Heritage Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 21414 S. Vermont Avenue, Torrance, California 90502
- CMS Provider Number
- 056308
- Inspections on file
- 35
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Heritage Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was transferred to a hospital, but the facility did not provide the required written bed hold notice or transfer agreement to the responsible party within the required timeframe. Staff interviews confirmed that the necessary forms were not completed, resulting in incomplete communication about the resident's bed hold status.
Several deficiencies occurred when staff failed to assess, monitor, and notify the physician after a resident experienced a change in condition, resulting in the resident being found unresponsive and later pronounced dead. Other issues included not providing prescribed constipation medications to a resident with no bowel movement for several days, failing to document and obtain orders for NG tube reinsertion after repeated removals, and not notifying the physician about a resident's antiplatelet therapy after a fall. These failures were confirmed through record review and staff interviews.
Two residents at high risk for falls were not adequately protected due to failures in implementing and monitoring fall prevention interventions, including a disconnected bed alarm and lack of required supervision during smoking. One resident sustained multiple fractures after a fall when the talking device was not in use, and another was left unsupervised in the smoking area, resulting in a fall and facial injuries. Additionally, an unlabeled spray bottle containing isopropyl alcohol was found on a medication cart, posing a risk for accidental exposure.
Surveyors observed that staff did not consistently wear hair nets, food in the refrigerator was not labeled or dated, a dented can was stored on the shelf, and the can opener and floor under the sink were not properly cleaned. Dietary staff and supervisors confirmed these lapses, which were not in accordance with facility policies for infection control and food safety.
The QAA committee failed to implement effective corrective actions for previously identified deficiencies, resulting in repeated issues with nutrition/hydration, pain management, infection control, care planning, and medication management. Despite setting goals to reduce falls, the facility did not consistently meet these targets, and leadership acknowledged ongoing challenges in resolving these deficiencies.
The facility did not maintain effective pest control in the kitchen, as evidenced by the presence of tiny flies around a sticky mat and moist area near the triple sink. The Dietary Supervisor noted that staff could not clean under the sink, and cleaning records showed a missed cleaning. The facility's policy requires regular pest control inspections and cleaning, but these were not consistently followed.
Nursing staff did not ensure call lights were within easy reach for two residents, including one with visual impairment and another with cognitive decline, despite care plans requiring this intervention. Additionally, a resident with aphasia and hemiplegia was not provided with a communication board, and staff were unaware of its use, contrary to facility policy.
A resident with a history of chronic pain conditions experienced unrelieved severe pain due to the facility's failure to administer prescribed topical pain medications, inadequate pain assessment and documentation, and lack of interdisciplinary intervention. The resident's requests for stronger pain relief were denied without documented rationale, and the Medical Director was not notified. As a result, the resident frequently refused care and activities, and pain management was not achieved.
Multiple deficiencies were identified, including late administration of metformin for a resident with diabetes, failure to ensure a chewable aspirin was chewed and to use gloves when handling hazardous medication for another resident, and improper disposal of discarded medications in medication carts, making them accessible and not irretrievable as required by policy.
Surveyors found that medication carts contained unsealed biohazard containers with discarded medications, creating unsanitary and unsecure storage conditions. During a medication pass, a resident self-administered medications unsupervised when an LPN left the medications unattended. Additionally, two residents' medications, including insulin and an inhaler, were not labeled with open dates as required by manufacturer instructions and facility policy. Staff interviews confirmed these practices did not meet facility standards for safe medication storage, supervision, and labeling.
Several residents with significant dental needs did not receive timely or adequate dental services, including follow-up for dentures and dental assessments. One resident was left without dentures after extractions, another had ill-fitting dentures with no reassessment, a third struggled to eat due to poorly fitting new dentures, and a fourth had visible dental issues but was not seen by a dentist. Staff interviews confirmed a lack of follow-up and coordination for dental care, despite facility policies requiring such actions.
A resident with osteoarthritis and joint contractures was not accurately assessed for range of motion (ROM) limitations in both arms, as the MDS was incorrectly coded to show no limitations despite clinical evidence and joint mobility evaluations indicating minimal to severe ROM deficits. MDS nurses and the DON confirmed the coding errors after reviewing the resident's condition and facility policy required accurate interdisciplinary assessments.
Two residents experienced repeated incidents after their care plans were not updated following significant changes in condition. One resident with a history of falls did not have new interventions added after a fall, leading to another fall. Another resident who repeatedly removed her NG tube did not have her care plan revised after each occurrence, despite increased risk. Nursing staff and the DON confirmed that care plans were not updated as required after these events.
Facility staff administered benzonatate capsules to a resident with a G-tube by puncturing the capsules and delivering the contents through the tube, despite manufacturer instructions and facility policy prohibiting this method. The resident, who was non-verbal and dependent on staff, received the medication in a manner not supported by professional standards or literature, as confirmed by interviews with the pharmacy and DON.
A resident with multiple pressure ulcers was found lying on a deflated low air loss mattress (LALM) that was prescribed for wound management. Staff interviews confirmed that it was the responsibility of CNAs and nursing staff to ensure the mattress remained inflated, but this was not done. The resident reported discomfort due to the hard bed, and the treatment nurse did not check the mattress during a recent visit, contrary to facility policy requiring pressure-relieving devices for at-risk individuals.
A resident with limited mobility and a physician's order for active assistive range of motion (AAROM) exercises to the left leg did not receive ROM exercises to the left ankle as required. The RNA performed exercises on other joints but omitted the left ankle, despite the resident's inability to move it independently and the importance of the intervention as outlined by PT recommendations and facility policy.
Two residents who were able to express toileting needs and request assistance were not placed on bowel and bladder retraining or toileting programs. Instead, they were routinely provided with incontinence care, such as diapers, without individualized interventions to restore or maintain continence, despite facility policies requiring such services. Staff interviews and documentation confirmed the absence of appropriate assessment and management for continence care.
A resident with a history of constipation, diabetes, and reflux was found without water at the bedside, exhibiting dry mouth and lips, and reported not having water since the previous evening. Despite care plan interventions and facility policy requiring regular hydration, staff failed to ensure water was available, placing the resident at risk for dehydration.
Two residents experienced medication administration errors, resulting in an 8% error rate. One resident with diabetes received metformin more than one hour after the scheduled time on several occasions, and another resident was given a chewable aspirin tablet to swallow whole rather than chew, contrary to manufacturer instructions. These actions were observed during medication passes and confirmed by staff interviews and record reviews.
A resident with Type 2 Diabetes Mellitus did not receive metformin as ordered, with multiple instances of late administration outside the facility's one-hour window for medication timing. Staff confirmed that the medication was not given as scheduled with meals, contrary to physician orders and facility policy.
Two residents experienced deficiencies in documentation and order management, including inaccurate MAR entries for medications after a resident's death and unclear, outdated physician orders for a splint, resulting in staff confusion and potential impact on care.
A CNA entered the room of a resident with Covid-19 without performing hand hygiene or wearing the required PPE, including a gown and face shield, as outlined in facility policy. The resident was dependent on staff for care and had multiple medical conditions, including severe cognitive impairment and a history of stroke. Interviews confirmed that infection control protocols for contact and droplet precautions were not followed.
Two residents with cognitive impairments and significant care needs were not included in IDT care planning meetings, and there was no documentation of their participation or that of their representatives, despite facility policy and regulatory requirements for resident involvement in care and discharge planning.
The facility did not provide the required 80 square feet of space per resident in rooms 29 and 30, which measured only 77.66 square feet each. Despite this, residents did not report any adverse effects or complaints. The facility had not submitted a room waiver for these rooms for 2023 or 2024.
A CNA failed to follow proper hand hygiene protocols for a resident on contact isolation due to C. diff. Despite knowing the resident's condition, the CNA used hand sanitizer instead of washing hands with soap and water, as required by the facility's policy and the isolation sign. The DON confirmed that hand sanitizer is ineffective against C. diff spores, highlighting the importance of proper handwashing to prevent germ spread.
A resident experienced a severe weight loss of 9.57% over 34 days due to the facility's failure to implement the RD's recommendation to increase enteral feeding. The facility did not monitor the resident's weight effectively or report significant weight loss to the physician and RD. Additionally, the facility failed to conduct weekly weight variance meetings and did not complete a full nutritional assessment upon admission.
A resident with a Stage 4 pressure ulcer experienced severe pain during treatment due to inadequate pain management. The RN relied on Lidocaine spray and did not evaluate the effectiveness of Tylenol or notify the physician when pain relief was insufficient. Despite the physician's suggestion for stronger medication, the RN declined without proper documentation. The facility's policies on pain assessment and management were not followed, resulting in the resident's unnecessary suffering.
The facility failed to maintain infection control practices, as CNAs did not perform hand hygiene between residents while passing lunch trays, and RNA 1 used an inappropriate cleaning agent for a cloth gait belt. Additionally, Resident 3's nephrostomy tube drainage bag was not maintained below kidney level, risking backflow and infection. These deficiencies were observed and confirmed through interviews and policy reviews.
The facility failed to ensure call lights were within reach for two residents, one with paraplegia and moderate cognitive impairment, and another with severe cognitive impairment. Observations showed call lights were inaccessible, contrary to care plans and facility policy. Staff interviews confirmed the importance of accessible call lights to prevent frustration and delays in care.
The facility failed to develop and implement individualized care plans for RNA services for two residents and did not follow care plan interventions for two other residents on Coumadin therapy. The absence of RNA service care plans and lack of monitoring for bleeding complications were confirmed by staff, highlighting deficiencies in addressing residents' care needs.
The facility failed to provide prescribed ROM and mobility services to several residents, leading to potential declines in their physical functioning. Residents with conditions such as hemiplegia, muscle wasting, and atrophy did not receive consistent RNA exercises as ordered, with numerous missed sessions documented. The deficiencies were attributed to insufficient RNA staffing, as confirmed by the Director of Staff Development and the Director of Nursing.
The facility failed to provide sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Aide (RNA) services. Interviews and record reviews revealed that 95 residents had physician's orders for RNA services, but staffing records showed that the number of RNAs present each day was often below the required minimum, especially on weekends. RNA staff reported being unable to provide services to all residents due to high workloads and frequent reassignments, leading to many residents not receiving the RNA services as ordered.
The facility failed to maintain separate logs for emergency medication supplies and did not ensure proper documentation of narcotic inventory counts at shift changes. Additionally, there were discrepancies in the administration records for narcotic medications for three residents, and the facility's consent policy for psychotropic medications was outdated. The ADON and DON acknowledged these issues, and the facility was in the process of updating the consent policy.
The facility's QAA and QAPI committees failed to ensure ongoing assessment of physical restraints, address severe weight loss, and manage pain during wound care. Additionally, Restorative Nurse Aide services were not implemented as ordered. The DON admitted to not identifying systemic issues, and the facility did not adhere to its QAPI program guidelines.
A resident with multiple medical conditions reported feeling cold due to high air conditioning settings, leading to disturbed sleep and discomfort. Despite informing staff, the issue was not resolved, as the resident's complaints were not reported to the charge nurse. The facility's policy to provide a comfortable environment was not met, resulting in the resident's discomfort.
A resident with dementia and other medical conditions was subjected to unnecessary physical restraints in the form of bilateral hand mittens to prevent NGT removal. The facility failed to conduct ongoing assessments or document the necessity of the restraints, as required by their policy. Staff interviews confirmed the lack of documentation and monitoring, placing the resident at risk for complications.
A resident with major depressive disorder and prescribed medication for psychosis was inaccurately assessed with a negative PASARR I, despite needing maximal assistance for ADLs. The medical records director misunderstood the criteria, and the DON admitted the oversight, contrary to the facility's policy requiring a Level II evaluation for positive Level I screens.
A medication labeling discrepancy was identified for a resident when a bubble pack was found to have an outdated routine order label, despite a change to a PRN order. The DON confirmed the need for a change of dose sticker, as per facility policy, to prevent potential medication errors.
The facility failed to ensure clean linen carts were free from unnecessary items and that clean gloves did not contain soiled gloves, leading to potential cross contamination and infection spread. CNAs and the Infection Preventionist acknowledged these issues, which were against the facility's Standard Precautions policy.
Failure to Provide Bed Hold Notice Upon Resident Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to the responsible party of a resident who was transferred to a general acute care hospital. Record review showed that the resident, who had severe cognitive impairment and was dependent in activities of daily living due to diagnoses including Huntington's disease, major depressive disorder, and dementia, was transferred for further assessment. There was no documented evidence in the medical record that a written bed hold notice or transfer agreement form was created or provided within 24 hours of the transfer. Interviews with facility staff, including an LVN, the Medical Records Supervisor, and the Director of Nursing, confirmed that the required bed hold and transfer forms were not completed at the time of the resident's transfer. Staff acknowledged that these forms are necessary to inform the resident or their representative of the bed hold policy and their rights, and that the facility's policy requires written notification prior to transfers. The absence of this documentation resulted in incomplete communication regarding the resident's bed hold status.
Failure to Provide Timely Assessment, Monitoring, and Physician Notification for Changes in Condition and Treatment Needs
Penalty
Summary
The facility failed to provide necessary care and treatment for several residents, resulting in significant deficiencies. For one resident with a history of congestive heart failure, diabetes, and end-stage renal disease, staff did not properly assess or monitor the resident after a change in condition was observed, specifically shivering and shaking. The LVN on duty only checked the resident's temperature, provided a blanket, and did not document the findings or notify the physician. The LVN also failed to inform the incoming nurse and RN supervisor about the change in condition during shift handoff. As a result, the resident was not monitored every two hours as required, and was later found unresponsive and pronounced dead after unsuccessful resuscitation efforts. Interviews confirmed that staff recognized the symptoms as a change in condition but did not follow protocol for assessment, documentation, or notification. Another resident with a diagnosis of constipation and other comorbidities was not provided with prescribed medications for constipation after having no bowel movement for three days. The care plan required monitoring and administration of PRN medications for constipation, but staff failed to assess, monitor, or administer the necessary medications as ordered. The resident reported ongoing constipation to staff, but the issue was not addressed, and documentation confirmed that no PRN medications were given during the period of no bowel movement. Staff interviews revealed a lack of monitoring and follow-through on bowel movement frequency and medication administration. Additional deficiencies included failure to document and obtain orders for nasogastric (NG) tube reinsertion for a resident who repeatedly pulled out the tube, as well as failure to document the location of tube placement. The care plan was not updated after repeated incidents, and required documentation was missing. In another case, after a resident on clopidogrel sustained a fall, the physician was not notified of the resident's antiplatelet therapy, preventing appropriate evaluation for internal bleeding. Facility policies and staff interviews confirmed that these actions were required but not performed, resulting in incomplete care and documentation.
Failure to Prevent Accidents and Ensure Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that residents identified as being at risk for falls were adequately protected from accidents and injuries. For one resident with a history of dementia, osteoporosis, repeated falls, and impaired cognitive skills, the care plan included the use of a talking device (bed alarm) to remind and redirect the resident to call for assistance. However, the device was found to be disconnected at the time of a fall that resulted in multiple fractures and hospitalization. Staff interviews and documentation revealed that the resident was able to manipulate or turn off the device, and the care plan was not revised after previous falls to implement new interventions, despite evidence that existing measures were ineffective. Another resident, who required supervision at all times due to fall risk and a history of repeated falls, was left unsupervised in the designated smoking area. The care plan and facility policy required direct supervision while smoking, but the assigned staff member left the resident alone after initially supervising for a short period. The resident subsequently fell from the wheelchair while attempting to pick up a dropped cigarette, sustaining a nasal fracture, facial abrasions, and swelling, and required transfer to an acute care hospital for evaluation and treatment. Staff interviews confirmed that there was no consistent assignment for smoking supervision, and the responsible staff acknowledged the failure to provide required supervision. Additionally, the facility failed to ensure that a spray bottle containing isopropyl alcohol on a medication cart was properly labeled. The bottle, used for hand sanitizing, was transferred from a larger container but left unlabeled, creating a potential risk for accidental exposure or ingestion by residents. Both the DON and QA LVN acknowledged the importance of labeling such containers to maintain safety and prevent accidental ingestion.
Failure to Maintain Food Safety and Sanitation Standards in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, handling, and sanitation in the kitchen, as observed during surveyor visits. Staff were observed not wearing hair nets while in the kitchen, and food items stored in the refrigerator were found without labels or open dates. A large dented can of pineapple was found on the shelf, and the counter-mounted can opener had a thick black tarry substance present. Additionally, the floor underneath the triple sink was found with small white particles and a thick black tarry film, and cleaning records for the floor were incomplete, with a missing signature for a specific date. Interviews with dietary staff and supervisors confirmed that these practices were not in line with the facility's own policies and procedures, which require proper hair covering, labeling and dating of food, removal of dented cans, and regular cleaning of equipment and floors. Staff acknowledged the importance of these measures for infection control and food safety, and admitted to lapses in following procedures, such as forgetting to wear hair nets, not labeling food, and not cleaning equipment and floors as required.
Failure to Implement Corrective Actions for Repeat Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to implement corrective actions from the previous re-certification survey, resulting in repeated deficiencies across multiple areas. These deficiencies included issues with nutrition and hydration, pain management, food procurement, sanitary food storage and preparation, QAPI/QAA improvement, reasonable accommodation of resident needs and preferences, development and implementation of comprehensive care plans, infection prevention and control, quality of care, pharmaceutical services, drug regimen review, and the labeling and storage of drugs. During interviews and record reviews, facility leadership, including the DON, Administrator, and QA nurse, acknowledged that these deficiencies had been identified previously and continued to fluctuate without consistent resolution. A review of QAPI reports on falls revealed that the facility set specific goals to reduce the number of repeated falls and falls occurring in the evening, but these goals were not consistently met over several months. The fall rates varied, with only one month meeting the targeted reduction, while other months failed to achieve the set objectives. The facility's QAPI policy outlined responsibilities for the committee, such as collecting and analyzing performance data, identifying and resolving negative outcomes, and utilizing root cause analysis, but the ongoing presence of repeat deficiencies indicated these processes were not effectively implemented.
Failure to Prevent and Address Kitchen Pest Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, resulting in an infestation of tiny flies (drain flies). During an initial observation with the Dietary Supervisor (DS), two small flies were seen flying over a sticky mat in front of the triple sink, and small white particles along with a black tarry substance were noted on the floor under the sink. The DS stated that staff are unable to clean under the sink. On a subsequent inspection, multiple tiny flies were observed flying from the mat, and the area around the drain was moist. Review of the Orkin Service Report showed that the kitchen was checked and treated as needed, but a review of floor cleaning assignments revealed a missing signature for the relevant date, which the DS confirmed meant the cleaning was not done. The DS also acknowledged that floors and areas under the sink should be cleaned daily and that water and dirt accumulation can harbor microorganisms. The facility's policy requires monthly pest control inspections and additional servicing as needed.
Failure to Ensure Call Light Accessibility and Communication Support
Penalty
Summary
Nursing staff failed to ensure that the call light device was within easy reach for two residents. One resident, who was blind and required substantial to maximum assistance with mobility and transfers, was observed in bed with the call light hanging on the floor, out of reach. The resident's care plan specifically included an intervention to keep the call light within reach due to a high risk for falls and visual impairment. Staff interviews confirmed the importance of keeping the call light accessible, especially for residents with visual impairments. Another resident, who had moderate cognitive impairment and required assistance with activities of daily living, was observed requesting help to retrieve the call light, which was also found hanging on the side of the bed and not within reach. The care plan for this resident indicated the need to encourage use of the call light for assistance, but this intervention was not followed at the time of observation. Staff acknowledged the importance of call light accessibility to prevent falls and ensure timely assistance. Additionally, a resident with hemiplegia, hemiparesis, and aphasia did not have a communication board available to assist with communication needs. The resident's care plan did not address aphasia, and both staff and family confirmed that a communication board had not been provided until after the issue was identified. Facility policy emphasized the use of alternative communication systems for residents with aphasia, but this was not implemented for the resident in question.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident with a history of gout, back pain, peripheral vascular disease, and other conditions, who experienced unrelieved pain in the shoulder, neck, and legs. Despite physician orders for Lidocaine patches and Aspercreme for topical pain relief, these medications were not administered to the resident over several months as documented in the Medication Administration Record. The resident consistently reported severe pain, rating it as 8 out of 10, and expressed that the prescribed Tylenol was ineffective, leading to refusal of the medication and further requests for stronger pain relief, which were denied by the physician without documented rationale. Staff interviews and record reviews revealed that the resident's pain was not adequately assessed or managed according to the facility's policies. Pain levels were not consistently documented, and there was no evidence that the physician was informed when the resident reported severe pain or when pain management interventions were ineffective. The Interdisciplinary Team did not convene with the resident and family to address ongoing pain management issues or the resident's refusal of pain medication. Additionally, the facility did not notify the Medical Director when the attending physician refused to prescribe stronger pain medication. As a result of unmanaged pain, the resident frequently refused activities of daily living, restorative nursing assistant services, and participation in facility activities. Staff noted that the resident's pain led to agitation, refusal of care, and a desire to leave the facility. The facility's failure to follow physician orders, assess and document pain appropriately, and involve the care team in addressing pain management contributed directly to the resident's ongoing discomfort and decreased participation in necessary care and activities.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and professional standards of practice for multiple residents. One resident with Type 2 Diabetes Mellitus did not receive metformin within one hour of the scheduled administration time on several occasions, as required by facility policy. The medication was intended to be given at 8:00 a.m. with meals, but was administered late on multiple days, including one instance where it was given at 10:00 a.m. instead of by 9:00 a.m. Staff interviews confirmed that this delay was outside the facility's policy and could affect the resident's blood glucose control. Another resident with a history of atherosclerosis and breast cancer did not receive aspirin 81 mg chewable tablet as intended. During medication administration, the nurse did not instruct the resident to chew the tablet, and the resident swallowed it whole, contrary to manufacturer instructions. Additionally, the same nurse failed to wear gloves while handling letrozole, a hazardous medication, despite facility policy requiring personal protective equipment for hazardous drugs. Staff interviews confirmed that these actions were not in line with facility protocols and manufacturer requirements. The facility also failed to ensure the proper disposal of discarded medications. Observations of three medication carts revealed that loose tablets, capsules, and liquids were stored in open red biohazard containers within the carts, making the medications accessible and not irretrievable as required by policy. Staff interviews indicated that both controlled and non-controlled medications were sometimes disposed of in this manner, and that the method did not guarantee medications could not be retrieved. The DON confirmed that this practice was not compliant with facility policy and posed a risk for accidental exposure or misuse.
Medication Storage, Supervision, and Labeling Deficiencies
Penalty
Summary
Surveyors observed that medication carts in three stations contained unsealed red biohazard containers filled with discarded medications, including tablets, capsules, and liquids. These containers were stored with open lids in the bottom drawers of the carts, and some were labeled with handwritten notes such as 'pills,' 'liquid meds,' or 'crushed pills.' Licensed nurses reported that these bins were used to dispose of refused or dropped medications, and in some cases, controlled substances were also discarded in this manner. The Director of Nursing confirmed that these practices were not in line with facility policy, as the presence of unsealed containers with accessible medications posed risks for accidental exposure and drug misuse, and did not maintain a clean, safe, or sanitary environment for medication storage. During medication administration, a nurse prepared nine medications for a resident and placed them in two medicine cups on the resident's bedside table. The nurse then turned away to retrieve gloves, during which time the resident ingested most of the medications unsupervised. The nurse intervened before the resident took blood pressure medications, stating that blood pressure should be checked first. Interviews with supervisory staff confirmed that medications should not be left unattended with residents and that staff are required to observe residents taking their medications to ensure proper administration and to monitor for any difficulties or side effects. Additionally, surveyors found that certain medications were not labeled according to manufacturer specifications and facility policy. An opened vial of Humulin N insulin for one resident and a Breyna inhaler for another resident were both missing open dates. Staff acknowledged that labeling with open dates is necessary to determine expiration and ensure medication efficacy and safety. The Director of Nursing confirmed that the lack of labeling could result in the use of expired or ineffective medications, as staff would be unable to determine when the medications should be discarded.
Failure to Provide Necessary Dental Services and Follow-Up
Penalty
Summary
The facility failed to provide necessary dental services for four sampled residents, resulting in unmet dental needs and lack of follow-up on dental care. One resident, who was dependent on staff for oral hygiene and eating, had teeth extracted and required dentures. Despite orders and recommendations for dental impressions and new dentures, there was no follow-up by the Social Services Director, leaving the resident without dentures and experiencing difficulty chewing. Another resident, who was edentulous and had cognitive impairment, reported that her dentures did not fit properly. Although she had informed staff of her concerns, there was no follow-up or reassessment of her dental needs after her last dental evaluation. The Social Services Director acknowledged that the facility did not follow up on dental concerns unless identified during quarterly assessments. A third resident received new dentures, but they did not fit properly, making it difficult for her to eat. Staff were aware of the issue, but no action was taken to address the ill-fitting dentures. Additionally, a fourth resident with chipped and discolored teeth had not been seen by a dentist since admission, despite expressing concern about his dental appearance and potential tooth loss. Staff confirmed that there were no dental orders or appointments for this resident. Facility policies required coordination and follow-up for ancillary services, including dental care, but these were not implemented for the affected residents.
Failure to Accurately Assess and Code Resident's Range of Motion Limitations
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for a resident by not identifying and documenting functional limitations in range of motion (ROM) in both arms. The resident, who had a history of osteoarthritis in the left shoulder and hand, as well as a contracture of an unspecified joint, was cognitively intact and required varying levels of assistance for activities of daily living. Despite these conditions, Section GG 0115A of the MDS was coded as zero, indicating no ROM limitations in both arms, on two separate assessments. Review of the resident's Joint Mobility Evaluations (JMEs) on two occasions showed minimal ROM limitations in both shoulders and severe limitations in both hands and fingers. Observations confirmed the resident was unable to raise both arms to shoulder height or open both hands, with both elbows bent and hands in a fisted position. These findings were inconsistent with the MDS coding, which failed to reflect the resident's actual functional limitations. Interviews with the MDS nurses revealed that they typically relied on input from licensed therapists and compared their assessments with JMEs when coding the MDS. Upon review, both MDS nurses acknowledged that the MDS assessments were incorrectly coded and should have indicated ROM limitations in both arms. The DON also confirmed the importance of accurate MDS coding for appropriate resident care. Facility policy required the resident assessment coordinator to ensure timely and accurate assessments, with all contributors attesting to the accuracy of the information provided.
Failure to Revise Care Plans After Significant Resident Incidents
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents following significant changes in their conditions. For one resident with dementia, osteoporosis, and a history of repeated falls, the care plan was not updated after a fall occurred. Despite documentation of a fall on 4/19/2025 and subsequent assessment by the Interdisciplinary Team (IDT), no new interventions or revisions were made to the resident's fall risk care plan. The care plan continued to reflect previous interventions without addressing the recent incident, and the resident experienced another unwitnessed fall on 5/22/2025. For another resident with dementia and dysphagia who was dependent for most activities of daily living, the care plan was not revised after the resident repeatedly pulled out her nasogastric (NG) tube. Nursing staff confirmed that the care plan was not updated after incidents on 8/12/2024 and 4/24/2025, despite the increased risk of aspiration and the need for additional interventions. Both the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) acknowledged that the care plan should have been revised after each occurrence to address the ongoing issue. Interviews with nursing staff and the Director of Nursing (DON) confirmed that care plans are intended to be updated when interventions are not effective or when a resident's condition changes. The facility's policy also indicated that care plans should be revised as new information becomes available. However, in both cases, the care plans remained unchanged after significant events, resulting in repeated incidents for both residents.
Improper Administration of Benzonatate via G-Tube
Penalty
Summary
Facility staff failed to ensure that medications were administered in accordance with professional standards of practice for a resident with a gastrostomy tube (G-tube). The resident, who had multiple diagnoses including dysphagia, aphasia, and a history of cerebral infarction, was non-verbal and dependent on staff for activities of daily living. The resident had physician orders for benzonatate capsules to be administered via G-tube as needed for cough, despite the medication's package insert stating that capsules should be swallowed whole and not broken, chewed, dissolved, cut, or crushed due to the risk of local anesthesia and choking if the contents are released in the mouth. Observations and interviews revealed that staff, following instructions from the facility's pharmacy, punctured the benzonatate capsules, extracted the liquid, and administered it via the G-tube, followed by a water flush. The pharmacist acknowledged that there were no specific references or literature supporting this method but stated it had been used based on experience and physician orders. The Director of Nursing later confirmed that a liquid formulation should have been selected for G-tube administration and expressed concerns about the safety and efficacy of aspirating the capsule contents for dosing. Facility policy required staff to check medication labels, drug handbooks, or consult the pharmacy to determine if a medication was on the 'do not crush' list before administering through an enteral tube. The policy also specified that liquid forms should be requested when possible and that the contents of capsules should not be crushed or administered through an enteral tube unless verified as safe. Despite these policies, benzonatate capsules were administered via G-tube in a manner inconsistent with professional standards and manufacturer instructions.
Failure to Maintain Inflated Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a low air loss mattress (LALM), prescribed for wound management and pressure ulcer prevention, remained inflated for a resident with multiple pressure-induced deep tissue injuries. The resident, who was admitted with diagnoses including muscle wasting, atrophy, and pressure ulcers on the sacral region and both heels, was observed in bed with a deflated LALM. The resident reported that the bed was hard, indicating the mattress was not functioning as intended. Interviews with nursing staff revealed that it was the responsibility of Certified Nursing Assistants (CNAs) to notify the charge nurse if the mattress was not inflated, and for nursing staff, including the treatment nurse and LVN, to ensure the mattress was properly set up and functioning. Despite these responsibilities, the treatment nurse admitted to not checking the mattress during a recent visit, and the Director of Nursing confirmed that a non-functioning LALM could hinder its preventive purpose. Facility policy required the use of appropriate pressure-relieving devices for residents at risk for skin breakdown, but this was not followed in this instance.
Failure to Provide Ordered Range of Motion Exercises to Resident's Left Ankle
Penalty
Summary
A deficiency was identified when a resident with a history of malignant neoplasm of the prostate, joint contracture, and muscle wasting did not receive active assistive range of motion (AAROM) exercises to the left ankle as ordered by the physician and recommended by physical therapy. The resident was cognitively intact but required significant assistance with activities of daily living and had documented functional range of motion limitations in one leg. The physician's order specified that a Restorative Nursing Aide (RNA) should provide AAROM exercises to the resident's left leg three times a week. During observation, the resident was unable to move the left ankle independently and expressed pain and difficulty when attempting to do so. While the RNA was observed performing range of motion exercises to the resident's shoulders, elbows, wrists, hands, left hip, and left knee, the left ankle was omitted. The RNA acknowledged during interview that she did not provide ROM exercises to the left ankle, despite being aware of the order and the importance of including the ankle in the exercises for the entire leg. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed that the RNA program was intended to maintain or improve residents' functional level and range of motion, and that the omission of ordered services could result in a decline in the resident's condition. Review of facility policy indicated that residents with limited ROM should receive treatment and services to prevent further decrease in ROM, but this was not followed in the resident's care.
Failure to Provide Bowel and Bladder Retraining and Toileting Programs
Penalty
Summary
The facility failed to provide appropriate bowel and bladder retraining and/or toileting programs for two residents, resulting in a deficiency related to continence care. Both residents were assessed as being able to express their needs and request assistance for toileting, yet neither was placed on a structured program to help restore or maintain normal bowel and bladder function. Instead, care plans and staff practices defaulted to providing incontinence care, such as the use of adult diapers, without individualized interventions aimed at promoting continence. For one resident, records indicated a history of mild protein-calorie malnutrition, muscle wasting, and dependence on staff for transfers and toileting. Despite being able to communicate needs and use a urinal, the resident was not included in a bowel and bladder program. Staff interviews confirmed that the resident could feel the urge to urinate or defecate but often lost control due to delays in assistance, and there was no explanation for the absence of a retraining program. The second resident had diagnoses including chronic cystitis, urinary tract infection, and diverticulosis, and was documented as always incontinent in both bowel and bladder. However, interviews and assessments revealed that the resident was aware of toileting needs and could call for assistance, but was routinely provided with diapers and not assisted to the bathroom. Staff acknowledged the lack of a bowel and bladder management program and recognized the need for better assessment and documentation. Facility policies reviewed indicated that services should be provided to restore or improve continence, but these were not implemented for the residents in question.
Failure to Provide Bedside Water for Resident at Risk of Dehydration
Penalty
Summary
A deficiency was identified when a resident was not provided with water at the bedside, as observed during a facility survey. The resident, who had a history of constipation, diabetes mellitus, and gastro-esophageal reflux, was noted to have dry mouth and lips and reported not having water since the previous evening. The resident's care plan specifically included interventions to offer and provide adequate fluids, and the nutritional review indicated the resident was at risk for dehydration and weight changes. Despite these documented needs, no water pitcher was present at the bedside during the observation. Interviews with multiple staff members, including CNAs, an LVN, the RN Supervisor, and the DON, confirmed that facility policy and standard practice required residents without fluid restrictions to have water available at all times. Staff described regular hydration rounds and responsibilities for ensuring water was provided, but in this instance, the process failed, resulting in the resident being left without water. Review of facility policies further supported the expectation that residents receive routine hydration care in accordance with their care plans.
Medication Error Rate Exceeds Acceptable Threshold Due to Timing and Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration, resulting in an observed error rate of 8%. For one resident with Type 2 Diabetes Mellitus, metformin 500 mg was not administered within one hour of the scheduled time on multiple occasions, contrary to the facility's policy and physician's order. The medication, intended to be given at 8:00 a.m. with meals, was administered as late as 10:00 a.m., and this pattern of late administration was confirmed through record review and staff interviews. The Director of Nursing confirmed that such late administration was not in accordance with facility policy and could impact the resident's care. Another resident, with diagnoses including atherosclerosis and breast cancer, was prescribed an aspirin 81 mg chewable tablet to be taken with breakfast. During a medication pass observation, the nurse did not instruct the resident to chew the tablet, and the resident swallowed it whole along with other medications. Staff interviews confirmed that the medication should have been chewed as per manufacturer instructions, and failure to do so could affect the medication's intended absorption and effectiveness. The order for the aspirin was later changed to an enteric-coated formulation, but at the time of the observation, the chewable form was in use and not administered as directed. The facility's policy on medication administration requires medications to be given within one hour of the prescribed time and according to the correct method of administration. Both deficiencies—late administration of metformin and improper administration of chewable aspirin—were observed and confirmed through interviews, record reviews, and direct observation, resulting in a medication error rate above the acceptable threshold.
Failure to Administer Diabetes Medication Within Required Timeframe
Penalty
Summary
A deficiency occurred when a resident with Type 2 Diabetes Mellitus did not receive their prescribed metformin medication within the facility's required timeframe. The facility's policy mandates that medications be administered within one hour of the scheduled time unless otherwise specified. However, review of the medication administration records showed that the resident's metformin, ordered to be given at 8:00 a.m. with meals, was administered late on multiple occasions, including at 10:22 a.m., 9:42 a.m., 4:12 p.m., 11:14 p.m., and 12:05 p.m. These late administrations were confirmed through observation, record review, and staff interviews. The resident required assistance with activities of daily living and had a diagnosis of diabetes, necessitating timely medication administration to manage blood glucose levels. Staff interviews confirmed that the medication should have been given by 9:00 a.m. and that late administration could result in the medication not being given with meals, as intended. The facility's Director of Nursing acknowledged that these late administrations were not in accordance with physician orders or facility policy, and that such deviations could lead to risks for the resident.
Failure to Ensure Accurate Documentation and Physician Orders
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records and Medication Administration Records (MAR) for two residents. For one resident with multiple complex diagnoses, including congestive heart failure, diabetes, cardiomyopathy, COVID-19, and end-stage renal disease, the MAR indicated that medications and treatments were documented as administered after the resident had already expired. Specifically, medications and a blood sugar reading were signed as given at times after the resident's recorded time of death. The nurse responsible admitted to documenting these administrations in error, stating she was overwhelmed and did not actually provide the medications. Additionally, the facility did not maintain clear and current physician orders regarding the use of a splint for another resident with a right leg fracture. The physician's order lacked specificity about the type of splint to be used, and when a CAM boot was discontinued by the physician, the order was not updated or discontinued in the electronic health record. This led to confusion among staff regarding whether the resident should still be using a splint or immobilizer, and which type was required. Staff interviews confirmed uncertainty about the resident's care plan due to the lack of clear documentation and order updates. Facility policies and job descriptions reviewed indicated that licensed nurses and charge nurses are responsible for accurate documentation and implementation of physician orders, including verifying medication administration and ensuring orders are current and specific. The observed deficiencies in documentation and order management had the potential to cause confusion among staff and impact the provision of necessary care and services.
Failure to Follow PPE and Hand Hygiene Protocols for Covid-19 Resident
Penalty
Summary
Certified Nursing Assistant (CNA 5) failed to follow proper infection prevention and control protocols when caring for a resident diagnosed with Covid-19. Specifically, CNA 5 entered the resident's room wearing only an N95 mask, without performing hand hygiene or donning a protective gown and face shield as required. CNA 5 proceeded to provide care and handle items in the resident's environment without the appropriate personal protective equipment (PPE) and without practicing hand hygiene before entry. The resident involved had a history of hemiplegia and hemiparesis following a stroke, severely impaired cognitive skills, and was dependent on staff for all activities of daily living. The facility's policy required staff to wear gloves, gown, N95 mask, and face shield, and to perform hand hygiene before entering the room of any resident on contact and droplet precautions due to Covid-19. Interviews with the CNA, Infection Preventionist Nurse, and RN Supervisor confirmed that the required infection control measures were not followed in this instance.
Failure to Include Residents in Care Planning Meetings
Penalty
Summary
The facility failed to ensure that two residents participated in care plan meetings to discuss their care and discharge goals, as required by federal regulations. For the first resident, documentation showed an admission and readmission with diagnoses including hemiplegia, hemiparesis, and aphasia. The resident had limited decision-making capacity, with the MDS indicating mild cognitive impairment and significant dependence on staff for activities of daily living. Interviews with the Social Service Assistant (SSA) revealed that no Interdisciplinary Team (IDT) meetings were conducted for this resident, and there was no documentation of such meetings. The SSA stated that IDT meetings are important, especially when families are undecided, but none were held for this resident. The family member interviewed was unaware of any IDT meeting being offered and expressed confusion about the care plan and discharge timing. For the second resident, records indicated admission with diagnoses of muscle wasting, spinal stenosis, and radiculopathy. The H&P noted the resident lacked capacity to make decisions, and the MDS showed mild cognitive impairment with dependence on staff for multiple care needs. The SSA did not recall conducting an IDT meeting for this resident and found no documentation of one. The Director of Nursing (DON) confirmed that IDT meetings should occur for each resident, at least quarterly or within 14 days of admission, especially for those with skilled needs. The DON acknowledged that without IDT meetings, care plans would lack cohesion and concerns might not be addressed in a timely manner. A review of facility policies indicated that the Social Service Department is expected to participate in all IDT functions, including care planning and discharge planning meetings. Policies also emphasized the importance of supporting residents' rights and documenting social service interventions in the care plan and progress notes. Despite these policies, the facility did not ensure that the two residents or their representatives were included in the care planning process, nor did it document their participation, resulting in a failure to meet regulatory requirements for resident involvement in care planning.
Plan Of Correction
Affected Residents Resident 1 is no longer a resident of the facility. Resident 2 still resides in the facility. On 5/8/2025, Resident 2 had an Interdisciplinary Team (IDT) meeting. The Resident Representative, Social Services Designee, Dietary Supervisor, Activities Director, MDS RN, and the Physical Therapist attended the IDT meeting. The medications, skin condition, nutrition, activities, rehabilitation, and discharge planning were discussed. The resident representative had no concerns regarding care and services. Other Residents Other residents have the potential to be affected by the same alleged deficient practice. On 5/8/2025, the Social Services Department did a compliance IDT meeting audit on all residents who are under skilled services. All other residents have completed IDT evaluations. No similar findings were noted. Systemic Changes The Director of Nursing and Director of Staff Development gave an in-service on 5/9/2025 to the case manager, social services director, rehab department, dietary supervisor, activities director, and MDS Nurse on the responsibility of the facility in initiating the IDT meetings within seven (7) days upon admission. Discussions regarding care issues or ongoing concerns and discharge planning will be discussed during the IDT meetings. During facility morning stand-up meetings, the team will discuss the IDT Conference Meetings scheduled for that day. Monitoring The Medical Records Designee will monitor compliance by doing a weekly IDT meeting audit on all new admissions to ensure compliance. Findings will be discussed with the Director of Nursing and Social Services Director to be addressed and corrected promptly. Significant findings will be submitted to the Administrator and shall be forwarded to the QA & A Committee quarterly for trending analysis, recommendations, corrective actions, and continuous quality improvement. Completion Date The corrective action will be completed on 5/25/25.
Inadequate Room Space for Residents
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident in multiple resident bedrooms, specifically in rooms 29 and 30, which measured only 77.66 square feet each. This deficiency was identified during an observation and interview with the Maintenance Supervisor, who confirmed the inadequate room size for the three residents living in each of these rooms. Despite the deficiency, it was noted that the residents' quality of life, care needs, and safety were not adversely affected, and no complaints were made by the residents regarding the room space. Additionally, the facility had not submitted a room waiver for these rooms for the years 2023 or 2024.
Failure to Follow Proper Hand Hygiene for C. diff Isolation
Penalty
Summary
The facility failed to ensure proper hand hygiene was followed by a Certified Nursing Assistant (CNA 1) for a resident on contact isolation due to Clostridioides difficile (C. diff). The resident, who was admitted with enterocolitis caused by C. diff, required contact isolation as per the physician's order. The isolation sign outside the resident's room indicated that staff and visitors should wash their hands with soap and water upon exiting the room. However, CNA 1 was observed using hand sanitizer instead of washing her hands with soap and water after providing direct care to the resident. During an interview, CNA 1 acknowledged the mistake, stating she knew the resident was on contact isolation for C. diff and admitted to using hand sanitizer instead of washing her hands. The Director of Nursing (DON) confirmed that hand sanitizer is ineffective against C. diff spores and emphasized the importance of washing hands with soap and water to prevent the spread of germs. The facility's policy on hand hygiene also specified that employees must wash their hands with soap and water when exposed to spores like C. diff, as alcohol-based hand rubs are not effective in removing them.
Failure to Prevent Severe Weight Loss in Resident
Penalty
Summary
The facility failed to prevent a severe unplanned weight loss in a resident, identified as Resident 129, who experienced a 9.57% weight loss over 34 days. The deficiency arose from the facility's failure to implement the Registered Dietician's (RD) recommendation to increase the resident's enteral feeding from four to five times daily, which was necessary to meet the resident's caloric needs. Despite the RD's recommendation, the resident's feeding regimen was not adjusted, resulting in inadequate caloric intake. Additionally, the facility did not monitor the resident's weight effectively or report significant weight loss to the resident's physician and RD as required by the care plan. The resident's weight was recorded weekly, showing a progressive decline, but the necessary change of condition documentation and communication with the healthcare team were not completed. This lack of communication and documentation meant that the resident's severe weight loss was not addressed in a timely manner, preventing the implementation of necessary interventions. The facility also failed to conduct weekly weight variance meetings to discuss and address the resident's weight loss, as there was no documentation of such meetings in the resident's progress notes. The RD did not complete a full nutritional assessment upon the resident's admission, and there was no follow-up on the initial mini nutritional assessment. The absence of these critical assessments and meetings contributed to the resident's continued weight loss and placed them at risk for further health complications.
Inadequate Pain Management for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to provide effective pain management for a resident with a Stage 4 pressure ulcer during treatment and repositioning. The resident, who had a history of dementia, osteoarthritis, and a pancreatic mass, was observed to be in severe pain, as evidenced by loud screaming and moaning during pressure ulcer treatment. Despite these clear signs of distress, the registered nurse (RN 6) did not administer adequate pain relief, relying solely on Lidocaine spray, which was insufficient for the resident's level of pain. The RN did not evaluate the effectiveness of the Tylenol administered prior to the treatment, nor did they notify the physician when the pain management was unsuccessful. The physician had suggested prescribing Norco, a stronger pain medication, but RN 6 declined, citing the use of Lidocaine spray and an undocumented claim that the resident's family did not want strong pain medication. This decision was made without proper documentation or consultation with the interdisciplinary team. The facility's Director of Staff Development and Treatment Nurse both acknowledged that the resident's pain was not managed effectively, and the treatment should have been paused to reassess the resident's pain level. The facility's policies on pain assessment and management, as well as pressure ulcer treatment, were not followed, leading to the resident experiencing unnecessary and severe pain during care.
Infection Control Deficiencies in Hand Hygiene, Equipment Cleaning, and Nephrostomy Tube Management
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. Certified Nursing Assistants (CNAs) 1 and 2 did not perform hand hygiene between residents while passing lunch trays, as observed on June 13, 2024. Both CNAs acknowledged the oversight during interviews, citing reasons such as rushing and forgetting, and recognized the importance of hand hygiene in preventing the spread of infection. The Infection Prevention Nurse confirmed that hand hygiene should be performed to prevent potential illness among residents, as per the facility's hand hygiene policy. Restorative Nursing Aide 1 (RNA 1) used an inappropriate cleaning agent for a cloth gait belt after assisting Resident 96 with walking exercises. RNA 1 used 70% isopropyl alcohol, which was not effective for disinfecting porous materials like fabric. The Infection Preventionist nurse confirmed that neither the isopropyl alcohol spray nor bleach germicidal wipes were suitable for fabric, and the only proper method was laundering the gait belts. The facility's policy indicated that equipment should be easily cleaned and disinfected, and fabric-based equipment should not be used if likely to be contaminated with body fluids. Resident 3's nephrostomy tube drainage bag was observed multiple times at the same level as the resident's body, contrary to the facility's policy that it should be below the level of the kidneys to prevent backflow and potential infection. Interviews with the Director of Staff Development and a Licensed Vocational Nurse confirmed the importance of maintaining the drainage bag below kidney level to ensure proper urine flow and prevent infection. The facility's policy on nephrostomy tube care reiterated the need for drainage to be below the kidney level.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility staff failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident 3, who has paraplegia and moderate cognitive impairment, requires maximum assistance for various activities of daily living. Despite the care plan indicating that the call light must be within reach, observations on multiple occasions showed that Resident 3's call light was hanging at the side of the bed and not accessible. Similarly, Resident 22, who has severe cognitive impairment and requires assistance for all activities of daily living, was observed with the call light on the floor and out of reach. Both residents have care plans that emphasize the importance of having the call light within reach to prevent falls and ensure timely assistance. Interviews with facility staff, including the Director of Staff Development, a Certified Nursing Assistant, and a Licensed Vocational Nurse, confirmed the importance of having the call light within reach to prevent frustration, potential falls, and delays in care. The facility's policy on answering call lights also mandates that call lights should be within easy reach of residents, especially those confined to bed or a chair. The failure to adhere to these guidelines and care plans resulted in the potential for Resident 3 and Resident 22 to not receive necessary assistance when needed, impacting their psychosocial wellbeing.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes, and interventions for four of eight sampled residents. Specifically, Residents 66 and 73 did not have care plans for Restorative Nursing Aide (RNA) services, despite physician orders indicating the need for passive range of motion (PROM) exercises to maintain their level of function and range of motion. This oversight was confirmed by the Minimum Data Set Nurses, who acknowledged the absence of RNA service care plans in the residents' comprehensive care plans. Additionally, the facility did not follow care plan interventions for Residents 9 and 103, who were at risk for bleeding while on Coumadin therapy. Although their care plans indicated the potential for bleeding complications, there was no documentation of assessments for signs and symptoms of bleeding. Licensed Vocational Nurse 6 and the Registered Nurse Supervisor confirmed the lack of monitoring for these residents, which was necessary to prevent complications from Coumadin therapy. The Director of Nursing emphasized the importance of comprehensive care plans as communication tools to address residents' care needs accurately. The facility's policy and procedure on care plans highlighted the need for measurable objectives and timetables to meet residents' medical, nursing, mental, and psychological needs. However, the facility's failure to develop and implement appropriate care plans for RNA services and to follow existing care plans for Coumadin therapy monitoring resulted in deficiencies that could negatively impact the residents' care and safety.
Failure to Provide Prescribed ROM and Mobility Services
Penalty
Summary
The facility failed to provide necessary treatments and services to maintain or improve the range of motion (ROM) and mobility for five residents, leading to potential declines in their physical functioning. For Resident 23, the facility did not consistently provide Restorative Nursing Aide (RNA) exercises for both legs and arm bicycle exercises as ordered, with numerous missed sessions documented in May and June. Resident 23, who has a history of right-sided hemiplegia and hemiparesis following a stroke, was observed with limited mobility and reported infrequent visits from RNA staff. Resident 66, who suffers from muscle wasting and ataxic gait, also did not receive the prescribed passive range of motion (PROM) exercises for both arms and legs. The RNA documentation showed multiple missed sessions throughout May, indicating a lack of adherence to the physician's orders. Similarly, Resident 84, with diagnoses of muscle wasting and atrophy, did not receive the ordered RNA services, including ROM exercises, strengthening exercises, and the application of a hand splint, as evidenced by numerous blank entries in the RNA documentation for May and June. Resident 117, who has right-sided hemiplegia and hemiparesis following an intracranial hemorrhage, was not provided with the required PROM exercises and walking exercises as ordered. The RNA documentation revealed significant gaps in service provision for May and June. Additionally, Resident 43 did not receive RNA exercises on a specific date, despite documentation indicating otherwise. The Director of Staff Development confirmed the missed sessions and attributed the deficiencies to insufficient RNA staffing, which was corroborated by the Director of Nursing, who emphasized the importance of RNA services in maintaining residents' functional mobility.
Inadequate Staffing for Restorative Nursing Aide Services
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Aide (RNA) services. This deficiency was identified through interviews and record reviews, revealing that 95 residents had physician's orders for RNA services, which included assistance with sit-to-stand transfers, range of motion (ROM) exercises, ambulation, and other activities. However, the facility's staffing records for May and June 2024 showed that the number of RNAs present each day was often below the required minimum of four, particularly on weekends. Interviews with RNAs and the Director of Staff Development (DSD) confirmed that the facility was understaffed, leading to many residents not receiving the RNA services as ordered. RNA staff reported being unable to provide services to all residents on their daily schedule due to the high workload and frequent reassignments to assist Certified Nursing Assistants (CNAs) with their duties. This situation was exacerbated when RNAs called out sick or were reassigned, resulting in remaining staff having to cover double or triple the workload. The Director of Nursing (DON) and the DSD acknowledged the staffing issues and the potential for residents to experience a decline in function if RNA services were not provided as ordered. The facility's policy and procedure on staffing indicated that adequate staffing should be provided on each shift to meet residents' needs, but this was not achieved, leading to the deficiency.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to maintain a separate log for emergency medication supplies and did not ensure that licensed nurses documented the inventory count of narcotics stored in the Cubex system at the change of shift. Observations revealed that 24 out of 124 shifts lacked nurses' signatures, and the remaining shifts had identical signatures for both performing and witnessing nurses. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged the lack of proper documentation and the absence of a policy for the Cubex cycle count. Additionally, the facility did not maintain accurate administration records for narcotic medications for three residents. For one resident, the administration of alprazolam was not recorded in the Emergency Drug Supply Log Sheet, despite being issued from the Cubex system. For another resident, there were discrepancies between the narcotic record and the electronic medication administration record (eMAR) for hydrocodone-acetaminophen doses. Similarly, for a third resident, the administration of Norco was not documented in the eMAR, as confirmed by the DON. The facility's consent policy for psychotropic medications was outdated and did not align with current regulations. The ADON and the facility consultant pharmacist acknowledged this issue, noting that the facility was aware of the outdated policy and was in the process of updating it. The policy failed to require new consent for dosage changes and did not hold the facility responsible for obtaining signatures or ensuring that all risks were disclosed to residents or their families.
Deficiencies in QAA and QAPI Committees
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to ensure ongoing assessment and reevaluation of the continuous use of physical restraints. Additionally, they did not identify, assess, and implement interventions for residents experiencing severe weight loss and pain during wound care treatment. Furthermore, the facility did not ensure that Restorative Nurse Aide services were implemented as ordered for residents. These deficiencies were identified during an interview with the Administrator, Quality Assurance Nurse, and the Director of Nursing (DON), where the DON admitted to not being able to identify systemic issues even before the survey. The facility's policy and procedure for the QAPI program, revised in March 2020, indicated that the facility should develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program focused on indicators of care outcomes and quality of life for residents. The policy aimed to measure current and potential indicators for outcomes of care and quality of life, establish and implement performance improvement projects to correct identified negative or problematic indicators, and reinforce effective systems and processes related to the delivery of quality care and services. However, the facility failed to adhere to these guidelines, resulting in the identified deficiencies.
Failure to Maintain Comfortable Room Temperature for Resident
Penalty
Summary
The facility failed to provide a comfortable room temperature for Resident 25, who was admitted with multiple medical conditions including a cardiac pacemaker, end-stage renal disease, cardiomyopathy, and diabetes. The resident, who had intact cognition and required moderate assistance with mobility, reported feeling cold in her room due to the air conditioning being set too high. Despite informing a nurse and a CNA about her discomfort, the issue was not resolved, and the resident continued to experience disturbed sleep and discomfort, resorting to using multiple blankets and a towel to keep warm. Interviews with staff revealed that the resident's complaints were not adequately addressed. CNA 7 and CNA 6 acknowledged the resident's discomfort but did not report it to the charge nurse, partly due to the roommate's preference for a colder room. The Maintenance Director confirmed that the air conditioning was centralized and that he was only informed of the issue after the resident's complaint. The facility's policy emphasized providing a homelike environment with comfortable temperatures, but this was not achieved for Resident 25, leading to her discomfort and potential health risks.
Failure to Monitor and Document Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary physical restraints, specifically the use of bilateral hand mittens, which were applied to prevent the removal of a nasogastric tube (NGT). The resident, who was diagnosed with unspecified dementia, bilateral primary osteoarthritis of the knee, and a stage 4 pressure ulcer, was unable to express needs or make decisions. Despite the resident's Minimum Data Set indicating no restraints, a physician's order dated February 25, 2024, required the use of hand mittens every shift. The facility did not conduct ongoing assessments or document the necessity of the restraints, as confirmed by interviews with staff, including a CNA, RN, and the ADON. The ADON acknowledged the lack of documentation regarding the reassessment and evaluation of the mittens' use, and the absence of an end date for the physician's order. The facility's policy required regular monitoring and documentation of restraints, but this was not adhered to, as evidenced by the lack of detailed records in the resident's electronic health record and Medication Administration Record. Interviews with the DON and RN revealed that the facility's policy required restraints to be monitored every two hours, with quarterly assessments to determine the need for continued use. However, the last assessment was conducted in January 2024, and there was no evidence of ongoing evaluation. The facility's failure to follow its policy and procedure for restraint use placed the resident at risk for complications such as skin breakdown and impaired circulation.
Inaccurate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to accurately complete a preadmission screening and annual resident review (PASARR) I for a resident diagnosed with major depressive disorder. The resident was admitted with this diagnosis and required maximal assistance for all activities of daily living, as indicated in the Minimum Data Set (MDS) assessment. The resident was also prescribed Quetiapine Fumarate for psychosis, which manifested as hostility and agitation. Despite these indicators, the PASARR I was marked as negative for a serious mental disorder, which was incorrect. Interviews with the medical records director (MRD) and the Director of Nursing (DON) revealed a misunderstanding and oversight in the PASARR process. The MRD believed the negative PASARR I was due to the resident's dementia, while the DON acknowledged that the PASARR I should have been positive, given the resident's mental disorder and medication. The facility's policy stated that a positive Level I screen should lead to a Level II evaluation, which was not followed in this case.
Medication Labeling Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that the label on a bubble pack for a resident's medication reflected the current dosage and any changes in dosage. During an observation at the nursing station, an LVN presented a bubble pack for a resident that was labeled with a routine order of hydrocodone-acetaminophen 10-325 mg to be taken every eight hours. However, a review of the resident's physician orders indicated that the routine order had been discontinued and replaced with a PRN order to be taken every six hours as needed for moderate to severe pain. The Director of Nursing confirmed that the routine order had been discontinued and that the nurse should have contacted the pharmacy to obtain a change of dose sticker for the bubble pack. The facility's policy and procedures for medication administration indicated that if a discrepancy exists, the medication nurse should consult the appropriate resources and affix a direction change sticker if the label directions are incorrect. This oversight had the potential to lead to a medication error.
Infection Control Deficiencies in Linen Handling and Glove Use
Penalty
Summary
The facility failed to ensure that clean linen carts were free from unnecessary items, which could lead to cross contamination and the spread of infections. During observations, it was noted that clean linen carts contained items such as trash bags, assignment sheets, and a container of perfumed body fragrance. Certified Nurse Assistants (CNAs) acknowledged that these items should not be in the linen carts as they could contaminate the clean linens and spread infections to other residents. Additionally, a box of clean gloves was found to contain soiled gloves with a brown substance, which was also acknowledged by the CNA as a potential source of infection. The Infection Preventionist (IP) confirmed that staff were not allowed to have personal items or any unnecessary items in the clean linen carts and that soiled gloves should not be mixed with clean gloves due to the risk of cross contamination. The facility's policy on Standard Precautions, dated October 2018, was reviewed and it stated that linen carts should be free from unnecessary items and that gloves should be removed promptly after use to prevent contamination. The policy also indicated that soiled resident-care equipment should be handled in a manner that prevents the transfer of microorganisms to other residents and environments.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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