Hemet Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemet, California.
- Location
- 1717 West Stetson Avenue, Hemet, California 92545
- CMS Provider Number
- 555297
- Inspections on file
- 46
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Hemet Hills Post Acute during CMS and state inspections, most recent first.
Two residents experienced incomplete and inaccurate nursing documentation related to skin monitoring and admission status. For one resident with cognitive impairment and anemia, a new left forearm discoloration and skin tear were identified and a care plan and MD order were initiated for every-shift monitoring, but MAR and TAR entries were missing or inconsistent, daily skilled charting described skin as normal, and weekly summaries failed to note the new bruise. For another newly admitted resident with multiple rib fractures and other injuries, an admission note was completed and later notes described stable status followed by respiratory distress and transfer out, but no night-shift progress note was entered despite facility protocol requiring progress notes each shift and for the first 72 hours after admission. The DON and nursing staff acknowledged that required documentation of residents’ conditions and changes was missing or incomplete.
A resident with metabolic encephalopathy and severe cognitive impairment repeatedly pulled out a G-tube over multiple episodes, each requiring ER transfer for replacement, while the care plan was not consistently revised to reflect these changes in condition or the effectiveness of existing interventions. Although the care plan identified risk for dementia-related behaviors and G-tube dislodgement with interventions such as an abdominal binder and behavior monitoring, revisions lagged behind actual events, and a later care plan entry added no new interventions. Direct care staff reported being unaware of G-tube pulling behaviors, whereas an RN and the DON acknowledged repeated incidents and stated that care plans should be updated with each change in condition, in contrast to the facility’s policy requiring ongoing assessment and IDT review when resident status changes or outcomes are not met.
A resident with poor balance, anemia, and moderate cognitive impairment developed new discoloration and a closed skin tear on the left forearm while on anticoagulant therapy, with the resident reporting the bruise appeared after someone grabbed her. The MD ordered continued monitoring, and the MAR required shift documentation of anticoagulant-related bruising, but nurses left required Y/N fields blank over multiple days. The TAR and MD orders directed every-shift monitoring of the left upper extremity discoloration for changes in size, location, and appearance with MD notification as needed, yet multiple shifts lacked any documentation of monitoring. Daily skilled charting and weekly nursing summaries during this period also failed to describe or assess the new bruise, despite a care plan calling for checks of the discoloration and monitoring for adverse effects of the allegation.
An outside vendor ultrasound technician entered a contact-precaution room and provided bedside care to a resident with metabolic encephalopathy and severely impaired cognition while wearing only gloves, without the required gown and mask, and later re-entered without hand hygiene or new gloves. A posted sign instructed all entrants to wear gown, gloves, and mask and to perform hand hygiene, and staff interviews (including an LVN, CNA, Infection Preventionist, and DON) confirmed that all individuals entering such rooms must follow these PPE and hand hygiene protocols, consistent with the facility’s transmission-based precautions policy.
A resident with hypothyroidism did not receive scheduled doses of Levothyroxine on two occasions. One dose was missed due to the medication not being available, and another was missed despite the medication being present and signed in by an LVN. Documentation was incomplete, and interviews confirmed the missed administrations.
A CNA entered the room of a resident on contact isolation for ESBL infection without wearing required PPE, despite posted signage and facility policy mandating gloves and gown before entry. Interviews confirmed staff awareness of the need for PPE to prevent infection transmission.
The facility did not ensure that glucometer calibration and quality control checks were consistently performed and documented as required. Multiple medication carts had missing entries for key information, and staff interviews confirmed that both night and day shift nurses failed to complete or verify the logs. Facility policy required thorough documentation and adherence to manufacturer instructions, but these were not followed, resulting in incomplete records for blood glucose monitoring.
A resident with a long-standing history of obstructive sleep apnea (OSA) and CPAP use was not assessed for continued CPAP therapy upon admission, despite hospital records and the resident's own report of OSA and CPAP use. Facility staff did not verify the diagnosis with the physician, did not include OSA in the care plan, and did not provide a CPAP machine, contrary to facility policy.
A deficiency was cited due to the presence of accident hazards in an area and insufficient supervision to prevent accidents. The environment did not meet safety standards, and oversight was inadequate to ensure resident safety.
Two residents with a history of stroke did not have their needs accommodated when one was unable to reach her call light due to improper placement, and another experienced significant delays in staff response to her call light. Staff and policy indicated that call lights should be accessible and answered promptly, but these procedures were not followed.
A resident with dementia and a history of confusion made specific allegations of prior sexual assault, which were documented by nursing staff but not reported to CDPH within the required two-hour window. Despite facility policy and staff acknowledgment of reporting requirements, the incident was not reported because it was interpreted as behavioral rather than an abuse allegation.
A resident with COPD and other comorbidities experienced a critically low oxygen saturation of 35% after removing his nasal cannula. Nursing staff delayed notifying the physician for several hours, despite facility policy requiring prompt notification of significant changes. The resident was eventually transferred to the hospital, where he required emergency intubation for respiratory failure and later expired.
A resident with significant cognitive and physical impairments, including dementia, blindness, and a below-knee amputation, fell from bed and sustained injuries when a CNA instructed the resident to turn away during a brief change and then moved to the opposite side, leaving the resident unsupervised. The resident required substantial assistance with bed mobility and was known to be at high risk for falls.
The facility failed to complete MDS quarterly assessments for 19 residents within the required 14 days, with delays ranging from 34 to 58 days. The MDS Coordinator and DON acknowledged the importance of timely assessments to ensure accurate and individualized care plans.
The facility failed to transmit MDS assessments for 21 residents within the required timeframe, as confirmed by the MDS Coordinator and DON. The assessments, with ARDs from November to December 2024, were transmitted late, affecting the timely development of care plans.
The facility failed to provide appetizing and flavorful food, as multiple residents reported dissatisfaction with the meals, describing them as bland, overcooked, and unappealing. A test tray evaluation confirmed the lack of flavor, which could discourage residents from eating and lead to unintended weight loss. The facility's policies emphasize the importance of flavorful and nutritious meals, but these were not adhered to, resulting in the deficiency.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with grime and debris found on storage shelves and fans. The Dietary Services Supervisor acknowledged the need for more frequent cleaning to prevent cross-contamination and potential foodborne illness among residents.
The facility failed to provide education and assistance regarding Advance Directives (AD) for two residents, potentially impacting their medical preferences during critical decisions. Both residents had the capacity to make decisions but were not provided with necessary AD information or materials, contrary to the facility's policy. The Social Service Director acknowledged the oversight in both cases.
The facility failed to complete the annual comprehensive assessments for two residents within the required 14-day timeframe, as mandated by CMS. The assessments for these residents were completed 35 and 37 days after the assessment reference date. The MDS Coordinator and DON acknowledged the delay, emphasizing the importance of timely completion to ensure accurate resident assessments and care plans.
A resident missed a follow-up visit for a surgical wound due to late transportation, and the facility failed to notify the physician or reschedule the appointment. Interviews with staff, including an LVN, the Case Manager, and the DON, revealed a lack of communication regarding the missed visit, which could delay necessary care and treatment.
A resident with a stage 4 pressure ulcer did not receive the necessary care as outlined in their care plan, which included heel elevation and pressure-relieving devices. Observations revealed the absence of these interventions, and the Treatment Nurse confirmed the oversight. Additionally, the Registered Dietitian's recommendations for nutritional support were not communicated to the physician, as required by facility practice. The Director of Nursing acknowledged these failures, which could affect the resident's wound healing.
A resident with pulmonary fibrosis was observed with a nasal cannula set at zero liters per minute, contrary to a physician's order for 2 LPM oxygen therapy. The LVN confirmed the error, acknowledging the responsibility to follow the physician's order. The DON emphasized the importance of adhering to the order to prevent distress or changes in the resident's condition.
A resident with rheumatoid arthritis was prescribed Norco for pain management, but the facility failed to conduct and document required pain assessments before and after medication administration. The LVN responsible did not follow the facility's policy, leading to potential unmanaged pain for the resident.
A facility failed to document the administration of PRN narcotic pain medications for a resident with rheumatoid arthritis, despite the medication being signed out multiple times. The LN responsible did not follow procedures for documenting in the MAR, leading to potential medication discrepancies and increased risk of diversion.
Two residents receiving oxygen therapy experienced lapses in infection control. One resident's oxygen humidifier was found on the floor, and another resident's nasal cannula was placed on their nostrils after being on the floor. Staff acknowledged these actions were against infection control protocols, as per facility policies.
The facility failed to provide consistent fingernail care for four residents, leading to poor hand hygiene and potential infection risks. Observations showed residents with uneven, discolored, and debris-filled nails, as well as chipped nail polish. Staff interviews revealed that nail care was performed irregularly, despite the facility's policy requiring regular cleaning and trimming. The residents had various medical conditions necessitating assistance with ADLs.
A resident with a Foley catheter experienced recurrent UTIs due to the facility's failure to consistently provide catheter care and monitor urinary output as per the care plan and physician orders. The lack of documentation indicated missed care, contributing to the resident's transfer to a hospital with sepsis. Staff interviews revealed confusion about care responsibilities, highlighting a need for adherence to facility policies.
The facility failed to implement proper infection control measures as staff did not perform hand hygiene before donning PPE and did not wear face shields or goggles in Droplet Isolation rooms. CNAs and an LVN were observed entering isolation rooms without required eye protection and without performing hand hygiene, despite facility policies mandating these precautions.
A resident with COPD was found with an empty humidification bottle on their oxygen concentrator, which had been dry since the previous day. Staff interviews revealed inconsistencies in the procedures for checking and maintaining oxygen equipment, with some staff unaware of the need for a care plan for as-needed oxygen. The facility's policy on oxygen administration was not followed, as the humidification bottle was not refilled as required.
Two residents received medications outside of physician-ordered parameters, leading to significant medication errors. One resident with hypertension and atrial fibrillation was given Amiodarone and Lisinopril despite vital signs being outside the prescribed limits. Another resident with hypotension received Midodrine when blood pressure was above the ordered threshold. The facility's policy requires verification of orders and documentation, which were not adhered to, resulting in these errors.
A resident with hypertension was administered PRN Clonidine for high blood pressure, but staff failed to document a follow-up assessment to evaluate the medication's effectiveness. The facility's policy requires such documentation, which was confirmed as necessary by both the DON and the LVN involved.
A resident with hypertension received Metoprolol outside prescribed parameters due to an incorrect order stating to hold if pulse was above 60, instead of below. The LVN and DON confirmed the error, noting the medication was administered incorrectly on multiple days, contrary to facility policy requiring order verification.
A resident on contact precautions for an infected abdominal wound was not properly protected as staff failed to don the required PPE. Observations revealed that CNAs entered the room without full PPE, contrary to facility policy. Interviews with the IP nurse and DSD confirmed the policy of wearing a mask, gloves, and gown, and working in pairs for food tray delivery and collection.
The facility failed to coordinate hospice services for two residents, leading to a deficiency in care continuity. Both residents, one with end-stage renal disease and the other with heart failure, lacked documented hospice visit schedules. Facility staff were unaware of hospice schedules and services, despite the facility's policy requiring coordination with hospice representatives. The hospice companies confirmed that schedules should have been provided, but they were missing from the facility's records.
A resident with parkinsonism and dementia exhibited aggressive behavior, including hitting staff and threatening self-harm, but the physician was not notified as required by the facility's policy. Despite documentation of the incident, the lack of communication with the physician represents a deficiency in the facility's procedures.
Two residents' room had black scuff marks, a dent with peeling wallpaper, and dried smudges, indicating a failure to maintain a homelike environment. Despite policies for regular cleaning and maintenance, staff interviews revealed lapses in updating maintenance logs and cleaning routines. The residents and a visitor expressed dissatisfaction with the room's condition.
A resident with parkinsonism and dementia exhibited aggressive behavior, but the facility failed to develop and implement a care plan to address this. Despite being alert and oriented, the resident was incapable of giving informed consent. A nurse confirmed the absence of a care plan, which was against the facility's policy requiring individualized care plans based on comprehensive assessments.
A resident with conditions such as intervertebral disc degeneration and scoliosis did not receive scheduled showers, as confirmed by the DON and CNA. The resident, capable of making decisions, was supposed to have showers twice a week but was not offered one until several days after admission, contrary to the facility's policy. This failure potentially affected the resident's well-being.
A facility failed to follow a physician's order for a resident prescribed Midodrine, a medication to increase blood pressure. The order specified not to administer the medication if the resident's systolic blood pressure (SBP) was greater than 120. Despite this, the medication was given on several occasions when the SBP was above the threshold, including readings of 146 and 138. The resident had a history of stroke, acute kidney failure, diabetes mellitus type 2, and orthostatic hypotension. An LVN confirmed the medication should have been withheld.
A facility failed to ensure a resident was free from unnecessary psychotropic medications, as there was no appropriate indication for Ativan and Seroquel use, and informed consent was not obtained from the resident's responsible party. The resident, diagnosed with parkinsonism and dementia, was noted to be alert and oriented but incapable of giving informed consent. The Director of Nursing acknowledged the need for clarification of medication orders and the absence of informed consent documentation.
The facility did not display direct care daily staffing information in a visible location, as required. During an unannounced visit, it was found that staffing information was kept in a binder at the nurses' station instead of being posted publicly. Interviews with an LVN and the DON confirmed the lack of public posting, and the DON was unaware of the requirement. The facility's policy mandates that staffing numbers be posted for every shift.
A resident was found self-administering eye drop medications without an assessment to determine if it was safe, as required by facility policy. The DON and an LVN confirmed the lack of evaluation, despite the resident having a physician's order for the medications.
A resident's wheelchair safety belts were found dirty and covered with dry crusted food during an unannounced visit. An LVN confirmed the belts' condition was unacceptable and should be clean. The resident, with significant medical conditions, required clean assistive devices as per their care plan, which the facility failed to maintain.
A resident with multiple health conditions, including quadriplegia, was found to have poor oral hygiene due to inconsistent care. During a survey, the resident was observed with mucus and a foul odor from the mouth. The care plan required staff to assist with oral care, but documentation showed it was not consistently provided, violating the facility's policy on maintaining personal hygiene.
A resident with significant medical conditions did not receive scheduled showers on multiple occasions, as confirmed by interviews and record reviews. The facility's staff failed to document the showers, leading to potential hygiene and skin condition issues.
The facility failed to address a resident's multiple episodes of poor meal intake and refusal of meals, increasing the risk for inadequate nutrition and hydration. The resident, with vascular dementia, depression, and dysphagia, required supervision with eating, but food substitutes were not consistently offered. Meal intakes were not always documented or reported to the charge nurse, physician, or dietitian.
A resident experienced multiple falls without new interventions being implemented by the facility. Despite a history of falls and medical conditions, the care plan was not updated after each incident. The IDT did not review the falls, and the facility's policies on fall prevention and documentation were not followed. The resident also reported slow staff response to assistance requests.
The facility failed to provide timely transportation for residents requiring dialysis, resulting in late arrivals and incomplete dialysis sessions for four residents. The Transportation Coordinator confirmed issues with the assigned transportation providers, leading to missed appointments and rescheduled dialysis sessions.
The facility failed to develop a care plan for a resident who had an order for a brace due to a fracture and required a white board for communication due to congenital deafness. Despite the physician's order and the resident's needs, there was no documented care plan addressing these issues, as confirmed by the DON.
A resident with a history of aggressive behavior and dementia was left unsupervised, leading to her wandering into another resident's room and physically assaulting her. The incident occurred due to inadequate supervision despite the resident's care plan requiring a 1:1 sitter at all times.
Incomplete and Inaccurate Nursing Documentation for Skin Monitoring and New Admission
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for two residents in accordance with accepted professional standards and facility policy. For one resident with moderate cognitive impairment, poor balance, and iron deficiency anemia, a change in condition was identified when the resident’s son reported discoloration and a closed, dry skin tear on the left forearm. A care plan and physician order were initiated to monitor the discoloration on the left upper extremity every shift for changes in size, location, and appearance, and to notify the physician if changes were noted. However, subsequent documentation in multiple parts of the record did not consistently or accurately reflect this skin condition. Review of this resident’s MAR for anticoagulant monitoring in December showed missing and incomplete entries, including multiple days with no "Y" or "N" documented and one day with "N" documented without supporting notes. The TAR for the same period showed inconsistent monitoring documentation, with some shifts documented and others missing, particularly for evening and night shifts over several days. Daily skilled charting from mid-December documented the skin as normal without describing the left forearm discoloration, and the weekly nursing summaries for the review period did not document the new skin change or bruise on the upper left arm. During interviews, an RN and the DON confirmed that daily skilled monitoring, weekly summaries, and other documentation should have reflected the resident’s skin condition and any changes, and acknowledged that notes were missing and that the licensed nurses’ documentation did not consistently or accurately reflect the resident’s skin condition. For a second resident admitted with multiple left rib fractures and other injuries, the facility failed to complete progress notes in accordance with its own protocols. The resident was admitted from an acute hospital with pain to the left ribs and abdomen, on bed rest with oxygen via nasal cannula, and had documented skin findings including tenderness over the left chest wall, a partial nail avulsion to a finger, abrasions to the ankle and elbow, and a scab to the knee. An admission progress note was completed on the evening shift, and later notes documented the resident resting comfortably and then developing shortness of breath and respiratory distress during therapy, leading to transfer to the hospital. However, there was no documented evidence of the resident’s status or condition between late evening on the day of admission and the following morning. In interviews, nursing staff and the DON stated that facility protocol required progress notes each shift for all residents, and specifically for the first 72 hours after admission, and acknowledged that the night shift progress note for this resident was missing. The facility’s charting and documentation policy required that notable changes and assessment data be documented in the medical record, but this was not done for this resident during the night shift. These findings show that for both residents, the facility did not ensure that nursing summaries, skin evaluations, monitoring records, and progress notes were complete and accurate, as required by physician orders, facility protocols, and the facility’s charting and documentation policy. The DON and nursing staff confirmed that documentation should have reflected residents’ conditions, changes in condition, and ongoing assessments, but in these cases, the records contained omissions and inconsistencies.
Failure to Revise Care Plan After Repeated G-Tube Dislodgements
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s care plan updated to reflect repeated changes in condition related to G-tube dislodgement. The resident, admitted with metabolic encephalopathy and documented as having severe cognitive impairment (BIMS score of 99), experienced multiple episodes of pulling out her G-tube between October 10, 2025, and November 13, 2025. Each episode required transfer to the emergency room for G-tube replacement. The care plan, dated October 2, 2025, and subsequently referenced on October 10, 2025, October 13, 2025, and November 12, 2025, identified the resident as being at risk for behaviors related to dementia and G-tube dislodgement, with interventions including use of an abdominal binder and monitoring of behaviors. However, the care plan was not revised after the October 21, 2025, episode despite additional G-tube dislodgements, and the interventions initiated on October 13, 2025, were not incorporated into the written care plan until after the October 29, 2025, incident. The care plan initiated on November 12, 2025, did not include any new interventions and did not reflect changes in condition or the effectiveness of interventions for each episode. Interviews with an LVN and a CNA assigned to the resident showed they were not aware of any behaviors related to the resident pulling out her G-tube, while an RN acknowledged repeated G-tube pulling behaviors beginning October 10, 2025, and that a new intervention was not implemented until November 13, 2025. The DON stated that care plans should be revised with each change in condition and that the IDT should evaluate incidents and revise care plans accordingly, but confirmed there were only two IDT reviews despite six G-tube dislodgement incidents, contrary to the facility’s care plan policy requiring ongoing assessment and revision when the resident’s condition changes or desired outcomes are not met.
Failure to Monitor and Document Bruising and Skin Discoloration per Physician Orders
Penalty
Summary
The facility failed to monitor and document a resident’s left upper extremity bruising and anticoagulant-related bruising as ordered and per facility expectations. The resident, who had poor balance, iron deficiency anemia, and moderate cognitive impairment (BIMS score 10), was noted on a change in condition report dated December 16, 2025, after the resident’s son reported discoloration and a closed, dry skin tear on the left forearm. When questioned, the resident stated there had been no bruise until “she grabbed me, and then there was a bruise.” The physician recommended continued monitoring. The resident’s MAR for anticoagulant monitoring required staff to document “Y” if monitored with no issues or “N” if monitored and issues were observed, but from December 9–12 and December 14–17, 2025, nurses left the field blank and documented “--” instead of a Y or N response. The physician’s order summary and TAR for December 2025 directed staff to monitor the left upper extremity discoloration every shift for changes in size, location, and appearance and to notify the MD if changes were noted. However, the TAR showed no documentation of monitoring on multiple shifts, including specific night, afternoon, and morning shifts later in the month. Daily skilled charting from December 15–24, 2025, contained no additional notes describing the skin condition, and from December 16–20, 2025, there was no documented assessment of the newly identified left upper extremity bruise by licensed nurses. Weekly nursing summaries from December 16–23, 2025, also documented no skin changes or breakdown despite the new bruise identified on December 16. The care plan initiated for skin discoloration on December 16, 2025, referenced monitoring for emotional distress and checking the area of discoloration, but the record review and interviews with the RN and DON confirmed that required every-shift monitoring and documentation of the bruise and skin discoloration did not occur as ordered.
Failure to Enforce Contact Precautions for Outside Vendor
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when an outside vendor ultrasound technician (UT) failed to follow posted contact precaution requirements while providing bedside care to a resident. A sign outside the resident’s room clearly indicated Contact Precautions and instructed staff and visitors to wear a gown, gloves, and mask prior to entering, and to perform hand hygiene upon entry and exit. The UT was observed at the bedside using an ultrasound machine with the probe touching the resident’s arm while wearing only gloves, without a gown or mask, and remained in the room for approximately five minutes. The UT later re-entered the room without performing hand hygiene or donning new gloves. Record review showed the resident had been admitted with diagnoses including metabolic encephalopathy and had a BIMS score of one, indicating severely impaired cognitive status. A physician’s order dated two days prior to the observation placed the resident on contact precautions. Interviews with an LVN, a CNA, the Infection Preventionist, and the DON confirmed that the resident was on contact precautions and that facility protocol required gown, gloves, mask, and hand hygiene for all individuals entering the room. They also stated that the UT should have been instructed on and should have followed the PPE requirements. Review of the facility’s policy on initiating transmission-based precautions indicated that signage is used to inform staff of the type of CDC precautions and PPE instructions, and that protective equipment such as gloves, gowns, and masks is to be maintained outside the resident’s room so anyone entering can apply the appropriate equipment.
Failure to Administer Levothyroxine as Ordered
Penalty
Summary
The facility failed to ensure that Levothyroxine was administered as ordered for a resident diagnosed with hypothyroidism. The resident did not receive the scheduled dose of Levothyroxine on two separate occasions. On November 30, the medication was not administered because it was not available, as documented in the Medication Administration Note. On December 4, although the medication was received and signed for by an LVN prior to the scheduled administration time, there was no documentation that the medication was given, and the MAR was left blank for that dose. Interviews with the resident, LVN, and DON confirmed that the resident missed doses of Levothyroxine on both dates. The DON verified that the medication was available for administration on December 4 and that there was no documented reason for the missed dose. Facility policy requires medications to be administered in accordance with prescriber orders, but this was not followed in these instances.
Failure to Follow Contact Isolation PPE Protocols
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to follow proper infection control protocols when entering the room of a resident who was on contact isolation precautions due to an extended spectrum beta lactamase (ESBL) infection in a right foot wound. Despite clear signage and the presence of a PPE cart with gowns and gloves outside the resident's room, CNA 1 entered without donning the required personal protective equipment to respond to the resident's call light. The facility's policy, as well as CDC guidelines, required staff to wear gloves and a gown before entering rooms under contact precautions. Interviews with CNA 1, the Infection Preventionist, and the Director of Nursing confirmed that CNA 1 was aware of the resident's isolation status and acknowledged the importance of wearing PPE to prevent the spread of infection. Record review indicated that the resident had moderate cognitive impairment and was under strict single room isolation with contact precautions. The facility's policy, dated September 2022, specifically instructed staff to wear gloves and a disposable gown upon entering rooms under contact precautions, which was not followed in this instance.
Failure to Document and Calibrate Glucometers per Protocol
Penalty
Summary
The facility failed to ensure that blood glucose meters (glucometers) were calibrated and that calibration was documented according to facility protocol and professional standards of practice on multiple occasions. Quality Assurance Logs for several medication carts across three stations showed missing documentation for multiple dates, with blank entries for critical information such as time, staff performing the check, machine lot number, test strip lot number, low and high control results, and actions taken. Interviews with nursing staff, including LVNs, an RN Supervisor, the Director of Staff Development, and the Director of Nursing, confirmed that the night shift was responsible for performing and documenting glucometer calibration, and that the day shift was expected to review and complete any missing documentation. However, there were acknowledged gaps in the logs, and staff confirmed that if documentation was missing, there was no way to verify if the glucometer checks were performed or if the readings were accurate. A review of facility policies indicated that staff were required to follow manufacturer instructions for glucometer use, including quality control monitoring, and to document all relevant information in the resident's medical record. Despite these policies, the logs for multiple medication carts in November were incomplete, with several days lacking any record of calibration or quality control checks. The Director of Nursing and other staff acknowledged that these omissions meant there was no assurance that glucometer readings for residents requiring blood glucose monitoring were accurate.
Failure to Assess and Provide CPAP Therapy for Resident with OSA
Penalty
Summary
The facility failed to assess and verify a resident's history of obstructive sleep apnea (OSA) and did not coordinate necessary CPAP therapy with the physician. The resident, who had a documented history of OSA and had used CPAP for 20 years, reported to staff that she was not allowed to use her CPAP machine in the facility. The resident also stated she typically slept in a sitting position and had informed both social services and nursing staff of her CPAP use. Review of the resident's hospital records confirmed a diagnosis of OSA and CPAP use, but there was no documentation in the facility's records that a CPAP machine was provided or that the need for CPAP therapy was verified. Interviews with facility staff revealed that the diagnosis of OSA was missed during the comprehensive assessment, and there was no care plan addressing sleep apnea. The DON confirmed there was no documented diagnosis or care plan for sleep apnea, and the resident was not placed on a CPAP machine. The MDS nurse acknowledged the oversight in reviewing the resident's medical history, and the ADON stated that the diagnosis should have been verified with the physician and included in the care plan. Facility policy indicated that CPAP should be used to improve oxygenation in residents with OSA, but this was not followed in the resident's case.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential accidents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of appropriate oversight in the affected area. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not ensuring proper placement and timely response to call lights. For one resident with right-sided weakness due to a cerebral infarction, the call light was placed on the right side of the bed, making it inaccessible to her. This resident expressed being cold and unable to reach the call light to request assistance. Both a CNA and the Director of Staff Development confirmed that the call light should have been placed on the left side, as documented in the resident's care plan, to allow her to call for help. Another resident, also with a history of cerebral infarction, reported that staff took 30 minutes or longer to answer her call lights. During observation, another resident was heard calling for help, and their call light remained on for about 17 minutes before a CNA responded. Staff interviews and facility policy indicated that call lights should be answered within seven to fifteen minutes, and that all staff are responsible for responding promptly. The care plans for both residents emphasized the need for timely assistance and the use of call lights, but these procedures were not followed.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse made by a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe. The resident, who had diagnoses including dementia and protein-calorie malnutrition and was documented as lacking capacity to make decisions, made specific and consistent statements alleging prior sexual assault. These allegations were documented in the resident's records and discussed among nursing staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON). Despite the facility's policy requiring immediate reporting of any suspected abuse, the staff determined that the resident's statements were behavioral in nature due to her history of confusion and did not report the incident to CDPH. Interviews with the DON, LVN, and RN confirmed that the incident was not reported as an allegation of abuse, even though all acknowledged that protocol required reporting any such allegations within two hours. Documentation showed that the resident had previously made similar allegations, but staff did not consider these as reportable events. The facility's failure to report the allegation as required by policy and regulation resulted in a deficiency related to timely reporting of suspected abuse.
Failure to Timely Notify Physician of Critically Low Oxygen Saturation
Penalty
Summary
The facility failed to notify the attending physician in a timely manner when a resident experienced a critically low oxygen saturation level of 35%. The resident, who had a history of chronic obstructive pulmonary disease (COPD), anxiety disorder, alcohol use disorder, and sepsis, was admitted with orders for continuous oxygen via nasal cannula. On the night in question, the resident was found without his nasal cannula and with severely low oxygen saturation. Although oxygen was reapplied and the resident's saturation improved somewhat, there was a significant delay in notifying the physician. Multiple staff interviews and record reviews revealed that the licensed nurse on duty did not contact the physician immediately after the resident's oxygen saturation dropped to 35%. The physician was not informed of the critical event until several hours later, around 11 a.m., despite facility policy requiring prompt notification of significant changes in a resident's condition. The Director of Nursing confirmed that the resident should have been transferred to the hospital at the time of the initial event and that the lack of close monitoring and delayed physician notification could have affected the resident's treatment. As a result of the delayed notification and intervention, the resident experienced prolonged hypoxemia and discomfort, ultimately requiring emergency transfer to the hospital. Upon arrival, the resident was intubated for respiratory failure and severe hypoxemia but subsequently expired. Hospital records indicated the resident was admitted with acute hypercapnic hypoxic respiratory failure, likely secondary to pneumonia, and ultimately suffered cardiac arrest.
Resident Fall Due to Inadequate Supervision During In-Bed Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure a resident was safe from a fall during in-bed care. The resident, who had diagnoses including COPD, Alzheimer's disease, left below-knee amputation, and legal blindness, required substantial to maximal assistance with bed mobility. While changing the resident's brief, the CNA instructed the resident to turn away from her and then moved to the opposite side of the bed. During this process, the resident turned and fell off the bed headfirst. The resident sustained discoloration to the top of the head with pain, discoloration to the left cheek, and a skin tear to the left elbow, necessitating transfer to the hospital for evaluation. Interviews and record reviews confirmed that the resident was at high risk for falls due to impaired balance, poor coordination, amputation, non-ambulatory status, sensory deficits, and cognitive impairment. Staff familiar with the resident indicated that two-person assistance was preferred for repositioning, and that residents should be turned toward staff to prevent falls. The incident was witnessed and reported, and the facility's policy required identification of possible causes within 24 hours of a fall.
Late Completion of MDS Quarterly Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessments for 19 out of 27 residents were completed within the required 14 calendar days as mandated by the Centers for Medicare and Medicaid Services (CMS). The residents affected by this deficiency were identified as Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131, and 141. The assessments were completed significantly late, ranging from 34 to 58 days after the assessment reference date, which is the final day of the observation period during which the resident's status is assessed and documented. During interviews, both the MDS Coordinator and the Director of Nursing acknowledged the late completion of these assessments. The MDS Coordinator emphasized the importance of timely assessments to ensure accuracy and prevent delays in updating residents' care plans. The Director of Nursing confirmed that the assessments should have been completed within the 14-day timeframe to ensure individualized, resident-centered care plans. The facility's policy, dated July 2017, and a document titled RAI OBRA-required Assessment Summary, dated October 2024, both indicated that assessments should be completed and submitted to CMS in accordance with federal and state guidelines.
Delayed MDS Assessment Transmission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for 21 out of 27 residents were transmitted to the State within the required timeframe. The assessments, which included both annual and quarterly evaluations, were not completed and transmitted within 14 days from the Assessment Reference Date (ARD) as mandated by federal and state guidelines. This delay in transmission was confirmed during an interview and record review with the MDS Coordinator, who acknowledged the importance of timely completion and transmission to maintain accurate care plans for residents. The residents affected by this deficiency included those with both annual and quarterly assessments, with ARDs ranging from early November to early December 2024, and transmission dates extending into January 2025. The Director of Nursing also confirmed that the assessments should have been completed and transmitted in a timely manner to ensure individualized, resident-centered care plans. The facility's policy, as well as the Resident Assessment Instrument Manual, clearly outlined the required timeframes for MDS completion and submission, which were not adhered to in these cases.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to provide appetizing and flavorful food to its residents, as evidenced by multiple resident interviews and observations. On January 13, 2025, several residents expressed dissatisfaction with the quality of the food, describing it as gummy, bland, overcooked, and lacking in taste. Specific complaints included gummy noodles, overcooked and burnt eggs, hard rice, and bland meals. On January 14, 2025, additional residents reported that the food was unappealing, with descriptions such as dry chicken, pink pork, and soggy pasta. On January 15, 2025, a resident noted that the vegetables were over-steamed and the pasta tasted like wet flour. A test tray evaluation conducted with the Dietary Services Supervisor confirmed that the pureed meals were bland and lacked flavor, which could discourage residents from eating and potentially lead to unintended weight loss. The Registered Dietitian emphasized the importance of providing flavorful food to encourage consumption and prevent weight loss. The facility's policies on food preparation and nutrition services, dated 2023, state that food should be prepared to conserve nutritive value and flavor, and that meals should be nourishing and attractive to meet residents' nutritional needs. However, the facility's failure to adhere to these policies resulted in the deficiency.
Sanitation Deficiencies in Food Storage and Preparation Areas
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Eight out of twelve storage shelves in the dry storage room were found to have brown grime, corrosion, and chipped coating, with onions, potatoes, and canned goods stored on them. Similarly, all seven storage shelves in the walk-in refrigerator had white buildup, brown grime, and dirt, where milk, eggs, vegetables, and fruits were stored. In the walk-in freezer, all seven storage racks exhibited brown grime and chipped coating. These conditions were acknowledged by the Dietary Services Supervisor (DSS), who stated that the shelves should have been cleaned more frequently to prevent cross-contamination, which could lead to foodborne illness among the residents. Additionally, two electric fans mounted on the wall above the preparation sink and dishwashing area were observed to have white debris on the blades and covers. The DSS confirmed that the fans had dust buildup and should be cleaned more frequently to avoid cross-contamination of food. The Registered Dietitian (RD) also stated that the storage shelves and fans should be kept clean to prevent cross-contamination, which could cause foodborne illness. The facility's policy on sanitization, dated 2008, indicated that all shelves should be kept clean, maintained in good repair, and free from breaks, corrosion, or chipped areas that may affect their use or proper cleaning.
Failure to Provide Advance Directive Education and Assistance
Penalty
Summary
The facility failed to provide education, materials, and follow-up regarding Advance Directives (AD) for two residents, which could potentially lead to their medical preferences not being honored during critical healthcare decisions. Resident 73 was admitted to the facility and had the capacity to understand and make decisions, yet there was no documented evidence that the resident or their representative was provided with education or information about AD. The Social Service Director (SSD) acknowledged that Resident 73 had no AD, was not provided education, and was not reviewed for AD, despite the facility's policy requiring such actions. Similarly, Resident 130, who also had the capacity to understand and make decisions, expressed interest in formulating an AD but was not assisted or provided with the necessary materials. The SSD confirmed that Resident 130 was not provided with assistance or materials to formulate an AD, even though the facility's policy mandates offering assistance and documenting the resident's decision. The lack of follow-up and documentation for both residents indicates a failure to adhere to the facility's policy on advance directives.
Delayed Annual Comprehensive Assessments for Two Residents
Penalty
Summary
The facility failed to complete the annual comprehensive assessments for two residents, identified as Residents 70 and 85, within the required 14 calendar days as mandated by the Center for Medicare and Medicaid Services (CMS). Resident 70's assessment was completed 37 days after the assessment reference date, while Resident 85's assessment was completed 35 days after the reference date. This delay in completing the Minimum Data Set (MDS) assessments was acknowledged by the MDS Coordinator, who confirmed that the assessments were completed late and emphasized the importance of timely completion and transmission to CMS to ensure accurate resident assessments and care plans. The Director of Nursing (DON) also confirmed that the assessments should have been completed within the 14-day timeframe to ensure accurate and resident-centered care plans. The facility's policy, as outlined in the RAI OBRA-required Assessment Summary and the MDS Completion and Submission Timeframes document, mandates that the assessment coordinator or designee is responsible for submitting resident assessments to CMS in accordance with federal and state guidelines. The failure to adhere to these guidelines had the potential to impact the delivery of resident-centered care for Residents 70 and 85.
Failure to Notify Physician of Missed Follow-Up Visit
Penalty
Summary
The facility failed to notify the physician when a resident missed a follow-up visit for a surgical wound to the spine. This oversight involved Resident 24, who was alert and capable of making decisions. The resident missed a neurosurgery follow-up appointment due to late transportation, and there was no documentation indicating that the physician was informed of the missed appointment or that it was rescheduled. This lack of communication had the potential to delay the care and treatment of the resident's skin condition. Interviews with facility staff, including an LVN, the Case Manager, and the Director of Nursing, revealed that the missed appointment was not communicated to the necessary parties. The LVN acknowledged that the physician and the Case Manager should have been notified to reschedule the appointment. The Case Manager confirmed that she was unaware of the missed visit and emphasized the importance of attending follow-up appointments. The Director of Nursing stated that it was the responsibility of licensed nurses to communicate missed appointments to the physician and the Case Manager, and acknowledged the absence of documentation regarding the notification.
Failure to Implement Pressure Ulcer Care Plan and Communicate Nutritional Recommendations
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a stage 4 pressure ulcer on the right heel. The care plan required heel elevation and the use of pressure-relieving devices, but during an observation, it was noted that the resident's heels were not offloaded, and no pressure-relieving devices were in place. The Treatment Nurse confirmed that the resident was lying on a regular mattress without the necessary devices, which contradicted the care plan. The Director of Nursing acknowledged that the facility did not follow the care plan interventions, which were essential for promoting wound healing and preventing the worsening of the pressure injury. Additionally, the facility did not communicate the Registered Dietitian's nutritional recommendations for the resident's wound healing to the physician. The recommendations included a daily multivitamin with minerals and laboratory blood tests, which were not communicated to the physician or medical director. The Director of Nursing stated that it was the facility's practice for licensed nurses to communicate such recommendations to the physician or medical director, but this was not done in this case. The facility's policy on notifying physicians of clinical problems was not followed, as the Registered Dietitian's recommendations were not communicated in a timely manner. The lack of communication and implementation of the care plan interventions had the potential to impact the resident's nutrition and the healing of the pressure injury.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to a physician's order for oxygen therapy for a resident, which was identified during an observation and interview. The resident, who was admitted with diagnoses including pulmonary fibrosis and anxiety, was observed with a nasal cannula set at zero liters per minute, despite a physician's order for oxygen at 2 liters per minute as needed for shortness of breath or oxygen saturation below 90%. This discrepancy was confirmed by the resident, who stated that he used oxygen to aid his breathing. Further investigation revealed that the Licensed Vocational Nurse (LVN) acknowledged the oxygen was set incorrectly and confirmed that it was the nurse's responsibility to ensure compliance with the physician's order. The Director of Nursing also stated that the oxygen order should be followed as prescribed to prevent distress or changes in the resident's condition. The facility's policy on oxygen administration, dated 2001, requires verification of a physician's order and proper adjustment of the oxygen delivery device, which was not followed in this instance.
Failure to Conduct Pain Assessments for a Resident
Penalty
Summary
The facility failed to ensure proper pain management for Resident 152, who was admitted with rheumatoid arthritis, a condition causing joint pain and swelling. The resident was prescribed Norco, a narcotic pain medication, to be administered as needed for moderate to severe pain. However, from December 2024 through January 2025, the facility did not conduct or document pain assessments before and after administering the medication. This lack of documentation and assessment was confirmed during interviews with the Registered Nurse (RN) and the Director of Nursing (DON), who stated that the facility's process requires such assessments to be documented in the Medication Administration Record (MAR). The Licensed Vocational Nurse (LVN) responsible for administering the medication admitted to not documenting the administration or conducting the necessary pain assessments. The facility's policy, dated March 2020, outlines the requirement for assessing pain levels prior to and after administering pain medications, as well as documenting the results. The failure to follow these procedures resulted in the potential for unrelieved or unmanaged pain for Resident 152, which could negatively impact their overall health and well-being.
Failure to Document PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure proper administration and documentation of PRN narcotic pain medications for a resident, leading to potential medication discrepancies and increased risk of controlled substance diversion. The resident, who was admitted with rheumatoid arthritis, had an order for Norco to be administered as needed for moderate to severe pain. However, the Medication Administration Record (MAR) did not reflect the administration of the medication, despite it being signed out on the controlled drug record multiple times in December 2024 and January 2025. Interviews with the RN and DON revealed that the Licensed Nurse (LN) responsible for administering the medication did not follow the facility's procedures for documenting the administration of PRN narcotic pain medications. The LN signed out the medication but failed to document its administration in the MAR, as required by the facility's policy. This lack of documentation was confirmed by the LN, who acknowledged the oversight and the importance of maintaining accurate medication records to ensure accountability and prevent diversion.
Infection Control Lapses in Oxygen Therapy
Penalty
Summary
The facility failed to implement proper infection control measures in two separate incidents involving residents using oxygen therapy. In the first incident, a resident with chronic obstructive pulmonary disease was observed with an oxygen humidifier placed on the floor, contrary to infection control standards. The Licensed Vocational Nurse confirmed that the humidifier should be attached to the concentrator to maintain infection control. The Director of Nursing also acknowledged that the humidifier should not be on the floor to prevent infection, as per the facility's policy on oxygen administration. In the second incident, another resident with dyspnea and a history of COVID-19 was found with a nasal cannula on the floor. A Certified Nursing Assistant picked up the nasal cannula from the floor and placed it on the resident's nostrils without replacing it, which was against infection control protocols. The Director of Nursing stated that a nasal cannula found on the floor should be discarded and replaced to prevent the spread of infection. Both incidents highlight a failure to adhere to the facility's infection prevention and control policies, which are intended to maintain a safe and sanitary environment.
Inconsistent Nail Care in LTC Facility
Penalty
Summary
The facility failed to provide consistent fingernail care for four sampled residents, leading to poor hand hygiene and potential risks for infections and skin injuries. Observations revealed that Resident 1 had medium-length fingernails with uneven edges and dark debris underneath, despite receiving assistance with meals. Resident 2 had chipped and cracked nail polish on both fingernails and toenails, with toenails being thick and long, causing discomfort. Resident 3's fingernails and toenails were long, with chipped and cracked nail polish, and Resident 4 had dark debris under the fingernails. Interviews with staff indicated that nail care was performed at least twice a week during showers, but there were no set times or days for this care, and it was considered ongoing. The residents involved had various medical conditions that contributed to their need for assistance with activities of daily living (ADLs). Resident 1 had amyotrophic lateral sclerosis and chronic pain syndrome, Resident 2 had diabetes mellitus type II and polyneuropathy, Resident 3 had Parkinson's disease and reduced mobility, and Resident 4 had idiopathic neuropathy and dementia. The facility's policy on nail care emphasized daily cleaning and regular trimming to prevent accidental scratching and skin injury. However, the lack of consistent nail care observed during the survey indicated a failure to adhere to this policy, potentially compromising the residents' hygiene and safety.
Failure to Provide Consistent Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with a Foley catheter. The resident's care plan included specific interventions to prevent complications related to the indwelling catheter, such as administering medications, changing the catheter per policy, and monitoring for signs of infection. However, the facility did not consistently perform Foley catheter care as ordered every shift, with multiple instances of missed care documented in the Treatment Administration Record (TAR) for August and September. Additionally, the facility did not consistently monitor the resident's urinary output as required by the physician's order. The lack of documentation for catheter care and output monitoring was acknowledged by the Director of Nursing, who confirmed that the absence of documentation indicated that the care was not provided. This oversight potentially contributed to the resident's recurrent urinary tract infections, which required multiple courses of antibiotics and eventually led to the resident being transferred to a general acute care hospital with a diagnosis of sepsis. Interviews with facility staff revealed discrepancies in the understanding of who was responsible for providing catheter care, with the Director of Staff Development clarifying that licensed nurses, not CNAs, should perform this task. The facility's policy on catheter care emphasized the importance of maintaining aseptic technique and monitoring for complications, but these procedures were not consistently followed, as evidenced by the resident's ongoing urinary issues and the eventual need for emergency medical intervention.
Infection Control Deficiency: Improper PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control measures were implemented, as observed during multiple instances where staff did not perform hand hygiene before donning personal protective equipment (PPE) and did not wear face shields or goggles when entering Droplet Isolation rooms. On several occasions, Certified Nurse Assistants (CNAs) and a Licensed Vocational Nurse (LVN) were seen donning gowns and gloves without performing hand hygiene, and they entered rooms without the required eye protection. These observations were made during the provision of care to residents in isolation, which included assisting with breakfast and performing incontinence care. Interviews with the Infection Preventionist (IP) and the Director of Staff Development (DSD) revealed that staff were expected to perform hand hygiene before donning PPE and to wear face shields in Droplet precaution rooms. The facility's policy on using PPE and hand hygiene was reviewed, indicating the requirement for N95 masks, gowns, gloves, and eye protection when caring for residents with suspected or confirmed SARS-CoV-2 infection. Despite these policies, the staff's failure to adhere to infection control protocols posed a risk of infection transmission to the vulnerable resident population.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident receiving oxygen therapy, as observed during an unannounced visit. The resident, who had an oxygen concentrator set at three liters per minute, was found with an empty humidification bottle, which had been dry since the previous day. The resident, suffering from chronic obstructive pulmonary disease (COPD), anxiety disorder, and atrial fibrillation, did not report the issue due to memory problems. Interviews with staff revealed inconsistencies in the procedures for checking and maintaining the oxygen equipment, with some staff unaware of the need to develop a care plan for residents receiving as-needed oxygen. The facility's policy on oxygen administration, which requires regular checks of the humidification bottle to ensure it is filled and functioning, was not followed. Staff interviews indicated a lack of clarity regarding responsibilities for checking and maintaining the oxygen delivery system. The Licensed Vocational Nurses (LVNs) were expected to check the oxygen concentrator every shift, but the humidification bottle was not refilled as required. This oversight had the potential to result in ineffective oxygen therapy and respiratory distress for the resident.
Medication Errors Due to Non-Compliance with Physician's Orders
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, as medications were administered outside of the physician's ordered parameters. For Resident 3, who was diagnosed with hypertension and atrial fibrillation, the medication Amiodarone was administered on multiple occasions despite the resident's pulse being below the ordered threshold of 70. Additionally, Lisinopril was given when the resident's systolic blood pressure was below the ordered parameter of 110. These errors were confirmed by LVN 1, who acknowledged administering the medications outside the specified parameters but was unsure why this occurred. Resident 4, diagnosed with hypotension, was also subject to medication errors. The medication Midodrine, intended to increase low blood pressure, was administered when the resident's systolic blood pressure exceeded the ordered parameter of 120. These instances were verified during a review with the Director of Nursing, who confirmed that the medications were given despite the vital signs being outside the ordered parameters. The facility's policy and procedure require that medications be administered as prescribed, with nurses verifying orders and parameters before administration. Documentation should be made in the Medication Administration Record (MAR) immediately after administration, and any deviations from the ordered parameters should be documented with a code and a progress note. However, these procedures were not followed, leading to the administration of medications outside the prescribed parameters for both residents.
Failure to Document Follow-Up on PRN Blood Pressure Medication
Penalty
Summary
Facility staff failed to follow up on the effectiveness of a PRN blood pressure medication for one resident, identified as Resident 2. The resident, who was admitted with a diagnosis of hypertension, had a physician's order for Clonidine 0.1 mg to be administered as needed when the systolic blood pressure exceeded 160 mmHg. On September 27, 2024, the resident's blood pressure was recorded at 184/92 mmHg, and the PRN Clonidine was administered accordingly. However, there was no documentation of a follow-up blood pressure check to assess the medication's effectiveness, as required by the facility's policy. Interviews with the Director of Nursing and LVN 2 confirmed that the follow-up assessment should have been conducted and documented within an hour of administering the medication. The facility's policy on medication administration mandates that vital signs be recorded as necessary prior to medication administration and that the results of PRN medications be documented, including the time results were noted. The lack of documentation and follow-up assessment for Resident 2's blood pressure after administering Clonidine represents a deficiency in adhering to these guidelines.
Failure to Verify Medication Parameters
Penalty
Summary
The facility failed to verify the accuracy of prescribed parameters for a blood pressure medication, Metoprolol Succinate, for a resident diagnosed with hypertension. The physician's order indicated that the medication should be held if the systolic blood pressure was below 110 or if the pulse was above 60. However, the medication was administered outside of these parameters on 10 out of 17 days in September 2024. The Licensed Vocational Nurse (LVN) confirmed that the ordered parameter to hold the medication if the pulse was above 60 was incorrect, as it is typically held if the pulse is below 60. The LVN acknowledged that she should have identified and corrected the error by contacting the physician for clarification. The Director of Nursing (DON) also confirmed that the parameter for Metoprolol was incorrect and stated that the medication should have been withheld until the nurse verified the parameters with the physician. The facility's policy and procedure require that medications be administered as prescribed and that any questionable orders be clarified with the prescriber. Despite this policy, the medication was administered daily outside the ordered parameters, indicating a failure to adhere to the facility's medication administration protocols.
Failure to Don Required PPE in Contact Precautions Room
Penalty
Summary
The facility failed to ensure that staff donned the required Personal Protective Equipment (PPE) when entering a contact precautions isolation room for a resident with an infected abdominal wound. The resident was admitted with a diagnosis of a peritoneal abscess and was placed on contact precautions as per physician orders and care plan instructions. The room had a sign indicating the need for staff to wash hands and don a mask, gloves, and gown before entry. During an unannounced visit, it was observed that a Certified Nursing Assistant (CNA) entered the resident's room wearing only a surgical mask, without the required gloves and gown. The CNA acknowledged the requirement to wear full PPE and admitted to not following the protocol. Another CNA was also observed entering the room without a gown while collecting a lunch tray, stating that she did not don a gown as she was not providing direct care. Interviews with the Infection Prevention (IP) nurse and the Director of Staff Development (DSD) confirmed that the facility's policy required staff to work in pairs when delivering or picking up food trays for residents on contact precautions. One staff member should don full PPE inside the room, while the other hands over the tray. Both the IP nurse and DSD stated that the observed actions of the CNAs did not align with the facility's policy, which mandates wearing a mask, gloves, and gown upon entering a contact precautions room.
Lack of Coordination in Hospice Services for Residents
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for two residents, leading to a deficiency in the continuity of care. For Resident 1, who was admitted with end-stage renal disease and required hospice care, the facility did not have a filled-out schedule from the hospice company indicating when hospice staff would visit. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and Social Services (SS), revealed a lack of awareness regarding the hospice staff's schedule and services, with the hospice binder containing a blank calendar. The hospice Director of Nursing confirmed that a schedule should have been provided, but it was not present in the facility's records. Similarly, Resident 3, admitted with heart failure and receiving hospice care, also lacked a documented schedule in the hospice binder. Despite Resident 3's awareness of hospice visits twice a week, facility staff, including an LVN and a Certified Nursing Assistant (CNA), were unsure of the hospice staff's schedule and services. The hospice Intake Coordinator confirmed that a schedule was supposed to be provided to the facility, but it was missing from the records. The facility's policy and procedure for hospice care coordination, revised in July 2017, indicated that it was the facility's responsibility to coordinate care with the hospice representative. However, the designated Director of Nursing (DON) failed to ensure that the hospice schedules were documented and communicated to the facility staff, resulting in a lack of coordination and potential disruption in the quality of care for the residents.
Failure to Notify Physician of Resident's Aggressive Behavior
Penalty
Summary
The facility failed to notify the physician when a resident exhibited aggressive behavior and refused to return inside the facility. On July 9, 2024, the resident, who had been admitted with diagnoses including parkinsonism, dementia, dysarthria, and anarthria, was found outside the facility hitting a staff member who was trying to encourage him to come back inside. Despite the intervention of a licensed nurse who attempted to redirect the resident's behavior, the resident continued to exhibit aggression by hitting the nurse, throwing water cups, and threatening to harm himself and others. The incident was documented in the resident's progress notes, but there was no record of the physician being notified of the resident's behavior on that day. An interview with a Licensed Vocational Nurse (LVN) confirmed that the physician should have been informed of the resident's aggressive behavior, but this notification did not occur. The facility's policy on charting and documentation, which requires changes in a resident's condition to be documented, was not followed in this instance.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as evidenced by the presence of black scuff marks, a dent with peeling wallpaper, and dried smudges on the walls and baseboards in their shared room. These deficiencies were observed during an unannounced visit initiated to investigate complaints and facility-reported incidents. The issues were noted on multiple occasions, indicating a lack of timely maintenance and cleaning. Resident 2, who has a history of intervertebral disc degeneration, cardiac arrhythmia, and scoliosis, expressed dissatisfaction with the cleanliness of the room, describing the dried brown smudges as gross. Resident 4, diagnosed with sepsis, type 2 diabetes mellitus with ketoacidosis, MRSA, ESBL, urinary tract infection, benign prostatic hyperplasia, and hypotension, had a visitor who also noted the uncleanliness and the longstanding nature of the dent and peeling wallpaper. Interviews with facility staff, including a CNA, Maintenance Assistant, and Housekeeping Director, revealed that the maintenance log had not been updated with the necessary repairs, and the housekeeping staff had not adequately cleaned the room. The facility's policies on maintaining a homelike environment, maintenance services, and cleaning were not adhered to, contributing to the observed deficiencies.
Failure to Implement Care Plan for Aggressive Behavior
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who exhibited aggressive behavior. During an unannounced visit, it was found that the resident, who had been admitted with diagnoses including parkinsonism, dementia, dysarthria, and anarthria, did not have a care plan addressing his aggressive behavior. Despite being alert and oriented, the resident was deemed incapable of giving informed consent, as noted in his medical records. An interview with a Registered Nurse confirmed the absence of a care plan for the resident's aggressive behavior, which the nurse acknowledged should have been in place. The facility's policy requires the Care Planning/Interdisciplinary Team to develop individualized comprehensive care plans based on residents' assessments, but this was not done for the resident in question.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate care and services for activities of daily living (ADLs) for a resident, specifically in relation to scheduled showers. The resident, who was admitted with conditions such as intervertebral disc degeneration, cardiac arrhythmia, and scoliosis, was capable of understanding and making decisions. According to the facility's shower schedule, the resident was supposed to receive showers on Wednesday mornings and Saturday evenings. However, the resident did not receive a shower until Sunday, which was confirmed by both the Director of Nursing and the Certified Nursing Assistant during interviews. The resident expressed feeling unclean due to not being offered a shower until several days after admission. The facility's policy, revised in February 2018, mandates offering showers or bed baths at least twice a week or according to the resident's preference. Documentation in the resident's bathing task indicated that no applicable bathing was recorded on the days leading up to the shower on Sunday, which was marked as requiring supervision or touch assist. This oversight had the potential to negatively impact the resident's physical and psychosocial well-being.
Failure to Follow Physician's Order for Midodrine Administration
Penalty
Summary
The facility failed to adhere to a physician's order for a resident who was prescribed Midodrine, a medication used to increase blood pressure. The physician's order specified that Midodrine should not be administered if the resident's systolic blood pressure (SBP) was greater than 120. However, the medication was given on multiple occasions when the resident's SBP exceeded this threshold. Specifically, the medication was administered on May 20, 2024, when the SBP was 146, and on May 21, 2024, at 9 a.m., 12 p.m., and 4 p.m., when the SBP was 127 and 138, respectively. The resident involved had a medical history that included stroke, acute kidney failure, diabetes mellitus type 2, and orthostatic hypotension. The failure to hold the medication as per the physician's order was confirmed during an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the Midodrine should have been withheld when the SBP was greater than 120. This oversight had the potential to result in dangerously high blood pressure for the resident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically Ativan and Seroquel, as there was no appropriate indication for their use. The resident, who was diagnosed with parkinsonism, dementia, dysarthria, and anarthria, was noted to be alert and oriented upon admission. However, the medical records indicated that the resident was incapable of giving informed consent. Despite this, informed consent was not obtained from the resident's responsible party for the use of these medications. The Director of Nursing acknowledged that the order for Ativan, which was incorrectly indicated for psychosis, should have been clarified with the doctor, as Ativan is typically used for anxiety. Similarly, the order for Seroquel, indicated for psychosis, also lacked proper clarification and informed consent documentation. The facility's policy on psychotropic medication use requires that informed consent be obtained from the resident or their representative before administering such medications. Additionally, the policy mandates that psychotropic medications should only be used when necessary to treat a specifically diagnosed condition documented in the medical record. The facility's failure to adhere to these policies resulted in the potential for the resident to receive unnecessary antipsychotic medications. The Director of Nursing confirmed the absence of documentation for informed consent and the need for clarification of the medication orders with the prescribing physician.
Failure to Display Daily Staffing Information
Penalty
Summary
The facility failed to display direct care daily staffing information in a prominent location, which is required to ensure residents, visitors, and staff are informed of staffing levels based on resident needs. During an unannounced visit to investigate quality care issues, it was observed that there was no posting of the daily staffing information in any visible location within the facility. Interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the staffing ratios were kept in a binder at the nurses' station and were not posted publicly. The DON was unaware of the requirement to post staffing ratios in a visible location. A review of the facility's policy indicated that direct care daily staffing numbers should be posted for every shift.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to conduct an assessment for self-administration of medication for one resident, identified as Resident 2. During an unannounced visit, surveyors observed two bottles of eye drop medications in Resident 2's open bedside dresser. Resident 2 confirmed that he self-administers these medications. However, there was no documented assessment to determine if Resident 2 was capable of safely self-administering his medications, as required by the facility's policy. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN 3) acknowledged the absence of an assessment for Resident 2's self-administration of medication. The facility's policy mandates that an interdisciplinary team must evaluate a resident's cognitive and physical abilities before allowing self-administration of medications. Despite having a physician's order for the medications, the necessary evaluation was not completed, leading to a deficiency in ensuring the safe self-administration of medications by Resident 2.
Failure to Maintain Clean Wheelchair Safety Belts
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident, as evidenced by the condition of the resident's wheelchair safety belts. During an unannounced visit, it was observed that the safety belts on the resident's wheelchair were dirty and covered with layers of dry crusted food. This observation was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the condition of the safety belts was unacceptable and that they should be clean. The resident involved had significant medical conditions, including anoxic brain damage, epilepsy, quadriplegia, and hypertension, which necessitated the use of two seatbelts in the wheelchair for proper positioning and support. The resident's care plan specifically indicated that the assistive device should be kept clean and in good repair. However, the facility's failure to adhere to this care plan and their own policy on maintaining assistive devices resulted in the deficiency noted during the survey.
Inconsistent Oral Care for Resident
Penalty
Summary
The facility failed to ensure consistent oral care and personal grooming for a resident, leading to poor oral hygiene. During an unannounced visit, a resident was observed with mucus draining from the left nostril and a foul odor emanating from the mouth. A Licensed Vocational Nurse confirmed the unpleasant smell and deemed it unacceptable. The resident's care plan indicated a need for assistance with activities of daily living, including oral care, which was not consistently documented as provided. The resident, admitted with conditions such as anoxic brain damage, epilepsy, quadriplegia, and hypertension, required assistance with daily activities. A review of the resident's documentation for May 2024 showed multiple dates where oral hygiene was not recorded as provided. The facility's policy stated that residents unable to perform daily activities independently should receive necessary services to maintain personal and oral hygiene, which was not adhered to in this case.
Failure to Provide Scheduled Showers and Document Care
Penalty
Summary
The facility failed to provide showers twice per week for one resident, leading to potential hygiene and skin condition issues. During an unannounced visit, it was observed and confirmed through interviews and record reviews that the resident, who was admitted with anoxic brain damage, legal blindness, and quadriplegia, did not receive scheduled showers on multiple occasions. The resident was dependent on staff for personal hygiene and was scheduled to receive showers every Monday and Thursday evening. However, there was no documented evidence that the resident received showers on several scheduled dates in May 2024. Interviews with the CNA, DSD, and RNS revealed that while the facility's policy required showers to be documented, there was a failure in documentation, leading to the assumption that the showers were not provided. The DSD and RNS acknowledged the importance of maintaining good hygiene and skin condition for the resident and confirmed that the lack of documentation indicated the showers were not given. The facility's policies on bathing and activities of daily living were reviewed, highlighting the requirement for regular showers and proper documentation, which were not adhered to in this case.
Failure to Address Poor Meal Intake and Provide Food Substitutes
Penalty
Summary
The facility failed to address a resident's multiple episodes of poor meal intake and refusal of meals, which increased the resident's risk for inadequate nutrition and hydration. The resident, who had vascular dementia, depression, and dysphagia, required supervision with eating and had a care plan that included providing additional calories and protein at meals. However, there was no documented evidence that food substitutes were offered during episodes of poor intake and meal refusals. Interviews with CNAs and the Director of Staff Developer revealed that meal intakes were not consistently documented, and the resident's eating difficulties were not always reported to the charge nurse or followed up with the physician and dietitian. The Registered Nurse Supervisor confirmed that the resident had episodes of refusing meals and poor oral intake, and that meal intakes were not being monitored every meal. The Registered Dietitian stated that the resident required setup with meals and liked foods that could be held with his hand, but no one informed her about the resident's poor oral intake and refusal of meals during the specified period. The facility's policy on nutrition and hydration emphasized the importance of providing small, frequent meals and between-meal snacks to reach caloric and protein goals, but this was not implemented according to the plan of care for the resident.
Failure to Implement New Fall Prevention Interventions
Penalty
Summary
The facility failed to implement new interventions to prevent fall incidents for a resident, identified as Resident C, who experienced multiple falls on March 6, 9, 15, 18, 20, and 26, 2024. Despite the resident's history of falls and medical conditions such as sarcopenia and transient ischemic attack, the facility did not update the care plan with new interventions after each fall. The care plan initially included interventions like anticipating and meeting needs and reminding the resident to call for assistance, but these were not revised following subsequent falls. The facility's documentation and review processes were inadequate, as there was no evidence that the Interdisciplinary Team (IDT) reviewed each fall incident or initiated new interventions. The Director of Nursing confirmed that no new interventions were implemented for falls occurring after March 6, 2024, and there was no documentation of IDT meetings to address the resident's fall incidents. This lack of action and documentation was contrary to the facility's policies, which require analysis of individual resident vulnerabilities and implementation of resident-centered fall prevention plans. Additionally, during an interview, Resident C reported having vision issues and needing assistance with changing adult briefs, but staff response times were slow. This indicates a potential gap in supervision and timely assistance, which could have contributed to the resident's repeated falls. The facility's policies on accidents, acute condition changes, and fall risk management emphasize the need for timely intervention and documentation, which were not adhered to in this case.
Failure to Ensure Timely Transportation for Dialysis Residents
Penalty
Summary
The facility failed to ensure timely transportation services for residents requiring dialysis, resulting in four residents (A, B, C, and D) arriving late at the dialysis center and receiving incomplete dialysis run time. Resident A's medical records indicated multiple instances of delayed or missed transportation, leading to rescheduled dialysis appointments and, in one case, a transfer to the emergency room due to a change in condition after dialysis. The Transportation Coordinator (TC) confirmed that Resident A's insurance usually arranged for his transportation, but there were significant delays, including a four-hour late arrival that caused a missed appointment. Resident B expressed dissatisfaction with the transportation company assigned by his insurance, citing frequent delays that led to incomplete dialysis sessions. The TC acknowledged the issue and stated that the facility had requested a change in transportation provider due to the consistent lateness. Resident C also experienced transportation delays, including an incident where the transportation company took him to the wrong location before finally bringing him to the dialysis center. The TC confirmed that Resident C missed a dialysis appointment due to late transportation and that his insurance only authorized a specific ambulance service, which caused further complications. Resident D and a family member reported multiple instances of late transportation, resulting in missed dialysis sessions. The TC confirmed that Resident D's family requested a change in dialysis schedule and transportation provider due to the consistent lateness. The facility's policies on transportation and end-stage renal disease care were reviewed, indicating that the facility is responsible for arranging transportation and ensuring comprehensive care plans for residents with dialysis needs. However, the facility failed to adhere to these policies, leading to the deficiencies observed in the report.
Failure to Develop Care Plan for Resident's Brace and Communication Needs
Penalty
Summary
The facility failed to develop a care plan for Resident C, who had an order for a brace to be applied to the right arm due to a fracture and required the use of a white board for communication due to congenital deafness. Despite the physician's order on December 18, 2023, for the brace and the resident's need for a white board for communication, there was no documented evidence of a care plan addressing these needs. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that a care plan should have been developed to include specific interventions for the brace and the white board. Resident C was admitted to the facility with multiple diagnoses, including altered mental status, diabetes mellitus, dementia, heart disease, and chronic kidney disease. The facility's policy required a baseline care plan to be developed within 48 hours of admission to meet the resident's immediate needs. However, the facility did not adhere to this policy, resulting in a lack of documented care plans for the resident's brace and communication needs, potentially delaying treatment and services necessary for maintaining or improving the resident's well-being.
Failure to Provide Adequate Supervision Leads to Resident-to-Resident Assault
Penalty
Summary
The facility failed to provide adequate supervision for a resident (Resident A) who required close monitoring due to a history of aggressive behavior and dementia. On February 19, 2024, Resident A was left unsupervised when the assigned CNA went to the restroom and asked another CNA to watch over Resident A. However, the second CNA also left Resident A unsupervised to check on another resident. During this period, Resident A wandered into another resident's (Resident B) room and physically assaulted her by hitting her multiple times while she was in bed. Resident A had a documented history of aggressive behavior, including yelling, screaming, and hitting staff and sitters. The care plan for Resident A indicated the need for a 1:1 sitter at all times due to her aggressive tendencies and risk of falls. Despite this requirement, the sitter assigned to Resident A was only present for four hours on the day of the incident, and the regular staff failed to provide continuous supervision as required. Resident B, who was cognitively intact, reported that she initially thought Resident A was a nurse but soon realized it was another resident who then assaulted her. The Director of Nursing acknowledged that the incident could have been avoided if proper supervision had been maintained. The facility's policy on safety and supervision emphasized the importance of preventing avoidable accidents and ensuring adequate supervision, which was not adhered to in this case.
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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