Highland Park Skilled Nursing And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 5125 Monte Vista St., Los Angeles, California 90042
- CMS Provider Number
- 555165
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Highland Park Skilled Nursing And Wellness Center during CMS and state inspections, most recent first.
A resident with toxic encephalopathy, depression, impaired safety awareness, and severe mobility limitations, who had a documented history of elopement and multiple recent elopement attempts, was not adequately supervised or protected despite care plan identification of elopement risk. On the day of the incident, staff noted increased confusion and observed the resident trying to open an exit door, but no 1:1 observation, wander guard, or enhanced monitoring was implemented, and staff instead attempted to block the exit with a medication cart. The resident was last seen in her room at lunchtime and was later found missing, having exited through a door opened for visitors, in contrast to facility policies requiring individualized elopement risk interventions and person-centered monitoring systems.
A resident with multiple chronic conditions was administered Ativan without a specific behavioral indication in the physician's order, and staff failed to monitor or document the resident's behaviors and side effects as required by facility policy. Interviews and record reviews confirmed that the MAR and MPDM forms lacked necessary documentation, and staff did not follow protocols for psychotropic medication management.
A resident with end-stage renal disease missed a scheduled hemodialysis treatment due to transportation issues, and the facility failed to arrange alternate transportation. Additionally, the resident was not monitored for fluid overload, and blood pressure medications were not administered as ordered. These failures led to the resident experiencing severe symptoms, requiring transfer to a hospital for emergency treatment.
A resident with multiple health conditions had medications left unattended on their bedside table by an LVN, contrary to facility policy. The resident was not approved for self-administration, and the medications were left unlabeled and uncovered, posing a risk of accidental ingestion by others. Staff confirmed this practice was against policy, which requires medications to be stored in the medication cart if refused.
The facility did not update the Daily Posted Nurse Staffing information from 2/14/2025 to 2/25/2025, as required by its policy. An observation on 2/25/2025 revealed that the posted staffing information was outdated by eight days. RN 1, covering for the DON, confirmed the lapse and acknowledged the importance of daily updates to ensure adequate staffing for resident care.
The facility failed to maintain the dignity and privacy of two residents. A resident with Alzheimer's was fed by a CNA who stood instead of sitting at eye level, violating the facility's policy. Another resident with an indwelling catheter had their urinary collection bag uncovered, contrary to the facility's requirement for dignity bags to ensure privacy. These actions did not align with the facility's policies aimed at promoting resident dignity and respect.
The facility failed to accurately assess the MDS for two residents, omitting diagnoses of anxiety and depression despite evidence of these conditions and prescribed medications. This oversight could hinder the development of individualized care plans, as confirmed by staff interviews and record reviews.
The facility failed to provide necessary respiratory services for three residents, leading to potential health risks. A resident with COPD was not given the prescribed continuous oxygen therapy, and their equipment was not properly labeled. Another resident's nebulizer equipment was improperly stored, and a third resident received excessive oxygen, contrary to physician orders.
The facility failed to follow proper food storage and dish sanitization practices. Several food items were improperly labeled or stored, with some past their use-by dates, and the dishwasher was operated below the required temperature. These deficiencies could lead to foodborne illness among residents.
The facility failed to maintain proper waste management as two dumpsters were observed with overflowing trash, causing the lids to remain open. The Maintenance Supervisor confirmed that the facility policy required trash to be compressed to keep lids closed, preventing the attraction of pests. The Waste Management policy indicated that waste containers must be closable and food waste should be placed in covered garbage cans.
The facility failed to update care plans for two residents. One resident's fall care plan was not revised after a fall with injury, despite being at high risk for falls. Another resident's care plan was not updated to reflect a new fluid restriction order. Both failures were acknowledged by facility staff, highlighting a lack of adherence to policies requiring care plan updates following changes in condition or physician orders.
A resident with dementia and mobility issues experienced a fall with a head injury, but the facility failed to conduct a Post Fall Evaluation, neuro checks, or an IDT meeting as required by their policy. The ADON confirmed these actions were not taken, despite the facility's Fall Management Program outlining these necessary steps.
A resident with an indwelling urinary catheter did not receive appropriate care as per physician's orders, leading to delayed identification of a potential UTI. Despite observations of sediment and concentrated urine, there was no documentation or physician notification, contrary to facility policy. The resident's medical history included conditions that increased UTI risk.
A facility failed to monitor the fluid intake of a resident on dialysis with a fluid restriction, leading to a deficiency. The resident's fluid intake exceeded the prescribed limits, and there was no record of fluid intake with medication administration. Staff were unaware of the fluid restriction, and facility policies were not followed, posing a risk of fluid overload or dehydration.
A resident with multiple diagnoses, including dementia and psychosis, was left with eight medications unattended on their nightstand by an IPN, contrary to facility policy. The resident was not approved for self-administration, and the IPN admitted to leaving the medications due to a disruption. This failure to supervise medication administration posed a risk of medication errors and potential harm.
A facility failed to act on a pharmacy consultant's recommendations during a Medication Regimen Review for a resident with type 2 diabetes, depression, and dementia. The review identified issues with medication administration, including the concurrent use of Saxagliptin and Sitagliptin, missing 'Do not crush' instructions for Ferrous Sulfate, and incorrect timing for Repaglinide. The facility lacked a designated staff member to review and follow up on these recommendations, resulting in no action being taken.
The facility did not ensure daily temperature checks of the Activity Room Refrigerator, which stored food brought by family for a resident, as required by policy. The temperature log lacked entries for several days, and the Dietary Services Supervisor confirmed the oversight.
The facility failed to meet the required 80 square feet per resident in 12 out of 22 rooms, with measurements ranging from 64.6 to 76.6 square feet per resident. Despite the deficiency, residents reported comfort, and observations showed adequate space for mobility aids and care provision. The Department recommended a waiver for the affected rooms.
A resident with severe cognitive impairments and multiple diagnoses, including malnutrition, refused more than 50% of meals for three consecutive times. The facility failed to notify the physician as required by policy, which considered this a Change of Condition (COC). The Director of Nursing confirmed the oversight, which could delay necessary care for the resident.
The facility failed to promote dignity for two residents by not covering a urinary catheter bag and standing above a resident while feeding. Staff acknowledged the importance of these actions for resident dignity, but they were not followed.
The facility failed to provide necessary ADL care and communication devices for two residents. One resident with severe cognitive impairment was not given a communication device in their primary language and was improperly positioned in bed. Another resident faced communication barriers due to the lack of a communication device in their preferred language. Staff interviews and observations confirmed the absence of required communication tools and proper positioning, leading to deficiencies in care.
The facility failed to ensure a safe environment for two residents, leading to potential risks for falls, injuries, and delayed care. One resident's room was cluttered, impeding emergency access, while another resident's overhead trapeze setup posed entanglement and injury risks. Staff acknowledged these hazards, but the facility's safety policies were not adequately followed.
The facility failed to ensure sanitary conditions in food storage and preparation, with issues including an oven with an unreadable temperature knob and improperly labeled or expired food items in the kitchen and dry storage.
The facility failed to follow its Antibiotic Stewardship protocol, leading to the inappropriate administration of antibiotics to two residents who did not meet the McGeer's Criteria. The physician was not notified of the residents' screening scores, resulting in unnecessary antibiotic use.
The facility failed to provide education, offer, and document the updated COVID-19 vaccinations for the year 2023-2024 for 96 out of 105 employees. Interviews and record reviews revealed incomplete documentation and lack of a clear process for notifying all employees about the vaccination clinic, placing residents and staff at risk for possible COVID-19 infection.
The facility failed to ensure that the call light was within reach of three residents, leading to a potential delay in the provision of services and assistance with ADLs. The call lights for these residents were found in inaccessible locations, contrary to their care plans and facility policy.
The facility failed to accurately document a resident's eating ability on the MDS. Despite being assessed as needing substantial/maximal assistance, the resident was observed eating independently with minimal assistance. Staff interviews confirmed the resident's ability to feed herself, highlighting a discrepancy in the MDS documentation.
The facility failed to accurately complete the PASRR form for a resident with schizophrenia, leading to the resident not receiving necessary psychiatric treatment. Despite medical records indicating a diagnosis of schizophrenia and the use of psychotropic medications, the PASRR forms were incorrectly marked as negative. Interviews with staff revealed lapses in the submission and verification process of the PASRR forms.
The facility failed to update the care plan for a resident with a history of seizures, despite changes in prescribed seizure medications. The care plan did not reflect all current medications, which was acknowledged by both the Registered Nurse Supervisor and the Director of Nursing.
A resident was found hiding Colace capsules to avoid taking too much medication, leading to a failure in proper medication administration as per the facility's policy. The DON confirmed that nurses must observe residents taking their medications to prevent double dosing or missed doses.
The facility failed to ensure a shower chair used by residents was in good condition and free from stains. A CNA was observed using a stained and worn-out shower chair, which was confirmed by the RNS, MS, and DON to be unsuitable for use. The facility's policy emphasized providing a safe, clean, and comfortable environment, which was not upheld in this instance.
The facility failed to post accurate nurse staffing information at the start of each shift, as required by its policy. The Director of Staff Development admitted that the information had not been updated since 3/24/2024 and was unsure of the required format.
The facility failed to ensure that 12 out of 22 resident rooms met the required 80 square feet per resident in multiple resident bedrooms. Despite the deficiency, residents reported feeling comfortable and having enough space for their belongings and mobility aids. The Department recommended approval of a room waiver request for the 12 rooms in question.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise, monitor, and implement safety measures for a resident with known elopement risk and cognitive impairment, resulting in an elopement. The resident was admitted with diagnoses including toxic encephalopathy, depression, difficulty walking, and lack of coordination, and had intermittent ability to understand and make decisions. Therapy notes documented that the resident was unsteady when walking and standing, required substantial/maximal assistance to walk ten feet, had a mobility function score of 0, and had impaired safety awareness. The care plan identified the resident as being at risk for decline in functional status and safety concerns during daily care tasks, and also documented a history of elopement at home and prior elopement or attempted leaving the facility without informing staff. On the day of the incident, the resident’s Change of Condition note indicated an increase in confusion that was a persistent change from usual cognitive function and documented that the resident had attempted to elope multiple times prior to the successful elopement. The resident was last seen in her room at 12:30 PM when lunch was delivered, and at 1:05 PM a CNA noted the resident was not in the room when picking up the lunch tray. By approximately 1:20 PM, staff determined the resident was missing and activated a code yellow. Interviews revealed that earlier that day the RN observed the resident attempting to open the exit door and redirected her back to her room after 12:30 PM, and the RN reported that the resident had tried to elope at least four times prior to successfully leaving. The RN stated a huddle was called to inform staff, including the primary CNA, to be more vigilant in watching the resident, although the primary CNA later reported not recalling this huddle, while another CNA confirmed it occurred. Staff interviews and policy review showed that the facility did not implement enhanced monitoring or safety devices consistent with the resident’s identified elopement risk and change in condition. The DON acknowledged that if staff knew the resident was attempting to exit through the door, the resident would be at risk for elopement and that the physician should have been notified to obtain an order for a wander guard. The DON also stated the resident should have been closely monitored with staff visually seeing the resident at all times or placing the resident on 1:1 observation, and that these interventions were not implemented. The RN reported that despite multiple elopement attempts, the resident did not have a 1:1 sitter, and staff instead tried to block the exit door with a medication cart. The facility’s wandering and elopement and resident safety policies required assessment of elopement risk, development of a person-centered care plan, and establishment of observation or monitoring systems, including more frequent safety checks when indicated, but the resident was able to leave through the exit door when visitors exited and was not observed by staff as she left.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use, specifically Ativan, by not providing a specific indication for its use and not monitoring for manifested behaviors or side effects as required by facility policy and care plan. The resident in question had multiple diagnoses, including congestive heart failure, dementia, and diabetes mellitus, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. The care plan indicated the resident had episodes of agitation and anxiety, with interventions to administer medications as ordered and monitor for side effects and effectiveness, as well as to document behaviors and potential causes. Record reviews revealed that the physician's order for Ativan lacked a specific manifested behavior for restlessness, which was necessary for accurate monitoring and administration. Interviews with the DON, LVN, MDS Nurse, and ADON confirmed that the order did not specify the required behavioral manifestations, and that staff did not document or monitor the resident's specific behaviors or side effects associated with Ativan use. The Medication Administration Record (MAR) and Monthly Psychoactive Drug Management (MPDM) forms did not reflect any monitoring for the resident's behavior or side effects during the period when Ativan was administered. Facility policies required that any order for psychoactive medications include a specific behavior manifestation and that residents be monitored for side effects and adverse consequences, with all occurrences documented monthly. Staff interviews and record reviews confirmed that these policies were not followed, resulting in incomplete and inaccurate documentation regarding the resident's behavior and medication use. This failure to follow established protocols led to the deficiency cited in the report.
Failure to Ensure Timely Hemodialysis and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received necessary hemodialysis treatment as scheduled, which was critical due to the resident's end-stage renal disease. On the day of the scheduled treatment, the transportation company contracted by the resident's insurance was unable to provide a driver, resulting in the resident missing the dialysis appointment. Despite multiple calls to the transportation company, no alternate transportation was arranged, even though a list of backup transportation options was available at the nurses' station. Additionally, the facility did not transcribe the physician's order to monitor the resident for signs and symptoms of fluid overload after the missed dialysis treatment. This oversight meant that the resident was not adequately monitored for potential complications arising from the missed treatment. Furthermore, the resident's blood pressure medications were not administered as ordered, which could have helped manage the resident's hypertension after the dialysis was canceled. As a result of these failures, the resident experienced shortness of breath, chest pain, and elevated blood pressure later that day, necessitating transfer to a general acute care hospital. The hospital records indicated that the resident suffered from acute fluid overload, bilateral pleural effusions, and pulmonary edema, requiring immediate medical intervention, including hemodialysis and other treatments to stabilize the resident's condition.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing a Licensed Vocational Nurse (LVN) to leave medications unattended on a resident's bedside table. This incident involved a resident with multiple diagnoses, including end-stage renal disease, hypertension, atrial fibrillation, and diabetes mellitus. The resident, who had intact cognition but required supervision for certain activities, was not approved for self-administration of medications. Despite this, medications were left at the bedside, posing a risk of accidental ingestion by other residents. During an observation, it was noted that the medications were left unlabeled and uncovered on the bedside table. Both a Certified Nurse Aide and an LVN confirmed the presence of the medications and acknowledged that leaving them unattended was against facility policy. The Registered Nurse Supervisor also confirmed that medications should not be left at the bedside and should be stored in the medication cart if refused by the resident. The facility's policies emphasized the importance of maintaining a safe environment and outlined procedures for handling medication refusals, which were not followed in this instance.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Posted Nurse Staffing information was updated and posted in accordance with its policy from 2/14/2025 to 2/25/2025. During an observation on 2/25/2025, it was noted that the Census and Direct Care Service Hours Per Patient Day (DHPPD) form displayed was dated 2/12/2025, indicating that the information had not been updated for eight days. This lapse was confirmed during an interview and record review with RN 1, who was covering for the Director of Nursing (DON) in her absence. RN 1 acknowledged that the DHPPD should be updated and posted daily at the beginning of each shift, and the failure to do so meant that the staffing information for the current day was not available. The facility's policy, titled Nursing Department - Staffing, Scheduling & Postings, revised on 1/22/2025, mandates that the facility post specific staffing information daily. This includes the facility name, current date, total number, and actual hours worked by registered nurses, licensed vocational nurses, and certified nurse aides, as well as the resident census. The policy emphasizes the importance of calculating projected and actual staffing hours to ensure adequate staffing levels for resident care. The failure to adhere to this policy had the potential to leave residents and visitors uninformed about the facility's staffing and census, as well as hinder the facility's ability to address staffing shortages effectively.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents by not adhering to its own policies. For Resident 35, who has Alzheimer's disease and severely impaired cognitive skills, the facility's policy requires staff to sit at eye level while assisting with feeding to avoid intimidating the resident. However, during an observation, CNA 2 was seen standing while feeding Resident 35, contrary to the facility's Restorative Dining Program policy. This policy aims to improve mealtime behavior, self-image, and socialization skills for residents who are unable to feed themselves. For Resident 43, who has an indwelling catheter due to obstructive uropathy, the facility's policy mandates that urinary collection bags be covered with a dignity bag to maintain the resident's privacy and dignity. During an observation, Resident 43's catheter bag was found uncovered, and CNA 1 confirmed the absence of a dignity bag. The Director of Nursing acknowledged that the facility's policy requires catheter bags to be covered to ensure residents' dignity and respect, as outlined in the facility's Resident Rights - Quality of Life policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments of the Minimum Data Set (MDS) for two residents, leading to potential issues in developing and implementing individualized care plans. Resident 42 was admitted with diagnoses including dementia with agitation, mood disturbance, psychotic disturbance, and anxiety disorder. However, the MDS did not reflect the anxiety disorder diagnosis, despite the resident being prescribed Buspirone for anxiety. Interviews with staff confirmed the resident exhibited anxiety symptoms, such as screaming and repetitive movements, which were not documented in the MDS. Similarly, Resident 49 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), anxiety, and depression. The MDS for this resident also failed to include the active diagnoses of anxiety and depression, even though the resident was prescribed medications like Buspirone, Sertraline, and Trazadone for these conditions. The psychological evaluation indicated moderately severe depressive symptoms and severe anxiety symptoms, yet these were not reflected in the MDS assessments. The MDS Nurse acknowledged the omissions in both cases, stating that the MDS should accurately reflect the residents' diagnoses to ensure proper care and monitoring. The facility's policy on the Resident Assessment Instrument (RAI) process emphasizes the importance of accurate assessments, which was not adhered to in these instances, potentially affecting the residents' overall well-being.
Failure to Administer Prescribed Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory services for three residents, leading to potential health risks. Resident 49, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), anxiety, and depression, was not administered the prescribed 2 to 3 liters per minute (LPM) of continuous oxygen therapy as indicated in the physician's order. During an observation, it was noted that Resident 49's oxygen concentrator was off, and the resident was not receiving any oxygen therapy, contrary to the physician's order for continuous administration. Additionally, the plastic respiratory equipment bag containing the nasal cannula tubing was not labeled or dated, which is against the facility's infection control policy. Resident 21, who also had COPD and other pulmonary conditions, had their nebulizer equipment improperly stored. The nebulizer, nebulizer cup, and aerosol mask were observed unbagged on the bedside table, which is a violation of the facility's policy requiring respiratory equipment to be stored in a labeled and dated bag to prevent contamination and infection. Resident 54, diagnosed with COPD and respiratory failure, was administered oxygen at a rate of 5 to 6 LPM, exceeding the physician's order of 2 to 3 LPM. This discrepancy was confirmed by a licensed vocational nurse who acknowledged the error and the potential harm of administering excessive oxygen, especially for a resident with COPD. The facility's policy mandates that oxygen be administered as prescribed, and deviations from this can lead to serious complications, including respiratory acidosis.
Improper Food Storage and Dish Sanitization Practices
Penalty
Summary
The facility failed to adhere to its food storage and handling policies, as observed during a survey. Several food items in the facility's kitchen were found to be improperly labeled or stored. Specifically, numerous refrigerated and frozen items were either past their use-by dates or lacked proper labeling, including items such as sausage, cheese frosting, turkey meat, tomato paste, spaghetti, milk, sour cream, apple juice, almond milk, gelatin cocktail, bread rolls, corn, carrots, juice, paprika, cayenne pepper, sugar cookies, baking soda, cereal, biscuit mix, and rice. The Dietary Services Supervisor (DSS) confirmed that per facility policy, all food items should be labeled with a receive date and a use-by date once opened, and items must be discarded after the use-by date to ensure food safety for residents. Additionally, the facility failed to ensure proper sanitization of dishes. During an observation, a staff member ran the dishwasher with the hottest temperature reaching only 100 degrees Fahrenheit, below the required 120 degrees Fahrenheit. The staff member admitted to not checking the temperature gauge during the cycle. The DSS stated that facility policy requires staff to check the temperature during each dishwashing cycle and to rerun the cycle if the temperature does not reach at least 120 degrees Fahrenheit. The facility's policy also mandates routine monitoring of the dish machine to ensure appropriate wash and rinse temperatures are maintained, and any deviations must be reported to the Dietary Manager. These deficiencies have the potential to result in foodborne illness among the residents consuming food at the facility.
Improper Waste Management in Facility Dumpsters
Penalty
Summary
The facility failed to ensure that two of three garbage dumpsters had their lids closed and were not overflowing with trash, as required by the facility's policy. During an observation, two dumpsters were seen with trash overflowing, causing the lids to remain open. This was confirmed during an interview with the Maintenance Supervisor, who stated that the facility policy required trash to be compressed to keep the lids closed and prevent the attraction of flies and rodents. A review of the facility's Waste Management policy indicated that waste containers must be closable and food waste should be placed in covered garbage cans.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise the care plan for two residents, Resident 42 and Resident 33, as per the facility's policy. Resident 42's fall care plan was not updated after a fall with injury occurred on January 3, 2025. Despite being at high risk for falls, as indicated in the Fall Risk Evaluation dated November 15, 2024, and having a history of falls, the care plan was not revised to include new interventions after the second fall. The Assistant Director of Nursing and the MDS Nurse both acknowledged that the care plan should have been updated to address the underlying causes of the fall and to implement new interventions. Resident 33's care plan was not revised to reflect an updated fluid restriction order from the physician dated January 15, 2025. The care plan still contained outdated fluid restriction measurements, which did not align with the physician's order. Licensed Vocational Nurse 1 confirmed that the care plan was not updated, and the Assistant Director of Nurses emphasized the importance of updating the care plan to prevent potential health issues such as fluid overload, edema, or dehydration. The facility's policies and procedures require that care plans be reviewed and revised following changes in a resident's condition or new physician orders. However, in these cases, the care plans for Residents 42 and 33 were not updated as required, potentially affecting the quality of care and services provided to these residents.
Failure to Conduct Post-Fall Evaluations and Meetings
Penalty
Summary
The facility failed to meet professional standards of quality for one resident, identified as Resident 42, by not conducting necessary evaluations and meetings following a fall with an injury. Resident 42, who was admitted with diagnoses including dementia with psychotic disturbance, lack of coordination, and reduced mobility, experienced a fall resulting in a laceration to the left upper eyebrow. Despite the fall and the resident's altered mental status and behavioral symptoms, the facility did not conduct an Interdisciplinary Team (IDT) meeting, a Post Fall Evaluation, or a neurological exam as required by their policy. The Assistant Director of Nursing (ADON) confirmed that the facility's policy mandates a post-fall evaluation, neuro checks for unwitnessed falls or head injuries, and an IDT meeting within 24 hours to revise the care plan. However, these actions were not taken for Resident 42 after the fall on January 3, 2025. The facility's Fall Management Program policy, reviewed in January 2025, outlines these requirements, but the licensed nurses failed to document the fall details, perform the necessary evaluations, or revise the care plan, as confirmed by the ADON during the review.
Failure to Monitor and Document Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter, as indicated in the physician's orders. The resident, who had a history of malignant neoplasm of the prostate, benign prostatic hyperplasia, obstructive uropathy, and reflux uropathy, was at risk for urinary tract infections (UTIs). The physician's orders required the staff to assess urinary drainage for signs and symptoms of infection every shift, including cloudiness, color, sediment, blood, odor, and amount of urine output. Observations revealed that the resident's Foley catheter tubing had small to moderate amounts of white sediment and concentrated yellow urine, indicating potential signs of infection. However, there was no documentation of these observations in the resident's Treatment Administration Record (TAR), Progress Notes, or Change of Condition/Situation, Background, Assessment, Request/Recommendation (COC/SBAR) forms. The Treatment Nurse confirmed that the presence of sediment or cloudiness should have been documented and reported to the physician for further evaluation and potential laboratory testing. Interviews with the Director of Nursing (DON) and the Treatment Nurse highlighted that the facility's policy required staff to monitor and report any signs of infection to the physician. The DON stated that minimal sediment or cloudiness should be monitored for eight hours, while moderate to severe sediment or cloudiness required immediate physician notification. The lack of documentation and communication with the physician regarding the resident's catheter condition resulted in a delayed identification of a potential UTI, which could lead to worsening infection and delayed treatment.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to accurately monitor the fluid intake for a resident with fluid restrictions and on dialysis, leading to a deficiency in care. The resident, who was admitted with end-stage renal disease and dependent on dialysis, had a physician's order for a fluid restriction of 1000 ml per day. However, the facility did not adhere to this order. Certified Nurse Assistant 4 confirmed that the resident's fluid intake exceeded the prescribed limits during meals, and there was no awareness of the fluid restriction. Additionally, the Licensed Vocational Nurse 1 admitted that there was no record of the fluid intake associated with medication administration, which was supposed to be documented in the Medication Administration Record. The Assistant Director of Nurses acknowledged that the CNAs were not supposed to provide extra fluids to the resident and that the fluid intake from meals and medications should have been recorded. The facility's policies and procedures for dialysis care and fluid restriction were not followed, as there was no documentation of fluid intake, and the staff failed to monitor and ensure compliance with the fluid restriction. This lack of monitoring and documentation had the potential to cause fluid overload or dehydration, posing a risk to the resident's health.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not supervising the medication administration for one of the residents, identified as Resident 39. During a record review, it was found that Resident 39 was not approved for self-administration of medications and was not allowed to keep medications at the bedside. Despite this, eight medications were left on the nightstand by the Infection Prevention Nurse (IPN) without supervision. The IPN admitted to leaving the medications unattended due to being disrupted, acknowledging that this was against the facility's policy, which requires medications to be administered directly by the licensed nurse preparing them. Resident 39, who was admitted with diagnoses including atherosclerosis, chronic pulmonary edema, psychosis, and dementia, was found to have intact cognitive skills for daily decision-making according to the Minimum Data Set. However, the resident required assistance with daily activities and was at risk for self-care performance deficits due to mood disorder and forgetfulness. The care plan for Resident 39 included maintaining a safe environment and providing assistance as needed. The failure to supervise medication administration posed a risk of medication errors and potential harm to Resident 39 and other residents who might access the medications.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to act upon the Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR) for December 2024 for one of the sampled residents, Resident 41. The MRR, conducted by the consulting pharmacist, identified several irregularities in Resident 41's medication regimen, including the concurrent use of Saxagliptin and Sitagliptin, the absence of a 'Do not crush' instruction for Ferrous Sulfate, and the timing of Repaglinide administration. These recommendations were not reviewed or acted upon by the facility, as indicated by the Medication Administration Record (MAR) for December 2024, which showed that the medications were administered without addressing the pharmacist's recommendations. Resident 41, who was initially admitted and later readmitted to the facility, had a medical history that included type 2 diabetes mellitus, depression, and unspecified dementia. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for substantial assistance with daily activities. Despite these needs, the facility did not ensure that the pharmacist's recommendations were reviewed and communicated to the attending physician, as required by the facility's policy and procedure for medication regimen reviews. Interviews with the Director of Nurses (DON), a licensed vocational nurse (LVN 1), and the Assistant Director of Nurses (ADON) revealed that there was no designated staff member responsible for reviewing and following up on the MRR. The responsibility was informally assigned to all licensed nurses, leading to a lack of accountability and oversight. As a result, the irregularities identified in the MRR were not addressed, and the attending physician was not notified, which could have led to potential adverse medication outcomes for Resident 41.
Failure to Monitor Refrigerator Temperatures for Resident Food
Penalty
Summary
The facility failed to ensure that the temperature of the Activity Room Refrigerator, which contained food brought by family members for a resident, was checked daily as per the facility's policy. During an observation and interview with the Dietary Services Supervisor (DSS), it was noted that the refrigerator contained a food container labeled with a resident's room number and bed, indicating it was brought by the resident's family. The facility's Policy & Procedure required that refrigerator temperatures be checked routinely throughout the day and maintained at 41 degrees or below. However, the temperature log for the refrigerator did not have documented temperatures from February 3 to February 9, both in the morning and evening. The DSS confirmed that staff should have checked and documented the refrigerator temperatures according to the policy.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 12 out of 22 resident rooms met the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. This deficiency was identified through observations, interviews, and record reviews conducted from February 10 to February 13, 2025. The rooms in question, specifically Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18, were found to have less than the required space per resident, with measurements ranging from 64.6 to 76.6 square feet per resident. Despite this, some residents expressed comfort with their space during interviews, and observations indicated that there was adequate room for mobility aids and the provision of care. The facility's Client Accommodation Analysis Form confirmed the deficiency, listing specific room measurements that fell short of the required square footage. For instance, one room with three beds measured 194 square feet, equating to only 64.6 square feet per resident. Despite the spatial limitations, observations noted that residents had enough space to move freely and that the care provided was not compromised. The Department recommended approval of a room waiver request for the affected rooms, acknowledging the facility's efforts to maintain adequate care and mobility within the limited space.
Failure to Notify Physician of Resident's Meal Refusal
Penalty
Summary
The facility failed to notify the resident's physician when a resident, who was diagnosed with protein-calorie malnutrition, dementia, Alzheimer's disease, and dysphagia, refused more than 50% of meals for three consecutive times. The resident was admitted with severe cognitive impairments and was dependent on assistance for daily activities, including eating. Despite the resident's refusal to eat, which was documented in the Nutrition Meal Intake records, the physician was not informed as required by the facility's policy. The facility's policy stated that if a resident ate less than 50% for three consecutive meals, it should be considered a Change of Condition (COC), and the physician should be notified. However, the Director of Nursing confirmed that the physician was not informed of the resident's poor meal intake. Additionally, the resident's care plan required monitoring and reporting changes in behavior or appetite loss, which was not adhered to. This oversight had the potential to delay necessary care and services for the resident, who was already at risk of severe malnutrition.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not ensuring proper handling of a urinary catheter bag and inappropriate feeding assistance. Resident 16, who had diagnoses including COPD, UTI, and difficulty walking, was observed with an uncovered urinary catheter bag, which should have been covered with a dignity bag to protect the resident's dignity. Multiple staff members, including CNAs and the Director of Nursing, acknowledged that the dignity bag should have been used to cover the catheter bag, but it was not in place when the resident returned from the hospital. Resident 11, who had diagnoses including nontraumatic subarachnoid hemorrhage, atrial fibrillation, and epilepsy, was observed being fed by a CNA who stood above the resident's eye level. The CNA admitted that she should have been sitting at eye level with the resident but did not do so because there was no available chair. Another staff member, an LVN, confirmed that feeding residents at eye level is important for their dignity and to encourage proper eating. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Provide Necessary ADL Care and Communication Devices
Penalty
Summary
The facility failed to provide necessary care and services to ensure the residents' abilities in activities of daily living (ADLs) for two sampled residents. Resident 15, who has severe cognitive impairment and multiple diagnoses including bilateral primary osteoarthritis of the knee and Alzheimer's disease, was not provided with a communication device in their primary language and was observed in an uncomfortable and improper bed position. Despite the care plan indicating the need for alternative communication tools and proper positioning, these interventions were not implemented. The Director of Nursing acknowledged the lack of frequent visual checks to ensure proper positioning and the absence of a communication board at the bedside. Resident 29, diagnosed with end-stage renal disease and other conditions, also faced a communication barrier due to the lack of a communication device in their primary language. The resident, who is capable of understanding and making decisions, reported difficulty in communicating with staff who did not speak their preferred language. The care plan for Resident 29 included the use of communication boards and translation assistance, but these measures were not in place. Interviews with staff confirmed the reliance on other staff members for translation and the absence of communication boards at the bedside. The facility's policies on positioning and body alignment, as well as accommodation of residents' communication needs, were not followed. The failure to provide appropriate communication devices and ensure proper positioning in bed for these residents led to deficiencies in their care. Observations and interviews with staff and residents highlighted the lack of adherence to the care plans and facility policies, resulting in inadequate support for the residents' ADLs and communication needs.
Failure to Ensure Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment for Resident 16 and Resident 36, leading to potential risks for falls, injuries, and delayed care. Resident 16's room was cluttered with multiple items such as nightstands, an oxygen concentrator, and a trash can, which were placed parallel to the bed. This clutter was observed to impede quick access to the resident in case of an emergency. Despite the resident's high fall risk and the use of medications that increase fall risk, the room arrangement was not adjusted to mitigate these hazards. The Director of Nursing (DON) acknowledged that the room was not free of accident hazards and that the clutter could delay staff response in an emergency situation. Additionally, the room was smaller than the required 80 square feet per resident, necessitating a room waiver, which further complicated the safety concerns for Resident 16, who was already at high risk for falls and anxiety attacks that could lead to injury. Resident 36's environment also posed safety risks. The resident had an overhead trapeze with multiple cords hanging from it, including the call light and bed remote. This setup was observed to be unsafe as the cords could potentially entangle the resident, who had periods of confusion. During an observation, the trapeze was seen making contact with the resident's face, which the resident confirmed was uncomfortable and unavoidable due to the need to reach the call light and bed remote. Staff, including a Registered Nurse (RN) and a Certified Nurse Assistant (CNA), acknowledged that the trapeze setup was not safe and could cause injury. The DON also confirmed that the trapeze could injure the resident if it made contact with her face or head. The facility's policies on resident safety and accommodation of needs were not adequately followed, as evidenced by the unsafe conditions in the rooms of Resident 16 and Resident 36. The clutter in Resident 16's room and the unsafe trapeze setup in Resident 36's room were not addressed, despite the known risks and the facility's own procedures requiring regular evaluation of resident safety. These deficiencies highlight a failure to provide a safe environment, putting residents at risk for accidents and delayed care.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure the storage, preparation, and distribution of food were conducted under sanitary conditions for fifty-two residents. The first deficiency was observed in the kitchen where the conventional oven's temperature knob had no visible settings, making it difficult for the dietary staff to determine the correct cooking temperature. Both the Dietary Staff Supervisor (DSS) and the Cook confirmed that they had to guess the temperature, which could result in improperly cooked food. The Maintenance Supervisor also acknowledged the issue, stating that the faded numbers on the temperature knob could be dangerous as it is crucial to know the exact temperature when cooking food for residents. The second deficiency involved improper labeling and storage of food items in the kitchen produce refrigerator and dry storage. Several food items, including Parmesan cheese, mayonnaise, pickle relish, liquid whole eggs, cream cheese, frozen sausage, pizza dough, and doughnuts, were either past their expiration dates or not labeled with a received or expiration date. Additionally, items in the dry storage such as black eye peas, ground black pepper, oregano leaves, domestic paprika, and dark chili powder were not labeled with open or expiration dates. The DSS admitted to missing the expired food items during inventory checks and acknowledged that all staff should ensure proper labeling and checking of food items. The facility's policies and procedures on food storage, which require all items to be correctly labeled and dated, were not followed.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship, leading to the inappropriate use of antibiotics for two residents. Resident 16, who had diagnoses including COPD, pneumonia, sepsis, and UTI, was prescribed Cefepime despite not meeting the McGeer's Criteria for antibiotic use. The Infection Prevention Nurse (IPN) confirmed that the resident's screening score was zero, indicating a suspected infection that did not meet the criteria for antibiotic administration. The physician was not notified of this score, and the antibiotic was administered regardless, contrary to the facility's protocol and the purpose of the Infection Screening Evaluation. Similarly, Resident 35, with diagnoses including ESBL resistance, an open wound, and diabetes with neuropathy, was prescribed Ertapenem Sodium without meeting the McGeer's Criteria. The IPN confirmed that Resident 35's screening score was also zero, and the physician was not informed. The antibiotic was administered despite the resident not meeting the criteria, and the physician was not consulted to confirm the necessity of the antibiotic. The Director of Nursing (DON) acknowledged that the physician should have been notified when the McGeer's Criteria score was zero, to determine whether to continue with the antibiotic. The facility's policy on Antibiotic Stewardship, which aims to optimize antibiotic use and reduce inappropriate prescriptions, was not followed, leading to the potential for antibiotic resistance and adverse side effects in the residents.
Failure to Provide and Document Updated COVID-19 Vaccinations for Staff
Penalty
Summary
The facility failed to provide education, offer, and document the updated COVID-19 vaccinations for the year 2023-2024 for 96 out of 105 employees. This deficiency was identified through interviews and record reviews, which revealed that the Employee List and Vaccines form was incomplete and did not indicate how many employees were offered, received, or declined the updated COVID-19 vaccine. Several staff members, including a Certified Nursing Assistant (CNA), the Infection Prevention Nurse (IPN), and the Director of Nursing (DON), confirmed that they were either not offered the updated vaccine or did not have the necessary consent or refusal forms on file. The IPN admitted that the updated vaccines were not ordered for the employees and that there was no clear process for notifying all employees about the vaccination clinic, given their different work schedules and shifts. The facility's policy, revised on 8/2/2023, stated that the facility would continue to offer vaccines and booster doses per the requirements of CMS, CDC, and ACIP and document such. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and incomplete Employee List and Vaccines form. The CDC recommends the 2023-2024 updated COVID-19 vaccines to protect against serious illness, but the facility failed to ensure that all employees were offered and documented for the updated vaccine, placing residents and staff at risk for possible COVID-19 infection due to missed vaccination dosages.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure that the call light was within reach of three residents, leading to a potential delay in the provision of services and assistance with activities of daily living (ADLs). Resident 5, who had diagnoses including difficulty walking, lack of coordination, and schizophrenia, was found with their call light placed inside a closed drawer of the nightstand. This was observed during a room check, and the Certified Nursing Assistant (CNA) confirmed that the call light should have been clipped to the bed. The Director of Nursing (DON) acknowledged that the call light being out of reach was inappropriate and not in line with the resident's care plan, which required the call light to be within reach due to the resident's risk for falls and fluctuating cognitive capacity. Resident 27, who had severe cognitive impairments and a history of falls, was found with their call light cord wrapped and hanging on the wall above the bed frame. This was observed during a room check, and the CNA confirmed that the call light should have been placed on the bed. The DON reiterated that the call light should be within reach unless otherwise specified in the resident's care plan, which was not the case for Resident 27. The care plan indicated the need for the call light to be within reach due to the resident's risk for falls and impaired mobility. Resident 15, who had severe cognitive impairments and required total assistance for ADLs, was found with their call light inside the nightstand drawer, out of reach. This was observed during a room check, and both the CNA and a Registered Nurse (RN) confirmed that the call light should be clipped to the bedside. The DON stated that it was not appropriate for the call light to be inside a drawer, as the resident would not be able to call for help or assistance. The facility's policy and procedure on call systems also indicated that call cords should be placed within the resident's reach.
Inaccurate MDS Documentation for Eating Ability
Penalty
Summary
The facility failed to ensure the assessment entries on the Minimum Data Set (MDS) related to eating were accurately documented for Resident 6. Resident 6, who was admitted with diagnoses including anorexia, legal blindness, and unspecified hearing loss, was assessed on the MDS as requiring substantial/maximal assistance with eating. However, observations and interviews revealed that Resident 6 was able to eat by herself with minimal assistance, such as being informed about the location of food on her plate and occasional encouragement to eat. This discrepancy between the MDS documentation and the actual ability of Resident 6 to eat independently was noted during an observation and confirmed through interviews with the Certified Nursing Assistant (CNA 6) and the Infection Control Nurse (IPN 2). Both staff members indicated that Resident 6 could feed herself despite her impairments. During a review of Resident 6's MDS with the Minimum Data Set Coordinator (MDSC), it was revealed that the MDS entry for eating was based on the weekly notes of licensed nurses, interviews, and documents from CNAs, as well as the MDSC's assessment. The MDSC acknowledged that the MDS should reflect the correct level of acuity and that Resident 6's eating ability should have been documented as requiring set-up or clean-up assistance rather than substantial/maximal assistance. The MDSC also admitted that they did not remember if they had assessed Resident 6's eating ability during the look-back period. The facility's policy on the Resident Assessment Instrument (RAI) process, which aims to provide accurate resident assessments, was not adhered to in this case, leading to the inaccurate documentation on the MDS for Resident 6.
Inaccurate PASRR Completion for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the preadmission screening assessment (PASRR) form was accurately completed for a resident with a mental illness. Resident 24, who had diagnoses including schizophrenia, was admitted and readmitted to the facility with a negative PASRR Level I screening. The PASRR forms dated 8/31/2023 and 1/29/2024 incorrectly indicated that Resident 24 did not have a serious diagnosed mental disorder or was prescribed psychotropic medications, despite medical records showing otherwise. This led to the resident not receiving the necessary psychiatric level of treatment and evaluation in the facility. Interviews with the Admission Coordinator (AC) and Minimum Data Set Coordinator (MDSC) revealed that the facility staff were responsible for submitting and verifying the PASRR forms. The AC admitted to incorrectly filling out the PASRR forms, failing to include Resident 24's diagnosis of schizophrenia and the use of psychotropic medications. The MDSC confirmed that Resident 24 had been diagnosed with schizophrenia and was on psychotropic medication at the time of readmission, and acknowledged that the PASRR should have been corrected within seven days. The Director of Nursing (DON) emphasized the importance of accurate PASRR completion to determine appropriate care and placement for residents. The facility's policy required a new PASRR upon readmission if there was a significant change in the resident's condition. However, the PASRR for Resident 24 was not updated accurately, leading to a deficiency in providing the necessary psychiatric care and evaluation for the resident.
Failure to Update Care Plan for Resident with Seizures
Penalty
Summary
The facility failed to review and revise the care plan for one of the residents who has a history of seizures. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, paroxysmal atrial fibrillation, and epilepsy. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and required substantial assistance with daily activities. Despite having a physician's order for multiple seizure medications, the resident's care plan did not reflect all current seizure medications, including Depakote, Levetiracetam, and Vimpat, after the discontinuation of Dilantin. During an interview, the Registered Nurse Supervisor (RNS) acknowledged that the care plan should have been updated to include all current seizure medications. The Director of Nursing (DON) also confirmed that all licensed staff are responsible for revising and updating care plans and that the resident's medication should have been revised when Dilantin was discontinued. The facility's policy indicated that care plans should be reviewed and revised based on assessed needs, new problems, changes in condition, and other appropriate times, which was not followed in this case.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that Resident 40 received all medications in accordance with the physician's order and the facility's policy and procedure. During a medication pass observation, Resident 40 was found in possession of three clear red capsules of Colace, a stool softener, which he had hidden in a zip lock bag. Resident 40 admitted to hiding the pills because he did not want to take too much and risk having diarrhea. This was confirmed by the Infection Prevention Nurse, who verified that the capsules in Resident 40's possession were indeed Colace capsules that he was supposed to take. The Medication Administration Record indicated that Resident 40 had been administered all 56 doses of Colace from 3/1/2024 to 3/27/2024, suggesting that the resident had been hiding the medication for some time. During an interview, the Director of Nursing stated that Licensed Vocational Nurses are required to observe residents taking their medications to ensure compliance. The failure to do so could lead to double dosing, missed medications, and potential adverse reactions. The facility's policy on medication administration mandates that medications must be given to the resident by the Licensed Nurse preparing the medication, and the nurse must chart the drug, time administered, and initial their name with each medication administration. The incident with Resident 40 highlights a lapse in this procedure, as the resident was able to hide the medication without the nurse's knowledge, potentially leading to an overdose or other harm.
Deficient Shower Chair Condition
Penalty
Summary
The facility failed to ensure that a shower chair used by residents was in good condition and free from stains. During an observation, a CNA was seen pushing a white shower chair with brown and yellowish stains and a ripped plastic woven backrest. The Registered Nurse Supervisor confirmed that the stains were old and the chair needed to be replaced, stating she would not want to sit on it if she were a resident. The Maintenance Supervisor was unaware of the chair's condition and agreed it should not be used. The Director of Nursing also acknowledged the poor condition of the chair and emphasized that CNAs should report old equipment to the charge nurse for replacement. The facility's policy, revised on 1/1/2012, indicated that residents should be provided with a safe, clean, comfortable, and homelike environment. The policy emphasized the importance of providing residents with a pleasant environment and person-centered care that focuses on their comfort, independence, and personal needs and preferences. The failure to maintain the shower chair in good condition was a deviation from this policy, potentially affecting the residents' dignity and self-worth.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to follow its policy to post nurse staffing information at the start of each shift. On 3/26/2024, the facility did not post the nurse staffing information for the current date and did not indicate the total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. This was confirmed during a general observation at the nurse's station and an interview with the Director of Staff Development (DSD), who admitted that the Nurse Staffing Information had not been updated since 3/24/2024. During a follow-up interview, the DSD revealed uncertainty about the required format for the Nurse Staffing Information sheets. The DSD stated that the staffing sheet was created by the previous DSD and had been copied and updated daily without verifying its accuracy or compliance with the facility's policy. A review of the facility's policy and procedure titled 'Nursing Department-Staffing, Scheduling & Postings' indicated that the facility should post the current date and the total number and actual hours worked by nursing staff per shift at the beginning of each shift, which was not adhered to in this instance.
Facility Failed to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that 12 out of 22 resident rooms met the required 80 square feet per resident in multiple resident bedrooms. During an observation of the facility and resident rooms, it was found that Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18 did not meet this requirement. Measurements of these rooms revealed that they ranged from 64.6 to 76.6 square feet per resident, which is below the mandated minimum. This deficiency was identified through a combination of observation, interviews, and record reviews conducted from March 26, 2024, to March 29, 2024. Despite the deficiency, residents in the affected rooms reported feeling comfortable and having enough space for their belongings and mobility aids such as wheelchairs and walkers. The facility's Client Accommodation Analysis Form confirmed the inadequate room sizes. However, observations indicated that the lack of space did not appear to affect the care and services provided to the residents. The Department recommended approval of a room waiver request for the 12 rooms in question.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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