Heritage Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Monterey Park, California.
- Location
- 610 North Garfield Avenue, Monterey Park, California 91754
- CMS Provider Number
- 055989
- Inspections on file
- 34
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Heritage Manor during CMS and state inspections, most recent first.
Surveyors found multiple food safety deficiencies during meal service in a conference room used as a temporary tray line area. An expired, ready-to-eat turkey sandwich remained in the refrigerator past its labeled use-by date, contrary to facility policy and FDA Food Code requirements. Staff serving food in the conference room did not have hair nets readily available, and a staff member wiped food contact surfaces with a kitchen towel that was then left on the counter instead of being stored in a sanitizer solution, with no sanitizer bucket or test strips present in the room. In addition, milk served during lunch was measured at 52.5°F, above the required 41°F or below for TCS foods, and staff reported there was no ice available in the conference room to maintain proper cold holding temperatures.
The facility failed to use its QAA/QAPI process to monitor and manage a temporary food service system put in place after the kitchen elevator became inoperable. Staff began transporting food and beverages by stairwell and using a conference room as a serving area, but no performance improvement project or monitoring was implemented for sanitation, infection control, or staff safety. Surveyors found expired food in the conference room refrigerator and cold beverages held above required temperatures, while the conference room lacked proper means to keep items cold. Food deliveries were left in the parking lot and carried by staff down the stairs to the basement kitchen. The RD’s sanitation audits did not include the conference room, and staff did not receive routine training or evaluation on safe food transport, fall prevention, or injury risk related to the new procedures, despite QA meetings discussing the elevator outage.
The facility failed to maintain a functional kitchen elevator, leaving it inoperable for an extended period despite prior maintenance recommendations, and did not notify the district office about the ongoing outage. As a result, dietary staff were required to carry all food, beverages, and supplies up and down stairs between the basement kitchen and an upstairs conference room used as a temporary meal staging and service area, with staff observed making multiple trips, becoming visibly fatigued, and one staff injury reported. Surveyors found cold beverages held above 41°F in a warm conference room without ice, and staff reported that vendor deliveries were left in the parking lot and then manually transported to the kitchen over a prolonged period, potentially delaying refrigeration. These practices were inconsistent with the facility’s own food safety and storage policies and FDA Food Code requirements for proper hot and cold holding and prompt refrigerated storage.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, resulting in care that was not individualized or consistent with regulatory requirements.
A resident with type 2 DM was admitted with no orders for insulin or hypoglycemic medications, yet the care plan included interventions for diabetes medication administration and blood sugar monitoring. Staff confirmed the care plan was not tailored to the resident's actual needs and was initiated before a full IDT review, leading to inaccurate and non-resident-specific interventions.
A licensed nurse responsible for MDS assessments did not complete required annual competency evaluations for two consecutive years. The nurse was unaware of the facility's comprehensive care plan policy, a key aspect of their role. The DON confirmed the lapse, and facility records showed that annual competency checks, including care planning, are mandated to ensure staff maintain necessary skills and knowledge.
A resident with a history of type 2 diabetes and cognitive impairment did not receive a comprehensive monthly medication regimen review by the consultant pharmacist. The pharmacist failed to review the full diagnoses, previous medication orders, and relevant records, resulting in the omission of diabetes medication and subsequent hyperglycemia.
A resident with acute respiratory failure, COPD exacerbation, and pulmonary hypertension experienced a significant decline in respiratory status. Despite physician orders for close monitoring, oxygen titration, and immediate notification of the physician and emergency services, staff failed to assess, document, and respond appropriately when the resident's oxygen saturation dropped. The LVN did not follow orders to increase oxygen, did not notify the physician or call 911, and did not implement the resident's POLST. The resident's condition worsened and resulted in death, with facility policies and procedures not followed throughout the event.
Staff failed to maintain privacy for multiple residents during personal care by not closing privacy curtains or providing alternative visual barriers when curtains were removed for cleaning. In several cases, residents were exposed during care without their consent, and staff did not follow facility policy to ensure privacy and dignity.
Dietary staff, including the Dietary Manager and Facility Cook, did not follow required recipes or measure ingredients when preparing pureed foods for residents on modified diets. Instead, staff estimated thickener amounts and did not verify food texture, resulting in inconsistent and inappropriate food consistencies. Facility policies and recipes required specific measurements and procedures, but these were not followed, and there was no system to check the final product before serving.
The facility did not follow its own food safety policies by failing to properly store a flour scoop to prevent contamination and by not calibrating a food thermometer according to established procedures. The scoop was left exposed on top of the flour container instead of being stored in a plastic bag, and the thermometer was incorrectly calibrated, with staff accepting an inaccurate temperature reading. These actions did not meet professional standards for food safety and equipment handling.
The facility did not have effective systems in place to ensure dietary staff followed pureed food recipes, resulting in improper food texture for all residents on pureed diets. Additionally, the facility failed to identify, investigate, and respond to an adverse event involving a resident who expired from respiratory distress, with staff not documenting vital signs, notifying the physician, or following POLST preferences. These deficiencies were not addressed by the QAPI committee, despite repeated concerns.
A resident with cognitive impairment and respiratory conditions was not served a meal at the same time as other residents in the dining room, resulting in the resident waiting at least 17 minutes and feeling disrespected and frustrated while watching others eat. Staff interviews indicated a lack of communication regarding the resident's presence in the dining room, leading to the delay.
A resident with acute respiratory failure and COPD exacerbation experienced a significant drop in oxygen saturation, but staff failed to immediately notify the physician or follow emergency protocols as required by facility policy and physician orders. The resident's condition deteriorated rapidly, and the physician was only contacted after the resident had expired. Documentation and interviews confirmed that vital signs were not properly recorded, and appropriate interventions were not initiated in a timely manner.
Two residents experienced an unclean and unsafe environment due to unresolved maintenance issues, including a broken sliding screen door with holes and tears and missing floor tiles under a bed following a water leak. Despite repeated notifications and existing preventative maintenance policies, the facility did not repair these issues for over a month, impacting the comfort and quality of life for the affected residents.
A resident with hypertension and hyperlipidemia was discharged home with home health services, but the MDS assessment was incorrectly coded as a discharge to an acute hospital. The error was identified during a review of records and acknowledged by the MDS Nurse, who confirmed the MDS did not accurately reflect the resident's actual discharge disposition.
A resident with impaired vision and multiple medical conditions did not have a care plan addressing his need for new eyeglasses, despite an optometrist's recommendation and the resident's reports of worsening vision. Staff were unaware of the resident's vision concerns, and there was no documentation or tracking of the eyeglasses order, resulting in unmet care needs.
A resident with severe cognitive impairment developed a pressure injury on the left big toe that progressed from partial-thickness to full-thickness loss while in the facility. Despite wound care notes recommending new footwear and the care plan identifying improper footwear as a risk, there was no assessment or intervention regarding the resident's shoes. The resident continued to wear tight, uncomfortable sneakers, and staff did not evaluate footwear as a contributing factor, contrary to facility policy.
A nurse failed to check a resident's heart rate before administering antihypertensive medications and did not provide food with Metoprolol and Metformin as ordered, resulting in a medication error rate above 5%. The resident, who had diabetes and hypertension and was dependent on staff, received medications contrary to physician orders and facility policy.
A nurse failed to check a resident's heart rate before administering Metoprolol and Amlodipine, as required by physician orders and facility policy. The nurse only checked blood pressure and was about to give the medications when prompted by a surveyor to check the heart rate, which was then found to be within the safe range. The resident had cognitive impairment and was dependent on staff, and the omission was confirmed as a significant medication error.
A resident with dysphagia and cognitive impairment was repeatedly served pureed food that was too thick and lumpy, contrary to physician orders and care plan requirements for a thin consistency. The resident's family member reported having to bring in homemade food due to the facility's failure to provide the correct texture, and direct observations confirmed the food did not meet prescribed standards. The dietary manager and registered dietician acknowledged the inconsistency, and the cook admitted to not following facility recipes.
A dirty and rusty commode was discovered in a shared bathroom used by six residents. Housekeeping staff were unaware of the issue and could not confirm if the restroom had been checked for cleanliness. The maintenance supervisor confirmed the commode had been in poor condition for several days, despite facility policies requiring sanitary equipment and regular preventative maintenance.
A resident's responsible party reported aggressive and rude behavior by a nurse to the Social Service Assistant (SSA), who failed to initiate a grievance process or inform the Social Service Director (SSD). The facility's policy requires prompt grievance resolution, but the SSD was unaware of the issue, and the Director of Nursing (DON) was not informed. This failure increased the risk of negative psychosocial impact on the resident.
A resident with dementia and osteoporosis fell from a shower chair in an LTC facility when a CNA left her unattended. The resident, who was dependent on staff for bathing, opened the armrest and fell, resulting in a fractured humerus. The CNA did not report the fall immediately and moved the resident without a nurse's assessment, violating facility policy. The resident was later transferred to a hospital for non-operative treatment.
A resident with severe cognitive impairment was found with ecchymosis and a skin tear, but the facility failed to report the injury of unknown source within the required two-hour timeframe. The CNA noticed the discoloration but did not report it immediately, leading to a delay in notifying the DPH. The facility's policy mandates immediate reporting to ensure resident safety and compliance.
A facility failed to follow its wound care protocol when an LVN did not change gloves or wash hands after handling a soiled dressing on a resident with a Stage 4 pressure ulcer. The LVN continued to treat the resident's wounds without performing necessary hand hygiene, contrary to the facility's policy. The resident had a history of diabetes, hypertension, sepsis, and antibiotic-resistant bacteria, and was dependent on staff for daily activities.
The facility failed to implement an effective infection prevention and control program during a Covid-19 outbreak, leading to improper cohorting of residents. A resident who tested positive for Covid-19 was mistakenly moved into a room with negative residents due to the lack of a proper line listing and reliance on verbal reports. The IP nurse did not consult local health department or CDC guidelines, relying instead on online resources, which contributed to the deficiency.
A resident with cognitive impairments and mobility issues eloped from the facility without staff knowledge. Despite expressing a desire to go home earlier, the resident left unnoticed, and the facility was only informed of the elopement by a family member. The facility's policy on preventing elopements was not effectively implemented.
A CNA was observed standing while feeding three residents, contrary to facility policy requiring staff to be seated to maintain dignity and prevent choking. The residents, who have severe cognitive impairments and are dependent on staff for eating, were fed in a manner that could compromise their dignity and safety. Staff interviews and policy reviews confirmed the importance of seated feeding.
The facility failed to develop comprehensive care plans for three residents, leading to potential risks in their care. One resident lacked a care plan for oxygen therapy, another for sepsis and pneumonia, and a third for medication preferences. Staff confirmed the absence of necessary care plans, which are essential for consistent and effective care.
The facility failed to properly assess, monitor, and evaluate a resident's skin condition related to MASD and fungal infection. The care plan was not implemented, weekly skin assessments were not conducted, and the primary physician was not notified of the worsening condition. The resident experienced severe pain and distress due to the untreated skin condition.
The facility failed to provide appropriate pain management for a resident with severe MASD and fungal dermatitis, resulting in unrelieved severe pain. Despite the resident's complaints and visible signs of discomfort, the staff did not assess or manage her pain effectively, and no pain medication was administered.
The facility failed to complete performance reviews and Annual Core Clinical Competencies (ACCC) for eight of nine CNAs, potentially impacting the quality of care provided to residents. The new Director of Staff Development (DSD) confirmed that the previous DSD did not conduct the required competency checks for 2023, leaving the CNAs' skills assessments incomplete or not done since 2022. The Administrator acknowledged the issue, emphasizing the necessity of annual competency checks to ensure proper care for residents.
The facility failed to label and date food items in the kitchen, including chicken bouillon, rice, sliced peaches, tofu, and green peas, as required by their policy and professional standards. The DSS and DON acknowledged that these items should have been labeled and dated to ensure they were fresh and safe for consumption.
The facility failed to complete necessary documentation and monitoring as part of its Antibiotic Stewardship Program for two residents, leading to potential inappropriate antibiotic use and incomplete monitoring during therapy.
The facility failed to provide reasonable accommodation of needs for two residents. One resident's call light was out of reach, potentially delaying care, while another resident, who speaks little English, was not provided with appropriate communication tools or translation assistance, leading to confusion and frustration.
A facility failed to notify a physician and family of a significant change in a resident's condition, leading to worsened MASD and a fungal infection. Despite the resident's complaints and the Treatment Nurse's acknowledgment of the issue, proper documentation and timely assessments were not conducted. The Primary Medical Physician did not assess the wound and relied on second-hand reports, resulting in inadequate care.
A facility failed to ensure proper care for a resident with a Foley catheter, resulting in urine backflow due to kinked tubing. This oversight, confirmed by multiple staff members, contradicted the resident's care plan and facility policies, posing a risk of recurrent UTIs for the resident with severe cognitive impairment and a history of sepsis secondary to UTI.
The facility failed to label and date the gastrostomy tube for a resident, leading to potential infection control issues. The resident had severe cognitive impairment and was dependent on assistance for all ADLs. The facility's policies on feeding tube care and infection control were not followed.
The facility failed to ensure that a resident had their nasal cannula and humidifier bottle dated and changed weekly, and another resident had their plastic storage bag for oxygen equipment changed weekly per facility protocol. This led to potential contamination and infection risks.
The attending physician failed to supervise the care of a resident with severe MASD, fungal infection, and dermatitis. The physician did not assess the resident's skin condition or provide a pain medication regimen, despite the resident experiencing significant pain and worsening skin conditions. The facility's policy requiring active physician supervision was not followed.
The facility failed to ensure that two residents on blood thinners were adequately monitored for bleeding and bruising. One resident on Plavix had no physician order or documentation for monitoring, while another on Aspirin and Eliquis lacked routine lab tests. The DON confirmed these lapses, which were against the facility's policy for anticoagulant therapy.
The facility failed to maintain a medication error rate below five percent, with errors including not checking expiration dates and not administering medications with food as ordered, affecting three residents.
The facility failed to document that two residents were offered or declined the flu vaccine for the 2023-2024 season, despite having the capacity to make decisions. The Infection Preventionist confirmed the absence of necessary documentation in the residents' medical charts.
The facility failed to ensure employee personal items were not stored in a medication room and did not maintain a sanitary environment for a resident. A jacket was found in the medication room, and a resident's bedside commode was left uncleaned for hours, leading to a strong smell and potential infection risk. The facility's policies on sanitation and infection prevention were not followed.
Improper Food Storage, Sanitation, and Cold Holding Temperatures During Meal Service
Penalty
Summary
Surveyors identified deficiencies in food safety and sanitation practices related to food storage and handling in a conference room being used as a temporary food service area. During observation of the conference room refrigerator, one prepared turkey sandwich was found with a use-by date of 2/22/26–2/23/26 that had not been discarded after expiration. The Dietary Supervisor (DS) stated that sandwiches were prepared the day before, served the next day, and discarded if not used by the labeled date, and acknowledged that the sandwich in the refrigerator was expired and should have been discarded. Facility policy and the 2022 FDA Food Code require ready-to-eat, time/temperature control for safety (TCS) foods to be labeled, dated, monitored, and used, frozen, or discarded by the use-by date. Additional deficiencies were observed in hygienic practices and surface sanitation in the same conference room tray line area. There were no hair nets readily available in the conference room, even though it was being used as a temporary food serving area. The DS stated that staff wore hair nets from the basement kitchen but confirmed that hair nets should be readily available in the conference room to prevent hair from contacting food. A staff member was observed wiping food contact surfaces with a kitchen towel and then placing the towel on the counter instead of storing it in a sanitizer solution between uses. The staff member stated that kitchen towels should be stored in sanitizer solution when not in use and that there was no sanitizer solution available in the conference room. The DS confirmed that a sanitizer solution bucket should have been present and that there were no sanitizer test strips in the conference room to verify sanitizer effectiveness, despite facility policy and FDA Food Code requirements for wiping cloths to be held in appropriate sanitizer solution. Surveyors also found improper cold holding temperatures for TCS beverages during lunch service in the conference room. Using the facility’s thermometer, the temperature of milk held for cold storage and served during lunch was measured at 52.5°F, above the required 41°F or below. The dietary aide reported that beverages were stored in the kitchen freezer to make them very cold before being brought to the conference room, and the DS stated that the conference room became warm during meal service, causing cold beverage temperatures not to remain at or below 41°F. The DS also stated there was no ice available in the conference room to keep beverages cold before service. Facility policy and the 2022 FDA Food Code require monitoring and maintaining proper hot and cold holding temperatures for TCS foods and beverages to keep them out of the danger zone.
Failure to Use QAPI to Monitor Temporary Food Service After Elevator Outage
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a QAA/QAPI plan to monitor and manage changes in food service operations after the kitchen elevator became inoperable. The elevator, which connected the basement kitchen to upper floors, had been broken since the last quarter of 2024, and staff began transporting food and beverages via the stairwell and using the conference room as a food distribution and serving area. Despite this significant operational change, the facility did not establish a performance improvement project or monitoring system under QAPI to oversee sanitation, infection control, or safety related to this temporary food service arrangement. Surveyors observed multiple issues in the temporary conference room service area and in the process of transporting and receiving food. In the conference room, a sandwich with an expiration date of 2/22/26–2/23/26 was found stored in a reach-in refrigerator past its use-by date. During lunch service, cold beverages were out of temperature range, with apple juice at 46.9°F and milk at 52.5°F, while the Dietary Supervisor acknowledged that cold foods and beverages should be at 41°F or below and that the conference room was warm and lacked ice for proper cold holding. The Registered Dietitian’s monthly sanitation audits were limited to the kitchen and did not include the conference room where food was being temporarily served. Additional observations and interviews showed that staff were manually carrying beverages and large pans of food up the stairs from the basement kitchen, and food vendors were leaving deliveries in the parking lot for staff to bring down the stairwell to the kitchen. The Dietary Supervisor reported that only one staff member had been injured during this period and acknowledged that no in-services on fall injuries or fall prevention had been provided, and that staff were not routinely trained in injury risk prevention while delivering food via the stairwell. The Administrator confirmed that while the elevator outage was discussed in monthly QA meetings, there was no documentation of a performance improvement project or monitoring of sanitation and infection control in the conference room, nor ongoing training and evaluation of staff skills and knowledge related to the new food transport and service procedures, despite facility policy requiring the QAA committee to identify quality issues, implement corrective plans, and monitor performance.
Failure to Maintain Functional Kitchen Elevator Resulting in Unsafe Food Handling and Staff Strain
Penalty
Summary
Facility staff and leadership failed to maintain a safe and functional environment by allowing the kitchen elevator, which connects the basement kitchen to the main floor, to remain inoperable for an extended period. The Assistant Administrator and Maintenance Supervisor reported that the elevator had been broken since the last quarter of 2024, with documented elevator company recommendations for maintenance and replacement that were not completed after early September 2024. The Administrator stated the elevator ultimately was deemed not repairable and needed replacement, and that the facility notified the state construction authority about the replacement project but did not notify the district office about the existing inoperable elevator. Because the elevator was not functioning, the facility relocated food distribution and tray set-up to an upstairs conference room and required dietary staff to transport all food, beverages, and supplies via the stairwell. Surveyors observed the conference room being used as a food distribution and serving area, containing a steam table, plate warmer, refrigerator, meal carts, and a fan. Dietary staff were seen repeatedly carrying trays of beverages and large pans of food up and down the stairs from the basement kitchen, with one dietary aide observed making multiple trips, breathing heavily, and sweating. The Dietary Supervisor confirmed that since the elevator failure, staff had been using the stairwell for food delivery and vendor deliveries, and reported that one staff member had been injured during this period and that the facility had not provided in-services on safe food delivery or fall prevention related to this change in process. Surveyors also identified failures in maintaining proper food temperatures and timely refrigerated storage under these altered conditions. During lunch service in the conference room, cold beverages such as apple juice and milk were measured at 46.9°F and 52.5°F, respectively, while the Dietary Supervisor acknowledged the room was warm during service, there was no ice available in the conference room, and that cold foods should be held at 41°F or below. In the basement, staff and the Dietary Supervisor described that food and supplies were now left by vendors in the parking lot and then carried down the stairs by kitchen staff, with one dietary aide stating it could take about two hours to bring supplies when working alone and acknowledging that dairy products left outside for a long time could spoil. These practices conflicted with the facility’s own food safety and storage policies and the FDA Food Code requirements for hot and cold holding and immediate refrigeration upon receipt.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Develop Resident-Specific Diabetes Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with type 2 diabetes mellitus. Upon admission and readmission, the resident's records indicated diagnoses including diabetes, hyperglycemia, gastrostomy, and dysphagia, with the resident being dependent on staff for multiple activities of daily living. The Minimum Data Set (MDS) assessment showed the resident had moderately impaired cognitive skills and was not prescribed insulin or any hypoglycemic medications. Despite this, the care plan initiated for the resident included interventions such as administering diabetes medications as ordered and monitoring for signs and symptoms of hyperglycemia and hypoglycemia, which were not applicable to the resident's current orders and condition. Interviews with nursing staff and review of the care plan revealed that the care plan was initiated before a full interdisciplinary team (IDT) care conference and did not accurately reflect the resident's needs or current medical orders. Staff confirmed that the interventions listed were not resident-specific and could cause confusion in care delivery. The facility's policy required the development of a comprehensive, person-centered care plan with measurable objectives and timeframes based on the resident's assessment, which was not followed in this instance.
Failure to Complete Annual Licensed Nurse Competency for MDS Nurse
Penalty
Summary
The facility failed to ensure that a licensed nurse specializing in Minimum Data Set (MDS) assessments completed the required annual competency evaluations for both 2023 and 2024. During interviews, the nurse admitted to not knowing the facility's policy and procedure for comprehensive care plans, which are essential for outlining all aspects of a resident's care. Another MDS nurse confirmed that developing comprehensive care plans is a key responsibility and that all MDS nurses should be familiar with the relevant policies. The Director of Nursing (DON) verified that the nurse had not completed the annual competency, which is intended to keep staff updated on necessary knowledge and skills. A review of facility records and policies showed that annual competency evaluations are part of the facility's training program for licensed nurses, with specific skills such as care planning included in the checklist. The facility's policies require ongoing training and competency assessments to ensure staff are equipped to provide person-centered care, including care planning, documentation, and communication with residents and families. The DON acknowledged the importance of these competencies for safe and effective resident care, and confirmed the deficiency in the nurse's training record.
Failure to Perform Comprehensive Medication Regimen Review for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a licensed pharmacist performed a comprehensive monthly medication regimen review (MRR) for a resident with a diagnosis of type 2 diabetes mellitus. The resident, who had moderately impaired cognitive skills and was dependent on staff for daily activities, was admitted and readmitted with a history of diabetes and hyperglycemia. Despite this, the MRR for the relevant month only included a recommendation regarding gabapentin and did not address the absence of diabetes medication. The pharmacist did not review the resident's full list of diagnoses, previous medication orders, hospital records, or laboratory results, and therefore did not identify the lack of diabetes medication. Interviews revealed that the consultant pharmacist did not have access to the resident's complete diagnoses and only reviewed certain records if clarification was needed, rather than as a standard practice. The Director of Nursing confirmed that the pharmacist did not conduct a comprehensive review as required by facility policy, which mandates access to residents' medical records and a thorough monthly review. As a result, the resident did not receive necessary diabetes medication, leading to an episode of hyperglycemia.
Failure to Provide Timely and Appropriate Respiratory Care and Emergency Response
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident diagnosed with acute respiratory failure with hypoxia, COPD exacerbation, and pulmonary hypertension. The resident had physician orders and a care plan requiring close monitoring of respiratory status, titration of oxygen therapy to maintain oxygen saturation at or above 94%, and immediate notification of the physician and emergency services in the event of significant changes. Despite these orders, when the resident was found with weakness, labored breathing, and an oxygen saturation of 88% while on oxygen via nasal cannula, the findings were reported to an LVN, but appropriate actions were not taken. The LVN did not follow physician orders to increase oxygen therapy or switch to a mask as required when the resident's oxygen saturation dropped further to 70%. There was no documentation of vital signs, treatments rendered, or timely notification to the physician. The LVN also failed to implement the resident's Physician Orders for Life-Sustaining Treatment (POLST), which included specific interventions for respiratory distress, and did not call 911 or escalate the situation as required by facility policy. The resident's condition continued to deteriorate, and the resident expired at the facility with the cause of death listed as cardiac dysrhythmia, acute respiratory distress, and pulmonary hypertension. Interviews and record reviews confirmed that the required assessments, documentation, and interventions were not performed. The facility's policies on oxygen administration, notification of changes, and medical emergency response were not followed. The failure to monitor, document, and respond appropriately to the resident's change in condition resulted in a delay in diagnosis, care, and respiratory services, ultimately leading to the resident's death.
Removal Plan
- The Director of Nursing (DON) and Registered Nurse (RN) supervisor evaluated current residents with oxygen order and/or with diagnosis of COPD for appropriate assessment and interventions.
- The Regional Nurse Consultant (RNC) provided one on one education to DON and Director Staffing Development (DSD) related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference.
- The Regional Nurse Consultant (RNC) conducted an interview with LVN 1 and CNA 1 regarding the death incident of Resident 98. The RNC investigated for the licensed nurse documentation, monitoring of change of condition and the reason for not calling 911 and for the possible root cause.
- The RNC provided one on one education to LVN 1 related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician including skills competency, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference.
- The DON or designee conducted re-education for licensed nursing staff on the following topics: documentation, oxygen administration, compliance with individualized interventions in each resident's care plan, implementation of POLST and notification of the physician and following physician orders.
- The DON or designee started auditing residents with COPD and or Oxygen order 3 times weekly to ensure physician's orders were carried out, resident specific care plans were implemented, and necessary respiratory equipment/supplies were in place, and monitor if change of condition occurred. Upon identification, the DON or designee would immediately address concerns and remedy any audit deficiencies with the licensed nursing staff immediately.
- A Quality Assurance and Performance Improvement (QAPI) Plan was implemented to track and report on above audit findings. The findings will be presented for the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months. After the initial three months, the QAA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance.
- The RNC discussed regarding Chronic Obstructive Pulmonary Disease (COPD) and pulmonary hypertension with post-test to LVN 1 to ensure understanding of the medical condition.
- The DON or designee provided education to licensed nurses regarding COPD and pulmonary hypertension with post-test to ensure understanding of the medical condition.
Failure to Provide Privacy During Personal Care and Absence of Privacy Curtains
Penalty
Summary
The facility failed to ensure the privacy and dignity of four residents during the provision of personal care. In one instance, a certified nurse assistant (CNA) changed a resident's brief without closing the privacy curtain, leaving the resident exposed from the waist down. The CNA later stated that the curtain was left open because the room was hot, but acknowledged that the curtain should have been closed to maintain privacy. The resident was non-verbal and unable to communicate, and a family member indicated that exposure to strangers would upset the resident. The Director of Staff Development confirmed that privacy should always be maintained during care. In another case, a CNA cleaned and changed a resident's gown without drawing the privacy curtain, exposing the resident from the waist down. The CNA claimed the curtain was left open so the resident could watch TV, but the resident reported not requesting this and expressed being upset about the exposure. The resident had intact cognition and was dependent on staff for personal hygiene and dressing. The Director of Staff Development reiterated that privacy should always be provided during such care. Additionally, two residents in a shared room were left without privacy curtains when the curtains were removed for washing. Both residents were present in the room during this time, and the door was left open. The maintenance supervisor stated the curtains would be reinstalled later, and a CNA indicated that care would be delayed or the door closed until privacy was restored. The Director of Nursing stated that it was not acceptable to leave residents without privacy curtains and that temporary measures should be used to maintain privacy. Facility policies reviewed indicated that residents have a right to personal privacy and dignity during care.
Failure to Follow Pureed Diet Recipes and Measurement Protocols by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff, including the Dietary Manager and Facility Cook, demonstrated appropriate competencies and skill sets in preparing pureed diets for residents. Observations revealed that staff did not measure or follow recipes when preparing pureed foods such as chicken, noodles, vegetables, rice porridge, and desserts. Instead, staff added thickener powder by estimation, without referencing the required recipes or measuring the ingredients, resulting in inconsistent food textures. The recipes and policies required specific measurements and procedures to ensure the correct texture and nutritional content, but these were not followed during food preparation. During multiple observations, staff prepared pureed foods by blending unmeasured amounts of ingredients and adding thickener powder without using the prescribed measurements. The Dietary Manager and other dietary staff did not check or follow the recipes, and there was no system in place to verify the final texture of the pureed foods before serving. The Dietary Manager acknowledged that the pureed chicken and noodles were too sticky and did not meet the required consistency, and also stated uncertainty about who was responsible for checking the final product. There was no log or documentation of texture checks being performed. Interviews with staff confirmed that recipes were not followed, and thickener was added based on experience rather than measurement. The Registered Dietitian stated that following recipes is necessary to ensure both nutritional adequacy and safe texture for residents with swallowing difficulties. Review of facility policies and recipes confirmed the requirement to follow specific procedures and measurements for pureed food preparation, which were not adhered to by the dietary staff.
Failure to Follow Safe Food Handling and Thermometer Calibration Procedures
Penalty
Summary
The facility failed to adhere to proper sanitation and safe food handling practices as outlined in its own policies and procedures. During an observation in the kitchen dry storage room, a scoop used for flour was found resting on top of the flour container and not stored in a plastic bag as required. The Dietary Manager confirmed that the scoop should have been placed in a plastic bag to prevent potential contamination, but it was left exposed, likely due to staff oversight. Additionally, the facility did not ensure that dietary staff correctly calibrated the food thermometer used to check food temperatures. The Dietary Manager demonstrated the calibration process by submerging the thermometer in ice water and accepting a reading of 39°F as accurate, whereas the facility's policy specifies that the correct reading should be 32°F. The Dietary Manager Assistant confirmed that the thermometer was not calibrated correctly, which could result in inaccurate temperature measurements for food served to residents. Review of facility policies confirmed the requirements for both food handling and thermometer calibration were not followed.
Failure to Systematically Identify and Address Adverse Events and Dietary Protocols
Penalty
Summary
The facility failed to implement a systematic approach to identifying, investigating, analyzing, and utilizing data related to monitoring and preventing adverse events, as required by its own Quality Assurance and Performance Improvement (QAPI) policy. Specifically, the QAPI committee did not address or develop a written plan to ensure dietary staff followed pureed food recipes for all residents prescribed a pureed diet. Observations revealed that dietary staff did not measure thickener powder when preparing pureed foods, instead relying on estimation and taste, and there was no documentation or log verifying the correct texture of the food. The Dietary Manager and Registered Dietitian confirmed that recipes were not consistently followed, and the Administrator acknowledged that concerns about food texture had been raised multiple times but were not discussed or addressed in QAPI meetings. Additionally, the facility did not have a system in place to identify and investigate adverse events, as demonstrated by the handling of a resident who expired from respiratory distress related to COPD and pulmonary hypertension. The charge nurse on duty did not document vital signs, failed to notify the physician or RN of the resident's significant change in condition, and did not follow physician orders regarding oxygen administration. The Director of Nursing did not investigate the possible cause of death until prompted by surveyors, and the Administrator was not informed of the resident's death or the circumstances surrounding it, indicating a lack of oversight and failure to recognize and respond to adverse events as required by facility policy. Furthermore, the facility did not ensure that the resident's Physician Orders for Life-Sustaining Treatment (POLST) were implemented according to the resident's preferences. The charge nurse did not notify the physician or call for emergency assistance when the resident's condition deteriorated, and the death was not reported or investigated in a timely manner. The facility's own QAPI policy requires systematic identification, reporting, investigation, and prevention of adverse events, as well as documentation and monitoring, but these procedures were not followed in the cases observed.
Resident Not Served Meal Timely in Dining Room
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and pulmonary edema, who also had moderately impaired memory and cognition, did not receive his meal tray at the same time as other residents dining in the communal dining room. During lunch, staff served meal trays to 11 out of 14 residents, leaving the resident in question waiting and observing others eat. The resident, seated at a corner table, waited at least 17 minutes before receiving his meal tray, during which time he ate a bread bun he had brought with him. The resident expressed feeling disrespected and frustrated by the delay and by having to watch others finish their meals before he was served. Staff interviews revealed that the resident typically did not eat lunch in the dining room, which may have contributed to the dietary staff not preparing his tray with the others. The treatment nurse acknowledged noticing the delay and stated that staff should have communicated the resident's presence to dietary staff to ensure all residents received their meals simultaneously. The facility's policy requires staff to protect and promote resident dignity, which was not upheld in this instance.
Failure to Notify Physician and Follow Emergency Protocols for Resident with Acute Respiratory Decline
Penalty
Summary
The facility failed to follow its policy and procedure regarding the notification of changes in a resident's condition, as well as professional standards of practice and physician orders, for a resident with acute respiratory failure, COPD exacerbation, and pulmonary hypertension. The resident had specific physician orders to monitor oxygen saturation and to notify the physician if the saturation dropped below 91% or was significantly lower than baseline. On the day of the incident, the resident's oxygen saturation was observed to decrease to 88% and then to 70%, but the physician was not notified immediately as required. CNA 1 reported to LVN 1 that the resident was experiencing labored breathing and a drop in oxygen saturation. LVN 1 assessed the resident, confirmed the low oxygen saturation, but did not document the vital signs, did not notify the physician, did not inform the RN on duty, and did not titrate the oxygen as per the physician's order. Instead, LVN 1 only called the physician after the resident had already passed away. Interviews with staff and review of documentation confirmed that the required notifications and interventions were not performed in a timely manner. The facility's policies required immediate action and notification of the physician in the event of significant changes in a resident's condition, including life-threatening situations. The failure to follow these policies and physician orders resulted in a delay in diagnosis, care, and services for the resident, who ultimately expired shortly after the onset of symptoms. Documentation and interviews confirmed that the expected standards of care and facility protocols were not followed during this critical event.
Failure to Maintain Safe and Homelike Resident Environments
Penalty
Summary
The facility failed to provide a homelike, safe, and clean environment for two residents by not addressing maintenance issues in their rooms. For one resident with dementia and hypertension, the sliding screen door in the room was out of track and had multiple holes and tears for over a month. The resident reported discomfort due to bugs, dirt, and leaves entering the room and stated that maintenance staff had been notified multiple times, but the issue remained unresolved. The Maintenance Supervisor confirmed that routine checks on screen doors were not conducted and that he was unaware of the problem until the survey, relying instead on staff reports that were not received. Another resident, who had severe cognitive impairment and was dependent for mobility, had unrepaired missing floor tiles below the bed due to a water leak that occurred about a month prior. The Certified Nurse Assistant confirmed the floor had not been repaired since the leak, and the Maintenance Supervisor acknowledged that, although the water pipe had been fixed, the floor remained unrepaired. Both staff members agreed that the resident should have a functional and homelike environment, but the necessary repairs had not been completed. Review of the facility's policies indicated that a preventative maintenance program was in place, requiring the maintenance of a safe, functional, and comfortable environment for residents. The policies also specified that the Maintenance Director was responsible for ensuring that the physical environment did not pose a safety risk and that all areas frequented by residents, including their rooms, should be maintained accordingly. Despite these policies, the facility did not address the reported maintenance issues in a timely manner, resulting in an unclean and unsafe environment for the affected residents.
Inaccurate MDS Discharge Coding for Resident Discharged Home
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was discharged home with home health services. Specifically, the MDS was incorrectly coded to indicate that the resident had been discharged to an acute hospital, rather than to their home under the care of a home health agency. This discrepancy was identified during a review of the resident's records, which included physician orders clearly stating the discharge to home with home health services. The error was acknowledged by the MDS Nurse during a concurrent interview and record review, confirming that the MDS did not accurately reflect the resident's actual discharge disposition. The CMS Resident Assessment Instrument (RAI) Manual requires that MDS discharge assessments accurately document the resident's discharge location and care needs, which was not met in this instance. The resident involved had a medical history of hypertension and hyperlipidemia and was admitted to the facility prior to the discharge event.
Failure to Develop and Implement Vision Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with impaired vision who required new eyeglasses. Despite the resident's report of worsening vision and inability to read due to outdated eyeglasses, there was no care plan addressing his visual impairment. The resident had been seen by an optometrist, who recommended new prescription glasses, but the care plan and clinical records did not reflect this need or the optometry visit. Additionally, there was no documentation or tracking of the eyeglasses order by social services, and nursing staff were unaware of the resident's vision concerns until informed by the resident himself. The resident's medical history included intervertebral disc degeneration, diabetes mellitus, and a below-knee amputation. The Minimum Data Set indicated moderate cognitive impairment and a need for partial assistance with personal hygiene. Despite these complexities, the facility did not assess or document the resident's sensory changes or coordinate care following the optometry visit. Interviews with staff confirmed a lack of awareness and communication regarding the resident's vision needs, and the facility's policy required interdisciplinary care planning that was not followed in this case.
Failure to Assess and Address Footwear Contributing to Pressure Injury Progression
Penalty
Summary
A resident with chronic atrial fibrillation, dementia, and spinal stenosis was admitted and later readmitted to the facility. Upon admission, the resident's skin was noted to be warm and dry, with some discoloration but no pressure injuries (PIs) documented. On a later date, redness was observed on the left big toe, but no staging or detailed wound description was recorded at that time, and no change in condition documentation was created when the skin condition worsened. Over the following months, wound progress notes indicated the development and progression of a pressure injury on the resident's left big toe, advancing from partial-thickness tissue loss to a Stage 3 PI with full-thickness tissue loss. Despite recommendations in the wound notes for new footwear, there was no documented assessment or evaluation of the resident's shoes to determine their effectiveness in preventing further injury. The care plan identified improper footwear as a predisposing factor but did not include any interventions related to footwear. Observations and interviews revealed that the resident preferred to wear older, tighter white sneakers, which caused discomfort due to the wound, even though a newer pair of shoes had been provided by family. The treatment nurse was unaware of the footwear issue and had not assessed whether the shoes contributed to the pressure injury. The facility's policy required individualized interventions based on risk and skin assessments, but these were not implemented or documented in relation to the resident's footwear.
Medication Error Rate Exceeds 5% Due to Missed Vital Checks and Food Administration
Penalty
Summary
A medication pass observation revealed that a nurse failed to maintain a medication error rate of 5% or less, with three errors identified out of 29 opportunities, resulting in a 10.34% error rate. Specifically, the nurse did not check the resident's heart rate prior to administering Amlodipine and Metoprolol, as required by the physician's order, and also failed to provide food during the administration of Metoprolol and Metformin, both of which were ordered to be given with food. The nurse acknowledged forgetting to check the heart rate and not providing food at the time of administration. The resident involved had diagnoses of diabetes mellitus and hypertension, lacked the mental capacity to make medical decisions, and was dependent on staff for activities of daily living. Physician orders specified that Amlodipine and Metoprolol should be held if the systolic blood pressure was below 110 or heart rate below 60, and that Metoprolol and Metformin should be administered with food. The facility's medication administration policy required obtaining and recording vital signs as ordered and providing food and fluids as appropriate, but these procedures were not followed during the observed medication pass.
Failure to Check Heart Rate Before Administering Antihypertensive Medications
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow physician orders and facility policy by not checking a resident's heart rate prior to administering Metoprolol tartrate and Amlodipine, both medications prescribed for hypertension. The physician's order specifically required that these medications be held if the resident's systolic blood pressure was less than 110 or if the heart rate was less than 60. During a medication pass observation, the LVN prepared and was about to administer the medications after checking only the resident's blood pressure, omitting the required heart rate check. When questioned by the surveyor, the LVN acknowledged forgetting to check the heart rate and subsequently measured it, finding it to be 65 beats per minute before proceeding with administration. The resident involved had a history of diabetes mellitus and hypertension, was cognitively impaired, and dependent on staff for activities of daily living. The facility's policy required obtaining and recording vital signs as per physician orders, and the Director of Nursing confirmed the necessity of checking heart rate before administering these medications. The failure to check the heart rate as required constituted a significant medication error, as it did not comply with the physician's order or facility policy.
Failure to Provide Prescribed Pureed Diet Consistency for Resident with Dysphagia
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, dementia, and recent pneumonia was not provided with food in the prescribed consistency. The resident had a physician order and care plan specifying a regular diet with pureed texture and thin consistency due to significant swallowing difficulties and risk for aspiration. Multiple assessments, including those by speech therapy and the registered dietician, emphasized the need for moist, thin pureed foods and close supervision during feeding. Despite these documented needs, the resident was repeatedly served pureed food that was too thick and contained lumps, as observed by both the resident's family member and facility staff. Observations revealed that the resident's family member had been bringing in homemade food and feeding the resident daily, stating that the facility's pureed food was too thick and caused the resident to gag and cough. During direct observation, the facility-provided pureed food was seen sticking to the spoon and not sliding off, with visible lumps, and the resident was observed coughing and unable to swallow the food. The dietary manager confirmed through a spoon test that the food did not meet the required thin consistency and acknowledged that the food was too thick, which could cause it to get stuck in the resident's mouth. Further investigation found that the facility's cook did not follow the facility's recipe for preparing pureed food, instead relying on personal experience and taste to determine texture. The registered dietician confirmed the importance of following recipes to ensure correct consistency, especially for residents at risk of aspiration and choking. The facility's policy required that foods be provided in the appropriate form as prescribed by the physician and assessed by the interdisciplinary team, but this was not followed in the resident's case.
Unsanitary Commode Found in Shared Resident Bathroom
Penalty
Summary
A deficiency was identified when a dirty and rusty commode was found in the shared bathroom between two rooms, used by six residents. During an observation, the unsanitary condition of the commode was noted. The housekeeper interviewed was unaware of the issue and stated she had not received any report about the commode's condition. She also could not recall if she had checked the shared restroom to ensure all equipment was clean and functional. The maintenance supervisor, upon concurrent observation, confirmed the commode was dirty and rusty and estimated it had been in that state for at least a few days. He acknowledged responsibility for ensuring all facility equipment was sanitary, clean, and functional. A review of the facility's policies and procedures revealed that maintaining a sanitary environment includes keeping resident care equipment clean and properly stored, and that a preventative maintenance program should be in place to ensure a safe, sanitary, and comfortable environment. The failure to identify and address the dirty and rusty commode resulted in an unsanitary environment for the residents using the shared bathroom.
Failure to Address Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances verbalized by a resident's responsible party (RP) and did not issue a written grievance decision in accordance with the facility's policy. The RP reported that during a visit, the admitting nurse was aggressive and rude to both the resident and the RP. This concern was communicated to the Social Service Assistant (SSA), who noted the issue but did not initiate a grievance process or inform the Social Service Director (SSD) responsible for handling grievances. The SSA only informed the Director of Nursing (DON) about the concern without further action. The facility's grievance policy requires prompt acknowledgment and resolution of grievances, but the SSD was unaware of the RP's concerns due to a lack of communication from the SSA. The SSD stated that if informed, she would have initiated a formal grievance process. The DON also stated she was unaware of any complaints and would have started an investigation if informed. The failure to address the grievance promptly and according to policy increased the risk of negative psychosocial impact on the resident's quality of life.
Resident Falls from Shower Chair Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident who was at risk for falls and had a history of dementia and osteoporosis. The resident, who was totally dependent on staff for bathing, fell from a shower chair when a Certified Nursing Assistant (CNA) left the resident unattended to adjust her own clothing. The resident opened the armrest of the shower chair and fell to the floor, resulting in a fracture of the left humerus. The CNA did not immediately report the fall to a Registered Nurse (RN) and instead moved the resident back to the shower chair without a licensed nurse's assessment, contrary to the facility's policy. The resident was later found by an RN with swelling and pain in the left arm, and an X-ray confirmed a fracture. The resident was transferred to a general acute care hospital for further treatment, where it was determined that surgery was not an option due to the resident's comorbidities. The resident received non-operative treatment, including pain management and a splint for the fracture. Interviews with facility staff revealed that the CNA did not follow the facility's policy on incidents and accidents, which requires that a resident not be moved after a fall until assessed by a licensed nurse. The CNA admitted to not reporting the fall due to fear. The facility's policies on accidents and supervision, as well as fall prevention, were not adhered to, leading to the resident's injury.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within the required timeframe, as per their policy and procedure on Abuse, Neglect, and Exploitation. The incident involved a resident who was found with ecchymosis on both arms and a skin tear on the left forearm. The allegation of abuse was made at 8:30 AM, but the facility reported it to the Department of Public Health (DPH) at 1:23 PM, five hours later, instead of within the mandated two-hour window. The resident involved had been admitted to the facility with diagnoses including dementia, anemia, and lack of coordination. The resident was assessed to have severe cognitive impairment and was dependent on facility staff for daily activities. During an interview, the resident initially claimed someone had grabbed and hit her but later retracted the statement, appearing confused and disoriented. The facility's Social Services Director assured the resident of her safety, but the delay in reporting the incident was a breach of protocol. Interviews with facility staff revealed that a Certified Nursing Assistant (CNA) noticed discoloration on the resident's arm during morning care but did not report it immediately, as the resident was not in pain. The discoloration was later reported by the resident's family member. The Director of Staff Development confirmed that CNAs were trained to report any changes in a resident's condition immediately, which did not occur in this case. The facility's policies required immediate reporting of such incidents to ensure resident safety and compliance with state and federal regulations.
Failure to Follow Wound Care Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedure for clean dressing changes, which led to a deficiency in the care of a resident with a Stage 4 pressure ulcer. During an observation, a Licensed Vocational Nurse (LVN) did not change gloves or wash hands after handling a soiled dressing while providing wound care to a resident. The LVN continued to use the same soiled gloves to clean and treat the resident's wounds, including a Stage 4 pressure ulcer on the right mid-back, without performing hand hygiene or changing gloves as required by the facility's protocol. The resident involved had a medical history that included diabetes, hypertension, sepsis, and antibiotic-resistant bacteria, and was dependent on staff for various activities of daily living. The facility's policy required handwashing and glove changes between handling soiled dressings and applying clean ones, which the LVN did not follow. This failure was confirmed through interviews with the LVN and the Infection Prevention Nurse, who emphasized the importance of hand hygiene in preventing infection spread.
Inadequate Infection Control and Cohorting During Covid-19 Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during a Covid-19 outbreak, as evidenced by the lack of a proper line listing and inadequate cohorting of residents. The Infection Preventionist (IP) nurse did not create a line listing for residents who tested positive for Covid-19 or were exposed, due to being occupied with testing and moving residents. This led to confusion and improper room assignments, such as moving a Covid-19 positive resident into a room with negative residents, increasing the risk of virus transmission. Resident 1, who tested positive for Covid-19, was mistakenly moved from Room A to Room B, where they were placed with Residents 3 and 5, both of whom tested negative. This error occurred because the facility's nurses began moving residents based on verbal reports without formal documentation or a line listing. The IP nurse later confirmed Resident 1's positive status and had to move them again to another room, as their original room was occupied by another positive resident. The IP nurse relied on online resources for guidance during the outbreak, neglecting to consult local health department or CDC guidelines. The facility's policy required heightened surveillance during periods of transmission, but the IP nurse was unable to track the necessary information due to the lack of a structured system. This deficiency in infection control practices had the potential to spread Covid-19 among residents, staff, and the community.
Resident Elopement Due to Insufficient Supervision
Penalty
Summary
The facility failed to provide sufficient monitoring and supervision to a resident who eloped from the facility. The resident, who had diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease (COPD), was admitted on 3/27/24. The resident's assessments indicated that he did not have the capacity to understand and make decisions for himself and required substantial assistance when walking. On 4/20/24, the resident was found missing at around 8 PM when a family member called the facility to inform them that the resident had gone home. The facility staff were unaware that the resident had left the premises or was missing until the family member's call. Interviews with the staff revealed that the resident had expressed a desire to go home earlier in the evening but was told he could not leave without a physician's order. Despite this, the resident managed to leave the facility unnoticed. The Director of Nursing (DON) confirmed that the resident left the facility without notifying the staff and that the facility was informed of the resident's departure by a family member. The facility's policy on elopements and wandering residents, dated 12/19/22, indicated that residents at risk for elopement should receive adequate supervision and have preventive measures in place, such as door locks and alarms, to help avoid elopements and prevent accidents. However, the staff interviews and the incident itself suggest that these measures were either not in place or not effectively implemented, leading to the resident's unsupervised departure from the facility.
Failure to Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA) was seated while assisting with feeding during meal times for three residents. During meal observations, the CNA was seen standing while feeding Residents 25, 33, and 388, which is against the facility's policy. This policy mandates that staff should be seated at eye level with residents during feeding to maintain their dignity and prevent choking hazards. The CNA admitted to standing due to a lack of available chairs and personal preference, despite knowing the protocol required her to be seated. Resident 25, who has severe cognitive impairments and requires supervision for eating, was observed being fed by the standing CNA. Similarly, Resident 33, who is dependent on staff for eating and has severe decision-making impairments, was also fed by the standing CNA. Resident 388, who is also dependent on staff for eating and has severe cognitive impairments, was observed in the same situation. All three residents have significant medical conditions, including dementia and dysphagia, which necessitate careful and respectful feeding practices. Interviews with other staff members, including another CNA and the Director of Staff Development (DSD), confirmed that the facility's policy requires staff to be seated while feeding residents to maintain their dignity and prevent choking. The DSD emphasized that standing while feeding can make residents feel rushed and emotionally distressed, and it poses a safety risk. The facility's policies and procedures were reviewed and confirmed to support these practices, highlighting the importance of treating residents with respect and dignity during mealtimes.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to potential risks in their care. Resident 12, who was admitted with acute respiratory failure, COPD, and other conditions, did not have a care plan for oxygen therapy despite having an order for oxygen via nasal cannula. Interviews with staff confirmed the absence of a care plan, which is essential for consistent and effective care. The facility's policy mandates that care plans include specific details about oxygen therapy, but this was not followed for Resident 12. Resident 2, who was readmitted with sepsis, pneumonia, and other serious conditions, also lacked a care plan addressing these diagnoses. Despite being treated for these conditions, there was no care plan outlining the necessary interventions and goals. Staff interviews revealed that the absence of a care plan posed a risk to Resident 2's health, as it left staff without clear guidance on how to manage and monitor the resident's conditions. Resident 31, who preferred to take medications at different times than the facility's usual schedule, did not have a care plan or physician's order to accommodate this preference. Medications were found left on the resident's bedside table, which is against the facility's policy. Staff confirmed that there should have been a care plan and physician's order to address the resident's medication preferences, and the lack of these documents could reduce the effectiveness of the medications and pose a risk to other residents.
Failure to Assess and Monitor Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that Resident 81 was properly assessed, monitored, and evaluated for skin breakdown related to moisture-associated skin damage (MASD) and fungal infection. The resident's care plan, which included specific interventions for monitoring and treating the skin condition, was not implemented effectively. The Treatment Nurse (TN) did not conduct weekly skin assessments as required, and Resident 81's name was not listed in the facility's computerized charting system to prompt these assessments. Additionally, the TN did not inform the physician or document a Change of Condition (COC) report when the resident's wound worsened, and the primary physician was not consulted before the Wound Consultant was involved in the resident's care. The physician order to leave the perineal area open to air at bedtime was also not implemented, and the primary physician did not physically assess the resident's skin condition to ensure the treatment was effective. Resident 81 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer. The resident was cognitively intact but dependent on assistance for personal hygiene and toileting. Despite the care plan indicating the need for regular skin assessments and monitoring, the facility failed to document and follow through with these interventions. The TN admitted to forgetting to assess the resident's skin condition due to the resident not being listed in the assessment history report. The resident's condition worsened, with severe pain and increased skin breakdown, which was not adequately addressed by the facility staff. Interviews with the resident, TN, and other staff members revealed a lack of communication and documentation regarding the resident's skin condition. The primary physician was not notified of the worsening condition, and the Wound Consultant was consulted without the physician's prior assessment. The resident expressed significant pain and distress due to the untreated skin condition, which impacted her ability to move and participate in activities. The facility's policies and procedures for skin assessment, incontinence-associated dermatitis, and notification of changes were not followed, leading to a delay in appropriate treatment and care for Resident 81.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure that Resident 81 was assessed and provided with appropriate pain management and interventions to relieve severe pain in the perianal and perineal areas due to severe Moisture Associated Skin Damage (MASD) and fungal dermatitis. Despite the resident's complaints of severe pain and visible signs of discomfort during wound care and hygiene activities, the staff did not take adequate measures to address her pain. The resident's care plan did not include specific interventions for pain management in the affected areas, and no pain medication was ordered or administered to the resident during the observed period. Resident 81, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer, was cognitively intact and able to communicate her pain. Despite this, the staff failed to recognize and manage her pain effectively. The resident reported experiencing the worst pain she had ever felt, particularly during brief changes and wound treatments, yet the CNAs and nurses did not stop to assess her pain or provide pain relief. The resident's Medication Administration Record (MAR) showed no record of pain medication being administered, and the CNAs did not report the resident's pain to the charge nurse. Interviews with the staff revealed a lack of communication and awareness regarding the resident's pain. CNAs assumed that the charge nurse was already aware of the resident's pain, and the Treatment Nurse did not confirm whether pain medication was given before wound treatment. The Director of Nurses (DON) acknowledged that the resident should not have been left to suffer from pain and that the staff should have taken immediate action to provide pain relief. The facility's policy on pain management emphasized the importance of recognizing and managing pain, but this was not followed in the case of Resident 81.
Failure to Complete Annual Competency Checks for CNAs
Penalty
Summary
The facility failed to complete a performance review for eight of nine Certified Nurse Assistants (CNAs) based on the outcome of the review for each of the CNAs. The CNAs did not have a completed Annual Core Clinical Competencies (ACCC), which is an assessment and training on the CNAs' ability to perform clinical nursing care. This failure had the potential to result in the facility's CNAs not being able to provide quality care to the resident population based on the Facility Assessment. The Director of Staff Development (DSD) confirmed that the previous DSD did not use the CNA Core Clinical Competencies checklist for any of the 2023 competency skills checks, leaving all the facility's CNAs' skills checks either incomplete or not done. During a review of the binder containing all the staff's annual competency checklists, it was found that nine full-time CNAs had no ACCC done since 2022. The DSD confirmed that the previous DSD did not conduct any ACCC with all nine CNAs. The Administrator (ADM) also confirmed the issue and stated that it was unacceptable for the CNAs not to have their annual competency skills check since 2022, as their skills needed to be refreshed yearly to take care of the facility's residents. The facility's policy and procedure indicated that competencies and skill sets for all new and existing staff must be consistent with their expected roles and that training requirements should be met annually and as necessary based on the facility assessment.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to implement its policy and procedure on food storage and professional standards of practice for food service safety. During an initial kitchen observation, a brown powdery substance identified as chicken bouillon was found in a clear plastic container without a label or date of when it was opened or used by. Additionally, the facility's refrigerator contained rice, sliced peaches, tofu, and green peas in clear plastic containers, all without use-by dates or preparation dates. The Dietary Service Supervisor (DSS) acknowledged that these items should have been labeled and dated to ensure they were still fresh and safe for consumption. The Director of Nurses (DON) confirmed that food in the kitchen should be labeled and dated to prevent spoilage and ensure resident safety. The facility's policy and procedure on food storage, revised on a specific date, indicated that all food products should be inspected for safety and quality, dated upon receipt, when opened, and when prepared. The Food Code 2022 also requires ready-to-eat, time/temperature control for safety food to be clearly marked with the date or day by which the food should be consumed, sold, or discarded. The failure to label and date food items had the potential to result in food contamination or growth of microorganisms, posing a risk to residents' health.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to complete the Surveillance Data Collection (SDC) form, a part of its Antibiotic Stewardship Program, before administering antibiotics to Resident 30. Resident 30, who had moderate cognitive impairment and required assistance with daily activities, was prescribed Ciprofloxacin for a urinary tract infection. However, the SDC form lacked documented evidence that the resident met the criteria for antibiotic use, as neither signs and symptoms of infection nor lab results were marked. The Infection Preventionist Nurse (IPN) confirmed that the SDC form was not completed, which is crucial for ensuring the appropriate prescription of antibiotics. Similarly, the facility did not implement its Antibiotic Stewardship Program for Resident 2, who had severe cognitive impairment and multiple diagnoses, including sepsis, COPD, UTI, pneumonia, and dementia. Resident 2 was prescribed Ceftriaxone and Metronidazole for pneumonia and UTI, but there was no documentation in the Antibiotic Stewardship Binder or the resident's medical chart to indicate that the resident was screened prior to antibiotic use. Additionally, an Antibiotic Time Out was not completed for either antibiotic, which is necessary to assess the ongoing need for the medication. The facility's policy on the Antibiotic Stewardship Program, which aims to optimize infection treatment and reduce adverse events related to antibiotic use, was not followed. The policy requires the Infection Preventionist to coordinate all stewardship activities, maintain documentation, and serve as a resource for clinical staff. The lack of adherence to these protocols resulted in the potential for unnecessary or inappropriate antibiotic use for both residents, as well as incomplete monitoring during antibiotic therapy.
Failure to Provide Reasonable Accommodation of Needs
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents. For Resident 30, the facility did not ensure the call light was within reach. Resident 30, who has a traumatic brain injury and moderate cognitive impairment, was observed lying in bed with the call light hanging on an IV pole, out of reach. The CNA admitted to placing the call light on the IV pole after stripping the bed and forgetting to return it to the resident's bedside. Both the LVN and DON confirmed that the call light should always be within reach to allow the resident to request assistance. The care plan for Resident 30 also indicated that the call light should be kept within easy reach, and the facility's policy supported this requirement. However, this was not adhered to, leading to a potential delay in care for Resident 30. For Resident 81, the facility failed to use appropriate communication tools or seek assistance from a translator. Resident 81, who has mild cognitive impairment and speaks little English, was observed getting frustrated when a CNA communicated with her in English. The CNA did not use the communication board available in the room or seek help from a staff member who spoke Resident 81's native language. Resident 81 expressed that she often felt confused and frustrated due to the language barrier. The DON stated that the CNA should have used the communication board or asked for translation assistance. The facility's policy indicated that information should be provided in a manner that the resident can understand, including using communication boards or writing materials, but this was not followed. These deficiencies had the potential to delay or prevent the provision of necessary care and services for both residents. Resident 30's inability to reach the call light could result in unmet needs, while Resident 81's communication issues could lead to confusion and frustration, impacting her overall well-being. The facility's failure to adhere to its policies and care plans contributed to these deficiencies, highlighting a need for better compliance with established procedures to ensure resident safety and satisfaction.
Failure to Notify Physician and Family of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure the physician and responsible party were notified of a significant change in condition for a resident with severe MASD and a fungal skin infection. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, urinary tract infection, and sepsis, experienced worsened skin breakdown and recurrent sepsis due to inadequate care and communication. Despite the resident's capacity to understand and make decisions, and her complaints of increased pain and delayed diaper changes, the facility did not take timely action to address her condition or notify her physician and family members appropriately. The Treatment Nurse (TN) acknowledged that the resident had severe MASD upon admission and that the condition initially improved but worsened again. The TN informed the Primary Medical Physician (PMP) about the change in the resident's wound condition but failed to document this communication in the nursing progress notes. The PMP did not assess the resident's wound and relied on the TN's report and a Wound Consultant's (WC) recommendations without direct evaluation. The PMP admitted to signing the treatment orders without assessing the wound, as he did not receive any images or reports about the wound condition. The Director of Nursing (DON) stated that the facility's policy requires notifying physicians and family members of any significant changes in a resident's condition. The DON emphasized the importance of documentation and regular assessments to ensure proper care. However, the facility's failure to follow these protocols resulted in the resident's condition worsening, as the necessary notifications and assessments were not conducted in a timely manner.
Failure to Prevent Urine Backflow in Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident with a Foley catheter received appropriate care to prevent urine from flowing back into the bladder, which could cause urinary tract infections. Resident 76 was observed with the Foley catheter tubing kinked on the bedrail, causing urine to flow back towards the bladder instead of freely into the drainage bag. This observation was confirmed by a Registered Nurse, the Infection Preventionist nurse, and the Director of Nurses, all of whom acknowledged that the catheter should not be kinked and that backflow of urine could lead to recurrent UTIs. The resident's care plan and the facility's policy and procedure both indicated that the catheter bag and tubing should be positioned below the level of the bladder to prevent backflow, but this was not adhered to in Resident 76's case. Resident 76 had a history of severe cognitive impairment, was dependent on assistance for all activities of daily living, and had been diagnosed with sepsis secondary to a urinary tract infection. The resident's medical records indicated that they had a Foley catheter for neurogenic bladder management and had been prescribed antibiotics for an abnormal urinalysis. Despite these precautions, the facility's failure to ensure proper catheter care as per their own policies and procedures resulted in a significant risk of recurrent urinary tract infections for Resident 76.
Failure to Label and Date Gastrostomy Tube
Penalty
Summary
The facility failed to implement its policy and procedure on the care and treatment of feeding tubes for Resident 72. Specifically, the gastrostomy tube (GT) for Resident 72 was not labeled with the date when the tubing was last changed or when it was due to be changed. This oversight was observed during a concurrent observation and interview with a registered nurse (RN), who acknowledged that the tubing should have been dated to determine the last time it was changed. The RN stated that undated tubing could lead to an infection control issue due to potential bacteria buildup. The Infection Preventionist (IP) nurse and the Director of Nurses (DON) also confirmed that the tubing should have been labeled and dated to prevent infection risks. Resident 72 was admitted with diagnoses including gastrostomy infection, other complications of gastrostomy, sepsis, and atherosclerosis of the aorta. The resident's cognitive status was severely impaired, and they were dependent on assistance for all activities of daily living (ADLs). The facility's policy on the care and treatment of feeding tubes, as well as its infection prevention and control program, emphasized the importance of using infection control precautions and maintaining a safe environment to prevent contamination and infection. However, the facility failed to adhere to these policies, resulting in a potential risk of complications for Resident 72.
Failure to Adhere to Oxygen Equipment Maintenance Protocols
Penalty
Summary
The facility failed to ensure that Resident 12 had their nasal cannula and humidifier bottle dated and changed weekly in accordance with the facility's protocol for oxygen administration. Resident 12, who was admitted with acute respiratory failure, COPD, and other conditions, was observed receiving oxygen via nasal cannula tubing without a current date. The humidifier bottle had a handwritten label dated 3/31/24 to 4/6/24, indicating it had not been changed for three days past the due date. The Director of Nurses confirmed that the nasal cannula and humidifier bottle should be dated and changed weekly to prevent lung infections, as per facility protocol and policy on oxygen administration dated 12/19/22. The facility also failed to ensure that Resident 59 had their plastic storage bag for oxygen equipment changed weekly per the facility's standard of practice. Resident 59, who was admitted with acute respiratory failure, COPD, emphysema, dementia, and quadriplegia, was observed with a plastic storage bag dated 3/30/24 attached to their oxygen concentrator machine. The bag contained a nebulizer mask and had not been changed for more than the required seven days. Registered Nurse 2 confirmed that the facility's standard practice was to change the plastic storage bags weekly and label them with the replacement date to prevent contamination and infection. The Infection Preventionist stated that the facility's infection control protocol required the plastic storage bag to be changed weekly every Sunday and labeled accordingly. Failure to change the bag weekly could lead to bacterial contamination, causing symptoms such as shortness of breath, respiratory infection, and potentially sepsis. The facility's policy on oxygen administration, revised on 2/23/24, indicated that oxygen equipment should be kept in a plastic bag when not in use and cleaned according to facility policy.
Physician's Failure to Supervise Resident Care
Penalty
Summary
The attending physician failed to take an active role in supervising the total program of care for Resident 81, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer. The physician did not physically assess, evaluate, or document the resident's skin condition during admission or subsequent visits, despite the resident suffering from severe MASD, fungal infection, and dermatitis. The physician also did not assess the resident's skin condition before ordering a skin treatment, nor did they provide a medication regimen for the resident's pain due to severe MASD. Resident 81 reported having redness of the buttocks upon admission, which worsened over time, causing significant pain. The resident stated that staff took a long time to change her diaper at night, contributing to the worsening of her condition. Despite requesting to see a doctor, Resident 81 had not seen any physician since her admission. Observations revealed multiple open lesions, redness, dry skin peeling, and rashes on the resident's perineal and perianal areas, causing severe pain rated between eight to ten on a pain scale. The Primary Medical Physician admitted to not assessing Resident 81's wound, relying instead on pictures sent by the facility's nurses, which he did not receive. The physician signed a skin treatment order without assessing the wound and did not order any pain medication for the resident. The Director of Nursing confirmed that physicians are supposed to assess all residents during their visits and that Resident 81 should not have suffered from pain without timely pain interventions. The facility's policy requires physicians to take an active role in supervising resident care, which was not followed in this case.
Failure to Monitor Residents on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that two residents, who were at risk for bleeding and bruising, were free of unnecessary medication while receiving blood thinners. Resident 2 was readmitted with multiple diagnoses including hemiplegia, hemiparesis, and dementia, and was prescribed Plavix. However, there was no physician order to monitor Resident 2 for bleeding and bruising, and no documentation indicated that such monitoring was performed. The Director of Nursing (DON) confirmed the absence of monitoring orders and documentation, acknowledging the risks associated with not monitoring for side effects of anticoagulants. Resident 50, who had diagnoses including end-stage renal disease and acute respiratory failure, was prescribed Aspirin and Eliquis. The resident's care plan indicated the need for monitoring for adverse side effects of anticoagulant therapy every shift. However, there were no physician orders for routine laboratory tests to monitor for complications. The DON confirmed the lack of routine lab orders, which was against the facility's policy for anticoagulant therapy, and acknowledged the importance of such tests to detect bleeding. The facility's policy on high-risk medications, including anticoagulants, required routine lab orders and monitoring for adverse consequences such as bleeding and hemorrhage. The failure to adhere to this policy for both residents had the potential to result in undetected side effects or adverse effects related to anticoagulant therapy, which could lead to a decline in the residents' health and wellbeing.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate was less than five percent. During a medication administration observation, four out of 30 medications administered resulted in an overall medication error rate of 13.33%, affecting three residents. The errors included administering medications without checking expiration dates and not following physician orders to administer certain medications with food. For Resident 37, the medication nurse attempted to administer Calcitriol and Folic Acid without checking the expiration dates on the bottles. The nurse admitted to forgetting to check the expiration dates, which is crucial to avoid the risk of using expired medications. Resident 37 had diagnoses including hypokalemia and hyperlipidemia and required substantial assistance with daily activities. For Residents 28 and 69, the medication nurse administered Metoprolol without offering food as ordered by the physician. Resident 28 had severe cognitive impairment and was totally dependent on staff for daily activities, while Resident 69 had moderate cognitive impairment and required partial assistance. The nurse confirmed the oversight and acknowledged the importance of administering Metoprolol with food to prevent potential side effects. The Director of Nursing also emphasized the importance of checking expiration dates and following physician orders to ensure resident safety.
Failure to Document Flu Vaccine Offer and Declination
Penalty
Summary
The facility failed to provide documented evidence that two residents, identified as Resident 53 and Resident 390, were offered or declined the influenza vaccine for the 2023-2024 flu season. Despite the facility's policy requiring annual flu vaccine offers and documentation of acceptance or declination, there was no record in the medical charts of these residents indicating that the vaccine was offered, administered, or declined. This deficiency was identified through a review of the residents' medical records and interviews with the Infection Preventionist (IP), who confirmed the absence of necessary documentation. Resident 53, admitted with diagnoses including hyperthyroidism, anemia, and mobility issues, and Resident 390, admitted with acute respiratory failure, congestive heart failure, type 2 diabetes, and immunodeficiency, both had the capacity to understand and make decisions. However, their medical charts lacked any documentation regarding the flu vaccine for the specified season. The IP acknowledged that the facility's policy was not followed, which required offering the vaccine and documenting the resident's decision, thus failing to ensure the residents were protected against the flu as per the facility's infection prevention and control program.
Failure to Maintain Sanitary Environment and Proper Storage in Medication Room
Penalty
Summary
The facility failed to ensure that employee personal items were not stored in one of the medication rooms. During an inspection, a black jacket was found hanging on the back of the door in the medication room at Nursing Station 2. The Registered Nurse (RN) acknowledged that the jacket should not be there and mentioned that employees have a designated lounge for their personal belongings. The Director of Nursing (DON) confirmed that personal belongings should not be stored in the medication room due to the risk of infection. The facility's policy on medication storage and infection prevention was reviewed, indicating that medications should be stored properly to ensure sanitation and security, and that the facility should maintain a safe and sanitary environment to prevent infections. The facility also failed to maintain a sanitary environment for one of the residents, Resident 6. Resident 6, who has chronic obstructive pulmonary disease (COPD), asthma, dementia, and lack of coordination, was found with a bedside commode full of feces and urine. The commode had not been cleaned for two and a half hours, resulting in a strong smell of urine and feces in the room. The RN and Certified Nurse Assistant (CNA) acknowledged that the commode should have been cleaned immediately after use to prevent the spread of infection and maintain a sanitary environment. Resident 6's family member also reported finding the commode full of feces and urine on multiple occasions during visits. The facility's policy on providing a safe and homelike environment was reviewed, which indicated that the facility should ensure a clean, comfortable, and sanitary environment for residents. The Infection Control Nurse (IPN) and DON both stated that an unclean bedside commode could lead to the spread of bacteria and infection, negatively affecting the resident's health. The failure to clean the commode in a timely manner was not in accordance with the facility's policies and procedures, leading to an unsanitary environment for Resident 6.
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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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