was in direct violation of guidelines issued by the Centers for Medicare and Medicaid Services (CMS), which require healthcare facilities to have policies and procedures to prevent the growth and spread of Legionella and other pathogens in water systems. Additionally, the facility did not maintain a clean and infection-free environment in Resident 19's room. The room was cluttered with personal belongings, plastic bags, and trash, creating a strong sour smell and posing a hazard. The resident had a history of chronic urinary tract infections and sepsis, and the cluttered environment increased the risk of infection. Interviews with the CNA, LN, IP, and DON confirmed that the room's condition was a significant infection control issue, and the facility's housekeeping policy was not followed.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST) for Resident 64 was fully completed and uploaded to the resident's Electronic Health Record (EHR) per facility policy. Resident 64's POLST form, which is crucial for documenting the types of medical treatment the resident wants to receive during serious illness, was missing essential identifying information. Specifically, Section A, which indicates the resident's preference for Cardiopulmonary Resuscitation (CPR), was marked for Do Not Attempt Resuscitation (DNR), but Section D, which requires the resident's name and signature, was left blank. This omission was confirmed during interviews with a licensed nurse (LN) and the Director of Nursing (DON), who both acknowledged that the lack of identifying information would necessitate performing a full code (CPR) in the event of a medical emergency, contrary to the resident's documented wishes on the incomplete POLST form. Resident 64 was admitted to the facility with diagnoses including diabetes and dependence on renal dialysis. The failure to complete and properly file the POLST form had the potential to delay treatment or result in the administration of incorrect life-sustaining measures. The facility's policy on POLST forms, which requires them to be completed based on the patient's expressed treatment preferences and signed by both the physician and the patient or their legally recognized healthcare decision-maker, was not adhered to in this case. This deficiency was identified through a review of Resident 64's medical records and confirmed through staff interviews, highlighting a significant lapse in ensuring the resident's treatment preferences were accurately documented and accessible in their EHR.
Failure to Ensure Accessible Bathroom Doors
Penalty
Summary
The facility failed to ensure that two residents, Resident 75 and Resident 81, received care and services safely when they were unable to open bathroom door #7. Resident 75, who had a diagnosis of muscle weakness and used a manual wheelchair and walker, reported difficulty in opening the heavy and sticky bathroom door. Observations confirmed that the door was difficult to open and close, and the door latch did not completely engage, leaving the door slightly ajar. The Maintenance Director verified that the door knob was loose and the door was heavy, possibly a fire door, which should have been accessible to residents independently according to the Director of Nursing's expectations. Resident 81, who had muscle weakness and had lost his right leg, also reported difficulty in opening the same bathroom door. He had informed the staff about the problem and expressed concerns about being trapped in the bathroom, especially in case of a fire. Observations showed that Resident 81 struggled to open the door due to its heaviness and the incline leading up to it. He had to use the call light for assistance to exit the bathroom. The Licensed Nurse and the Director of Nursing acknowledged that the door was too heavy for Resident 81 to open independently, posing a risk for falls and feelings of claustrophobia. The facility's policy on Resident Accommodation of Needs was not followed, as residents did not have easy access to the bathroom. The Director of Nursing confirmed that the expectation was for residents to open bathroom doors independently to maintain their level of independence and dignity. The failure to ensure accessible bathroom doors led to feelings of entrapment and the inability to maintain independence with activities of daily living for the affected residents.
Failure to Develop and Implement Care Plans for Psychotropic and High-Risk Medications
Penalty
Summary
The facility failed to develop and implement care plans for psychotropic and high-risk medications for three residents. Resident 80's care plan did not include monitoring for the use of duloxetine and cariprazine, both psychotropic medications, nor did it address the use of high-risk blood thinner medications apixaban, ticagrelor, and naproxen. This lack of documentation meant that licensed staff were not guided on how to monitor the resident's progress and potential adverse effects of these medications. The Director of Nursing (DON) and a Licensed Nurse (LN) acknowledged these findings during a review of the resident's medical records. Similarly, Resident 57's care plan did not include monitoring for the use of blood thinner medications clopidogrel and aspirin, which had been prescribed for stroke prevention. The absence of a care plan meant that nursing staff were not provided with guidelines on how to manage the safe use and monitoring of these medications. The DON confirmed that the care plan should have reflected the necessary nursing care and how the medications were being addressed. Resident 28's care plan also lacked documentation for monitoring the use of duloxetine, an antidepressant medication. The medical records did not indicate a plan of care for depression or how the nursing staff should monitor the resident's progress and safety. This deficiency was confirmed by LN 2 during a review of the resident's medical records. The facility's policies on care plans and chemical restraints were not followed, as they require comprehensive care plans to meet residents' medical, nursing, and psychosocial needs, including monitoring for adverse reactions and ensuring mental well-being.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for Resident 72, who had a history of epilepsy, Merrf syndrome, and muscle weakness. The fall risk assessment for Resident 72 was not completed accurately, as the section on medications was left blank, resulting in an incorrect fall risk score. Despite multiple falls in February 2024, the fall interventions were not updated, and necessary measures such as a fall mat were not implemented. The Director of Nursing acknowledged that the fall risk assessment score should have been higher, indicating a high fall risk, and that additional interventions should have been in place. Resident 72 experienced multiple falls, including incidents on 2/5/24, 2/11/24, and 2/16/24, where she was found on the floor by staff or her roommate. Despite being identified as a high fall risk, the interventions in place were inadequate, and the care plan was not updated to reflect new measures after each fall. The use of a body alarm was attempted but was unsuccessful as Resident 72 removed it, and this failed intervention was not updated in the care plan. Additionally, Resident 72 eloped from the facility on 1/29/24, and staff were unaware of her absence until contacted by the police. The elopement risk evaluation indicated a moderate risk, but no care plan was initiated to address this risk. The facility's policy and procedure for elopement were not followed, as the staff did not monitor Resident 72's whereabouts effectively. The Director of Nursing confirmed that the process for handling elopements was not properly executed, leading to Resident 72's unsupervised departure from the facility.
Failure to Follow Physician's Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to follow the physician's orders for supplemental oxygen administration for Resident 80, who has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and asthma. The physician's order dated 1/17/2024 specified that Resident 80 should receive 2 liters (L) of supplemental oxygen via nasal cannula. However, observations on 3/4/2024 and 3/6/2024 revealed that Resident 80 was receiving 5 L and 3.5 L of supplemental oxygen, respectively. Additionally, a review of the resident's clinical records indicated multiple instances in January and February 2024 where Resident 80 was administered 3 L of supplemental oxygen instead of the ordered 2 L. Interviews with licensed nurses confirmed that the facility was not adhering to the physician's orders, and the Director of Nursing acknowledged that the facility's policy and procedure on oxygen therapy were not followed. Resident 80's care plan, dated 1/24/2024, indicated that the resident was at risk for injury related to respiratory problems and included an intervention to administer oxygen as ordered by the physician. Despite this, the facility failed to consistently follow the prescribed oxygen flow rate. Licensed Nurse 6 admitted that the current oxygen administration did not align with the physician's orders and stated that she would contact the physician to update the order. Licensed Nurse 4 also confirmed that any changes in oxygen support should be preceded by a call to the physician for a new order. The Director of Nursing reviewed the facility's policy and procedure on oxygen therapy and acknowledged that it was not adhered to, leading to the deficiency in care for Resident 80.
Inappropriate Use of Full Siderails for Resident
Penalty
Summary
The facility failed to apply appropriate siderails for Resident 63, who was ordered half siderails but was found with two full bed siderails in use. This discrepancy was observed on multiple occasions, with Resident 63 lying in bed with full siderails up bilaterally. Resident 63's medical records indicated a high risk for falls and specified the use of half siderails for bed mobility and transfers. However, the facility did not adhere to this order, and full siderails were installed instead, without proper assessment, care plan, or consent for their use. During interviews, both a licensed nurse and the Director of Nurses confirmed the presence of full siderails and acknowledged the order for half siderails. The Director of Nurses reviewed the resident's siderail assessment, care plan, and consent, confirming that they only supported the use of half siderails. The facility's policy required a thorough assessment and interdisciplinary team involvement to determine the appropriateness of siderail use, which was not followed in this case.
Failure to Monitor Adverse Effects of High-Risk Medications
Penalty
Summary
The facility failed to monitor the adverse effects of high-risk medications in two residents. Resident 80 was prescribed multiple blood thinners and a pain medication known to have bleeding side effects, including apixaban, ticagrelor, and naproxen. A review of Resident 80's medical records revealed no documented monitoring of these medications for adverse effects. During an interview, the Director of Nursing (DON) acknowledged the oversight and the increased risk of bleeding due to the combination of these medications. Similarly, Resident 57 was prescribed aspirin and clopidogrel for stroke prevention, both of which have potential bleeding side effects. A review of Resident 57's medical records also showed no documented monitoring for adverse effects. The DON confirmed that nursing monitoring should have been part of daily care and resident assessment. The facility's policy on medication monitoring and management was reviewed and found to be lacking in specific guidelines for newer blood thinner medications used in the facility.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to develop and implement psychotropic medication side effect and behavior monitoring for one out of five sampled residents (Resident 80). Resident 80 was prescribed duloxetine and cariprazine to treat anxiety, but the nursing staff did not monitor for adverse effects or targeted behaviors as required by manufacturer instructions and standards of practice. This oversight was confirmed during a review of Resident 80's medical records, which showed no documented daily monitoring for the use of these medications. During an interview and record review with a Licensed Nurse and the Director of Nursing, it was confirmed that the monitoring for duloxetine and cariprazine was overlooked. The facility's policy on chemical restraints requires that psychotropic drug assessments include monitoring for adverse drug reactions and behavioral manifestations. However, this policy was not followed in the case of Resident 80, leading to a failure in ensuring safe medication use and proper mental health care monitoring.
Failure to Conduct Annual Facility Assessment Review
Penalty
Summary
The facility failed to ensure a review of the Facility Assessment was conducted at least annually. The last review and update of the Facility Assessment was on January 17, 2018. During an interview and record review with the Administrator and Director of Nurses on March 7, 2024, the Administrator confirmed that the Facility Assessment had not been updated since January 17, 2018. The facility policy mandates that the Facility Assessment be reviewed and updated annually and as necessary. This failure had the potential to negatively affect the health and well-being of all residents residing in the facility.
Room Size Deficiency
Penalty
Summary
Four rooms in the facility did not meet the required square footage per resident, as observed and confirmed by the Maintenance Director and the Administrator. Specifically, room 5, a 3-bed room, measured 236.73 square feet instead of the required 240 square feet; room 18, a 3-bed room, measured 238 square feet instead of 240 square feet; room 22, a 3-bed room, measured 231.2 square feet instead of 240 square feet; and room 45, a 2-bed room, measured 140 square feet instead of 160 square feet. Despite these deficiencies, residents in these rooms reported no concerns about the space, and staff members indicated they could perform their duties effectively in the smaller rooms. During interviews, residents expressed satisfaction with the space provided, and staff members, including certified nursing assistants and a licensed nurse, stated they had no issues working in the smaller rooms. The Administrator confirmed the measurements and acknowledged the shortfall in required square footage. The facility recommended continuing the room waiver, contingent upon compliance with federal regulations regarding Resident Rights and Physical Environment.
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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