Huntington Park Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington Park, California.
- Location
- 6425 Miles Avenue, Huntington Park, California 90255
- CMS Provider Number
- 056144
- Inspections on file
- 36
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Huntington Park Nursing Center during CMS and state inspections, most recent first.
A resident with DM, HTN, and CHF, who had intact cognition and required assistance with ADLs, was observed with a purple bruise over an inch in size on the upper arm, with no clear cause identified. The resident reported that staff had not applied any treatment and was unsure if nurses were aware of the bruise. The care plan and skin policy required daily body checks, CNA reporting of discolorations, and licensed nurse assessment, documentation, and MD notification for new skin changes. An LVN confirmed she had not been informed of the bruise, had not notified the MD, and that the expected assessment and follow-up for the bruise had not been completed.
A resident with chronic pain and a severe pressure ulcer did not receive prescribed Hydrocodone-Acetaminophen as needed because staff failed to reorder the controlled medication from the pharmacy at least seven days in advance, as required by facility policy. The resident reported pain and was informed by nursing staff that the medication was unavailable and had to be reordered, resulting in discomfort until the medication was delivered.
Surveyors identified that the facility did not maintain sanitary conditions in the kitchen, as the ice machine had visible buildup inside the gasket and a container of gelatin mix powder was not labeled with a use-by date or contents. The Dietary Supervisor and Maintenance Manager both acknowledged these lapses, which were not in accordance with facility policy.
A resident with cognitive and physical impairments was repeatedly observed in bed without access to their call light, despite care plans and facility policy requiring it to be within reach. Staff interviews confirmed the call light was moved during care and not returned, leaving the resident unable to call for assistance.
Three residents with significant immobility and risk for pressure ulcers were found lying on low air loss mattresses (LALMs) that were set at weights much higher than their actual body weights. Staff and the DON confirmed that the LALMs should have been set according to each resident's weight, as required by facility policy and the manufacturer's instructions. The incorrect settings resulted in mattresses that were too firm, potentially reducing the effectiveness of pressure redistribution for these residents.
A resident with severe cognitive impairment and hypertension was administered hydralazine 24 times outside of physician-ordered blood pressure hold parameters. Nursing staff failed to follow the specified guidelines, as confirmed by MAR review and staff interviews, resulting in medication being given when blood pressure readings indicated it should have been held.
Surveyors found that the facility did not follow infection prevention protocols for three residents, including improper reuse and handling of urinary catheter drainage bags, failure to change oral suction cannisters daily, and allowing catheter bags and tubing to touch the floor. These actions were inconsistent with facility policy and staff knowledge, and were confirmed through observation and staff interviews.
A resident with dementia, Alzheimer's disease, diabetes, and muscle weakness experienced a significant decline in mobility and increased dependency in ADLs, progressing from walking with assistance to requiring a wheelchair and mechanical lift. Despite these changes, there was no timely assessment or notification to the physician or responsible party, as confirmed by interviews with therapy and nursing staff, the responsible party, and the physician. Facility policy required such notifications, but documentation and communication were lacking.
Two residents with significant medical histories were inaccurately assessed in the MDS as having no oral or dental issues, despite both reporting problems with missing or broken dentures and difficulty chewing. Observations and interviews confirmed the discrepancies, and the MDS nurse acknowledged the coding errors, which did not reflect the residents' actual oral and dental conditions.
A resident who required maximal assistance with personal hygiene was repeatedly observed with long, dirty fingernails containing a yellow and brown substance. Staff interviews and photographic evidence confirmed the lack of proper nail care, despite facility policies and care plans requiring staff to maintain resident cleanliness and grooming.
A resident with dementia, Alzheimer's, diabetes, and muscle weakness experienced a significant decline in mobility and ADL function after PT and OT services were discontinued. Despite a physician's order for PT/OT evaluation and a wheelchair, nursing staff failed to assess the decline, notify therapy, or implement the order, resulting in delayed care and treatment.
A CNA transferred a resident with severe cognitive impairment and muscle weakness using an electric stand-up lift without the required second staff member, contrary to the resident's care plan and facility policy. Staff interviews and training records confirmed that two-person assistance was necessary for safe transfers, but the CNA performed the transfer alone.
A resident dependent on hemodialysis did not have a required dialysis emergency kit (e-kit) at the bedside, as confirmed by multiple observations and staff interviews. The resident's care plan and physician orders specified the need for an e-kit to manage bleeding risks, but the kit was not present or accessible, contrary to facility policy and standard practice.
A resident with cognitive and physical impairments was readmitted, but the attending physician did not complete a required comprehensive assessment or provide a current H&P as mandated by facility policy. The only available H&P was from a prior hospitalization, and staff confirmed that the physician did not see the resident or establish a new baseline after readmission.
A resident with multiple chronic conditions experienced ongoing left ear pain and hearing loss, and although an ENT consultation was ordered, facility staff did not follow up to ensure the consultation occurred. Interviews confirmed that neither nursing nor social services took action to arrange the specialist visit, resulting in unmet medical needs.
A resident with multiple medical conditions and intact decision-making capacity was not provided with meals that matched their documented food preferences, including a preference for boiled meats and a dislike of milk. Despite care plans and dietary orders specifying these preferences, the resident was repeatedly served grilled fish and a milk-based supplement, and was not offered appropriate substitutes or snacks. Staff and dietary supervisor interviews confirmed that the resident's preferences were not honored, in violation of facility policy.
A resident with ESRD, spina bifida, and neurogenic bladder was not consistently provided the prescribed renal diet, receiving incorrect menu items including Italian crusted fish and double protein portions instead of the required baked fish. The dietary supervisor confirmed the error, and the DON acknowledged the importance of adhering to therapeutic diets for residents with kidney failure.
Three residents were found with perishable food items, such as opened ranch dressing, lemonade, and jalapenos, at their bedsides that were not labeled with names or dates and were not refrigerated as required. Staff did not ensure these items were properly stored or labeled, despite facility policy and manufacturer instructions indicating the need for refrigeration after opening.
A resident with dementia, Alzheimer's disease, diabetes, and muscle weakness experienced a significant decline in mobility and self-care abilities. Although a physician's order was written for PT/OT evaluation and a wheelchair, the order was not communicated to or carried out by the therapy department. Nursing and therapy staff were unaware of the order, resulting in delayed treatment and services for the resident.
A resident's personal wheelchair was not documented in the facility's inventory list, contrary to policy. Despite the resident's capacity to make decisions and the presence of identifying information on the wheelchair, staff interviews revealed that the inventory list was not updated to include the wheelchair, nor was it signed by the resident or their representative. This oversight had the potential to result in the wheelchair being lost or stolen.
A resident with a high fall risk experienced three falls over five months due to the facility's failure to implement a comprehensive, resident-centered care plan. Despite the resident's history of falls and muscle weakness, the care plan lacked necessary monitoring and supervision. The facility's policy emphasized individualized care plans and supervision for high-risk residents, but these were not effectively implemented.
The facility failed to ensure call lights were within reach for five residents, including those with muscle weakness, Alzheimer's disease, and hemiplegia. Observations revealed call lights on the floor or under pillows, leaving residents unable to call for assistance. Staff confirmed that call lights should be within reach to prevent delays in care and reduce fall risks.
The facility failed to provide treatments and services to prevent a decline in ROM and mobility for two residents. One resident did not receive a recommended knee splint or restorative nursing services, leading to decreased mobility and ROM. Another resident missed multiple days of scheduled ambulation exercises, risking functional decline.
A resident received lorazepam for behaviors not indicated in the care plan, with CNA observations improperly used for clinical justification and no documented risk-benefit analysis from the physician for continued use beyond 14 days.
The facility failed to remove expired Ozempic for a resident and did not properly store medications for two discharged residents. The expired medication was used beyond its recommended period, and the medications for discharged residents were mixed with current residents' medications, creating a potential for errors and drug diversion.
The facility failed to label and date food items in the kitchen and dry storage room, including milk, juice, cooked beans, apple sauce, margarine, sausages, rice, and dry beans. Cook 1 admitted to not knowing the preparation dates and acknowledged the importance of labeling for safety. The Dietary Staff Manager confirmed the requirement for labeling to prevent cross-contamination and ensure food safety.
The facility failed to implement enhanced barrier precautions (EBPs) for 16 residents, increasing the risk of MDRO transmission. Observations revealed no EBP signage or PPE outside the rooms of residents with conditions requiring EBP, such as wounds and indwelling medical devices. The Infection Preventionist Nurse confirmed that EBP was not being implemented, despite the facility's policy requiring it.
The facility failed to offer advance directives to a resident with severe cognitive impairment and multiple diagnoses, as required by their policy. This oversight was confirmed through interviews and record reviews, revealing a lack of documentation in the resident's chart.
The facility failed to ensure that two residents' beds were not positioned against the wall, restricting their ability to get out of bed freely and increasing the risk of entrapment and injury. Both residents had cognitive impairments and required assistance for repositioning, but there was no documented preference or care plan for the bed positioning. The DON confirmed that this practice posed a high risk for entrapment and was considered a restraint.
The facility failed to develop and implement an individualized care plan for a resident with decreased mobility and ROM limitations in the right leg. Despite the resident's diagnoses and MDS indicating functional limitations, no care plan was created to address these needs, resulting in the resident not receiving necessary interventions such as physical therapy or leg exercises.
The facility failed to accurately monitor and record the total amount of calories received via enteral feeding for a resident with dementia, gastrostomy, and dysphagia. Discrepancies in the administration and recording of the enteral feeding led to the resident not receiving the prescribed amount of nutrition, as confirmed by observations, interviews, and record reviews.
A resident with GERD and chronic gastritis was served food containing bell peppers despite having informed the Dietary Staff Manager to avoid such ingredients. The dietary staff failed to accurately document and honor the resident's food preferences, leading to potential digestive discomfort.
A resident with significant ADL and functional mobility concerns was discharged from OT services due to the end of insurance coverage, despite continued need for skilled therapy. The facility failed to explore alternative means to continue therapy, leading to a deficiency in care.
A resident with stage renal disease and dependence on renal dialysis signed an arbitration agreement in English, despite only understanding Spanish. The facility's policy required that such agreements be presented in a language the resident understands, but this was not followed, leading to a potential waiver of the resident's right to a jury trial without his knowledge.
A resident did not receive privacy during a wound care procedure, as the curtains were not completely closed, exposing the procedure to staff and visitors. The resident expressed discomfort, and facility staff acknowledged the importance of providing privacy to maintain dignity.
The facility failed to revise the care plan for a resident with osteoporosis, who required substantial assistance with ADLs and transfers. The care plan lacked specific safety interventions, leading to an incident where a CNA moved the resident's knee too hard, causing pain and the need for a splint. Staff confirmed that the care plan should have included measures to prevent injuries.
A facility failed to ensure an accurate assessment of a resident's lower extremities, leading to inconsistent documentation and potential improper interventions. The resident had fractures in both femurs and osteoporosis, and the assessments varied, with some indicating impairments and others not. The DON confirmed the inaccuracies, emphasizing the importance of correct evaluations for proper care planning.
Failure to Notify MD of New Bruising and Skin Change
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident who was observed with a purple skin discoloration on the right upper arm. During an observation and interview in the resident’s room, the discoloration measured more than an inch, and the resident reported not knowing the cause, speculating it might have occurred when going to the bathroom. The resident stated she was unsure if nursing staff were aware of the bruise and that nothing had been applied to it. Review of her records showed she had diagnoses of diabetes mellitus, hypertension, and congestive heart failure, had intact cognition and decision-making capacity, and required assistance with ADLs including dressing, toileting, personal hygiene, transfer, and mobility. The resident’s care plan for potential skin breakdown, related to thin fragile skin, directed staff to perform daily body checks and to monitor, document, and report to the physician any changes in skin status, including bruises or discolorations, and to notify the nurse of new areas of skin breakdown noted during care. In an interview, an LVN stated she had not been informed of the resident’s arm bruise and confirmed the physician had not been notified. The LVN also stated the bruise should have been assessed for size, redness, hardness, and possible blood thinner use, and the cause should have been identified. Facility policy on Skin and Wound Monitoring and Management required licensed nurses to assess and document skin issues and obtain and implement treatment orders as appropriate, and required CNAs to report skin discolorations to licensed nurses, but this process did not occur for the resident’s arm bruise.
Failure to Timely Reorder Pain Medication Resulting in Resident Discomfort
Penalty
Summary
The facility failed to ensure that a resident's pain medication, Hydrocodone-Acetaminophen, was reordered from the pharmacy at least seven days in advance, as required by the facility's policy and procedure for medication ordering and receiving. The resident, who had chronic pain, a stage 4 pressure ulcer, and acute osteomyelitis, was admitted with intact cognition and required substantial assistance with activities of daily living. The physician's order specified the use of Hydrocodone-Acetaminophen for moderate to severe pain. On the day in question, the authorization form for the pain medication refill was faxed to the resident's physician, but the physician was unavailable to sign until several days later. The refill authorization was eventually received and sent to the pharmacy, but the medication was not delivered or available for administration on the day the resident requested it. The Medication Administration Record confirmed that the resident did not receive the pain medication on that day. Interviews with the resident and nursing staff confirmed that the resident experienced pain and was informed by staff that the medication was unavailable and needed to be reordered. Staff acknowledged the importance of timely medication ordering and the negative impact of pain on the resident's well-being. The facility's policy required controlled substances to be reordered at least seven days in advance, but this was not followed, resulting in the resident being without necessary pain medication.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices for all residents. Specifically, the inside gasket of the kitchen ice machine was found to have yellow and white buildup, which the Dietary Supervisor acknowledged as water residue that should not be present and could cause contamination. The Maintenance Manager confirmed responsibility for cleaning the inside of the ice machine and stated that the buildup was not supposed to be there, indicating a lapse in regular cleaning and maintenance as required by facility policy. Additionally, a container of gelatin mix powder in the kitchen's dry storage room was found without a use-by date or content label. The Dietary Supervisor confirmed that the container should have been labeled with both the received and use-by dates, and acknowledged that the expiration date was not visible. This failure to properly label food items was contrary to the facility's policy and could result in the use of expired or unidentified food products.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
Staff failed to ensure that a resident's call light was within reach, as required by the resident's care plans and facility policy. The resident, who had diagnoses including cognitive communication deficit, generalized muscle weakness, and dementia, was assessed as having moderately impaired cognition and required moderate to total assistance with daily activities such as hygiene, toileting, and dressing. Multiple care plans for the resident specifically directed staff to keep the call light within reach to minimize fall risk, support communication, and anticipate needs. During several observations, the resident was found lying in bed with the call light either hanging behind the bed or clipped to an overhead light, both out of the resident's reach. Staff interviews confirmed that the call light was not accessible and that it had been moved during care and not returned to the resident's reach. Staff acknowledged that the resident would be unable to call for assistance in this situation. Facility policy also required staff to ensure call lights were within reach and secured as needed.
Failure to Set Low Air Loss Mattresses to Resident Weight
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs) for three of four sampled residents were set according to each resident's actual weight, as required by both facility policy and the manufacturer's instructions. Observations and interviews revealed that the LALMs for these residents were set at weights significantly higher than the residents' actual weights, resulting in mattresses that were too firm. This practice was confirmed by both the treatment nurse and the director of nursing, who acknowledged that the mattresses should be set to match the resident's weight to provide appropriate pressure redistribution. One resident, with a history of hemiplegia, hemiparesis, respiratory failure, and dementia, was observed on a LALM set at 350 lbs despite weighing only 123 lbs. Another resident, who had hemiplegia, hemiparesis, and a stage four pressure ulcer, was also found on a LALM set at 350 lbs while weighing 159 lbs. A third resident, diagnosed with quadriplegia and diabetes, was observed on a LALM set at 230 lbs, though his weight was 156-157 lbs. In each case, staff confirmed that the LALM settings were incorrect and not in accordance with the residents' actual weights. The facility's own policy and the LALM manufacturer's manual both require that the mattress pressure be adjusted based on the patient's weight to prevent skin breakdown and pressure ulcers. Staff interviews indicated awareness of the importance of correct LALM settings, yet the deficiency persisted across multiple residents. The incorrect settings had the potential to compromise the effectiveness of the pressure redistribution, as noted by the staff and the director of nursing during interviews.
Failure to Follow Hold Parameters for Antihypertensive Medication
Penalty
Summary
Licensed nursing staff failed to administer hydralazine according to the physician-ordered hold parameters for a resident with a history of hemiplegia, hemiparesis, and essential hypertension. The resident was cognitively impaired and dependent on staff for all activities of daily living. The medication order specified that hydralazine should be held if the systolic blood pressure was less than 110 mm Hg or the diastolic blood pressure was less than 60 mm Hg. Despite these clear instructions, the medication was administered 24 times over a period of approximately five weeks when the resident's blood pressure readings met the criteria for holding the medication. The MAR and interviews confirmed that the licensed nurse was responsible for following the hold parameters but did not do so, resulting in the resident receiving hydralazine outside of the prescribed safety limits. The DON acknowledged that the failure to follow hold parameters put the resident at risk. Facility policy required medications to be administered in accordance with physician orders, but this was not followed in the case of this resident.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for three residents, resulting in multiple deficiencies related to the handling of urinary catheters and oral suction equipment. For one resident with an indwelling urinary catheter, the drainage bag and tubing were repeatedly disconnected and reconnected between a bedside drainage bag and a leg bag. The tubing tip was left uncapped and exposed to air or tucked inside a dignity bag, and the same drainage bag was reused daily for up to a month. Staff interviews confirmed awareness of this practice, which was inconsistent with facility policy requiring a new drainage bag and tubing whenever the closed system is compromised. Another resident, who was dependent on staff for all care and required frequent oral suctioning, had a suction cannister at the bedside that was not changed daily. The cannister, containing oral secretions, was observed to have been in use for over a week, with staff confirming that the cannister and tubing should be disposed of daily. The facility did not have a policy specifying the required frequency for changing suction equipment, but staff and the infection preventionist stated that best practice was to change it every 24 hours to prevent bacterial growth. A third resident with a chronic indwelling urinary catheter was observed multiple times with the catheter bag and tubing touching the floor. The infection preventionist confirmed that the bag and tubing should be kept off the floor to prevent contamination, and the facility's policy also required this. Despite these requirements, the issue persisted over several observations, and staff acknowledged responsibility for ensuring the catheter bag was properly positioned.
Failure to Notify Physician and Responsible Party of Resident's Decline in Mobility and ADLs
Penalty
Summary
The facility failed to promptly notify the physician and responsible party of a significant change in condition for a resident who experienced a decline in mobility and increased dependency in activities of daily living (ADLs). The resident, who had diagnoses including dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness, was initially able to walk independently or with a walker and required only moderate assistance with ADLs. Over time, the resident became increasingly dependent, eventually requiring a wheelchair and mechanical lift for transfers, and was no longer able to stand or walk. Despite this notable decline, there was no documented evidence in the electronic medical record of a timely assessment or physician notification regarding the resident's change in condition. Interviews with therapy staff, nursing staff, and the responsible party confirmed that the decline was observed but not communicated to the physician or responsible party as required. The responsible party reported noticing the resident spending more time in bed and sleeping more, but stated that these changes were not discussed with him by the facility. Therapy staff were also unaware of the resident's current status and had not been referred for reassessment. The facility's policy required documentation of assessment findings and prompt notification of the physician and responsible party in the event of a change in condition. However, both the MDS nurse and DON confirmed that the significant decline in the resident's functional status was not properly assessed or communicated, and the physician stated he was not aware of the change. This lack of timely notification and assessment constituted the deficiency identified by surveyors.
Inaccurate MDS Coding of Oral/Dental Status for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected their oral and dental status. For one resident with diagnoses including Parkinson's disease, dementia, diabetes mellitus, and dysphagia, the MDS indicated no oral or dental issues, despite the resident stating difficulty chewing due to lack of natural teeth and broken dentures. Observation confirmed the resident was eating breakfast and expressed these concerns directly. The MDS nurse acknowledged that the MDS was incorrectly coded and did not reflect the resident's actual oral and dental condition. Similarly, another resident with dementia, diabetes mellitus, dysphagia, and muscle weakness was assessed in the MDS as having no oral or dental issues. However, during observation and interview, the resident reported having no natural teeth and experiencing difficulty chewing due to loose dentures. The MDS nurse confirmed that this resident's MDS was also inaccurately coded, failing to represent the true oral and dental status. The facility's policy required the interdisciplinary team to ensure MDS accuracy, but this process was not followed in these cases.
Failure to Maintain Resident Nail Hygiene and Personal Grooming
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for one resident by not ensuring the resident's fingernails were kept clean and neat. Multiple observations over three consecutive days revealed that the resident's fingernails were long and had a yellow and brown substance underneath. Interviews with staff, including a CNA and the Infection Preventionist Nurse, confirmed that the resident's fingernails were dirty and required cleaning, and that it was the responsibility of the nursing staff to ensure residents' fingernails were clean as part of infection control and personal hygiene. The resident involved had a history of ulcerative colitis and dementia, was dependent on staff for most activities of daily living, and required maximal assistance with personal hygiene. The resident's care plan included a goal to keep the resident clean, dry, and well-groomed. Facility policy and the CNA job description both specified that nail care was part of routine hygiene responsibilities. Despite these requirements, the resident's fingernails remained unclean over several days, as documented by both direct observation and photographic evidence.
Failure to Implement Timely PT/OT Orders for Resident with Declining Mobility
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for physical therapy (PT) and occupational therapy (OT) services in a timely manner for a resident with a history of dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness. The resident was initially admitted with the ability to walk independently or with a walker and received PT and OT services upon admission. These therapy services were discontinued after the resident achieved maximum potential, and the resident was discharged from therapy with an order for the Restorative Nursing Assistance (RNA) program. However, as the resident's mobility declined over several months, no further referrals for PT or OT were made, and the RNA program was not re-initiated for PT. Despite a significant decline in the resident's mobility and increased dependency in activities of daily living (ADLs), there was no documented assessment or intervention by nursing staff. The resident's responsible party reported noticing the decline and requested more therapy, but therapy services were not resumed. Nursing progress notes and physician orders did not reflect any assessment or action regarding the resident's mobility decline, and there was no evidence that the physician's order for a PT/OT evaluation and wheelchair was communicated to or carried out by the therapy department. Multiple staff interviews confirmed that the order for PT/OT evaluation, written and signed by the physician, was overlooked and not implemented. The PT and OT staff were unaware of the order and the resident's current functional status until the issue was brought to their attention during the survey. The facility's policies and job descriptions required that physician orders be carried out promptly and that referrals to therapy be made as needed, but these procedures were not followed, resulting in delayed care and treatment for the resident.
Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) transferred a resident using an electric stand-up lift without the required assistance of a second staff member. The CNA entered the resident's room alone and used the lift to transfer the resident from a wheelchair to the bed, despite facility policy and the resident's care plan both specifying that a two-person assist was necessary for such transfers. The resident involved had multiple sclerosis, generalized muscle weakness, and severely impaired cognition, and was assessed as needing maximal assistance with transfers and mobility. Interviews with facility staff, including the CNA, Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that two staff members were required to safely operate the electric stand-up lift. The CNA acknowledged being alone during the transfer and stated awareness of the two-person requirement. Facility training records showed the CNA had received in-service education on proper transfer procedures, which included the need for assistance from another staff member. The facility's policy emphasized the resident's right to a safe environment, including safe support for daily living activities.
Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to provide a dialysis emergency kit (e-kit) at the bedside for a resident who required hemodialysis. The resident, admitted with chronic kidney disease requiring hemodialysis, anemia, and hypertension, had physician orders for hemodialysis three times a week and a care plan identifying a high risk for bleeding. The care plan specifically required that an e-kit be available at all times to manage potential bleeding events. Multiple observations on different occasions confirmed that there was no e-kit present in the resident's room, either pinned to the wall, on the nightstand, or inside the bedside drawer. The resident also confirmed not having seen an e-kit in the room. Interviews with staff, including an LVN and the DON, confirmed that the e-kit should always be at the resident's bedside and checked daily to ensure it is stocked. The facility's policy required ongoing assessment and oversight for residents receiving hemodialysis, including monitoring for complications and implementing appropriate interventions. Despite these requirements, the absence of the e-kit at the bedside represented a failure to follow the care plan and facility policy for providing safe and appropriate dialysis care.
Physician Failed to Complete Required Assessment After Resident Readmission
Penalty
Summary
The facility failed to ensure that a resident's attending physician conducted an initial comprehensive assessment following the resident's readmission. Specifically, after being readmitted, the resident—who had diagnoses including cognitive communication deficit, generalized muscle weakness, and dementia—did not have a History and Physical (H&P) completed by the attending physician within the required timeframe. The only H&P available in the resident's record was from a prior hospitalization, and there was no documentation of a new, facility-based assessment after readmission. Interviews with the Medical Records Director and the Director of Nursing confirmed that the physician did not provide a current H&P after the resident's return, as required by facility policy. The Director of Nursing stated that the physician is supposed to physically see the resident and complete a comprehensive assessment to establish a baseline for care. The absence of this assessment delayed the establishment of the resident's current health status, which is essential for guiding care and services.
Failure to Follow Up on ENT Consultation Order
Penalty
Summary
The facility failed to follow up on a physician's order for an Ear, Nose, and Throat (ENT) consultation for a resident who was experiencing left ear pain and hearing loss. The resident, who had multiple diagnoses including end stage renal disease, anemia, hypertension, diabetes mellitus, and peripheral vascular disease, reported ongoing left ear pain and difficulty hearing for over a month. Despite a documented order for an ENT consultation and treatment for the resident's left ear pain, there was no evidence in the medical record that the consultation was scheduled or followed up by nursing staff, social services, or administration. Interviews with the resident, Social Services Director, and Director of Nursing confirmed that no follow-up calls or actions were taken to ensure the ENT consultation occurred after it was ordered. The Social Services Director acknowledged that no contact had been made with the ENT provider, and the Director of Nursing stated that the resident's needs were not being met due to the lack of follow-up. The facility's social worker job description indicated responsibilities for communication and intervention, but these were not fulfilled in this case.
Failure to Honor Resident Food Preferences and Provide Alternatives
Penalty
Summary
The facility failed to honor a resident's food preferences and provide appropriate meal alternatives as required by the resident's care plan and dietary orders. The resident, who had diagnoses including dementia, diabetes mellitus, dysphagia, and muscle weakness, was cognitively intact and able to make decisions regarding their care. Documentation indicated that the resident should be offered choices for snacks and that staff should honor food and fluid preferences. However, the resident reported not liking the meals provided, specifically grilled chicken and fish, and stated that no substitutes or snacks were offered. The resident also expressed a dislike for milk, which was not accommodated. Observations confirmed that the resident was served grilled fish and Ensure, despite the diet ticket specifying a preference for boiled meats and a dislike of milk. Staff interviews revealed that while there was a process for requesting meal substitutes, boiled beef was not offered as an option. The Dietary Supervisor acknowledged that the meal provided did not align with the resident's documented preferences and that the facility's policy required satisfaction of resident tastes and provision of food substitutions. This failure to provide preferred foods and alternatives was directly observed and confirmed through interviews and record reviews.
Failure to Provide Prescribed Renal Diet to Resident with ESRD
Penalty
Summary
The facility failed to follow the prescribed renal diet for a resident diagnosed with end stage renal disease (ESRD), spina bifida, and neurogenic bladder. The resident was admitted with orders for a renal diet, regular texture, and thin consistency fluids, as documented in the medical record and care plan. Despite these orders, the resident reported occasionally receiving incorrect menu items during mealtimes. On one observed occasion, the resident was served Italian crusted fish instead of the baked fish specified for the renal diet, and received a double portion of protein per his request. The dietary supervisor confirmed that the Italian crusted fish was not appropriate for the renal diet and that the resident should have received baked fish with simple seasonings. The dietary supervisor acknowledged responsibility for checking plates before food carts left the kitchen and before nursing staff distributed meals, but failed to ensure the correct meal was served. The director of nursing confirmed that not following the therapeutic diet could negatively impact the resident's health, especially given the resident's ESRD and need for dialysis. The facility's policy required all special diets to be prepared and served as planned, but this was not followed in the resident's case.
Failure to Label and Properly Store Perishable Food Brought by Visitors
Penalty
Summary
The facility failed to follow its policy and procedure regarding the labeling and storage of food items brought in by family or visitors for three residents. In each case, perishable food items that required refrigeration after opening were found at the residents' bedsides, unlabeled and undated, and not stored in a refrigerator as required by the manufacturer's instructions and facility policy. Staff did not ensure that these food items were properly labeled with the resident's name and date, nor did they offer to store the items in a refrigerator. One resident with diabetes mellitus and end stage renal disease was observed with an opened, unlabeled bottle of ranch dressing at the bedside, which indicated it should be refrigerated after opening. The resident stated that staff did not offer to store the bottle in the refrigerator and could not recall when it was opened. Another resident with dementia and diabetes had two bottles of lemonade at the bedside, both labeled to be kept refrigerated, but neither was labeled with the resident's name or date. The resident and a CNA were unaware of how long the lemonade had been at the bedside. A third resident with diabetes and a local skin infection had an opened, unlabeled, and undated jar of jalapenos at the bedside. The resident reported receiving the jar the previous day, and staff confirmed that there was no labeling or dating on the item. The facility's dietary supervisor and infection preventionist both acknowledged that the facility did not have a refrigerator for residents' food items and that perishable foods should be consumed immediately or discarded. However, staff did not ensure compliance with these procedures, resulting in the presence of potentially perishable and improperly stored food items in resident rooms.
Failure to Implement Physician Order for PT/OT Evaluation and Wheelchair
Penalty
Summary
The facility failed to ensure that a physician's order for physical therapy (PT) and occupational therapy (OT) evaluation, as well as a wheelchair, was carried out for a resident with significant mobility and self-care deficits. The resident, who had diagnoses including dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness, was initially able to ambulate with a walker and perform some activities of daily living (ADLs) with moderate assistance. Over several months, the resident experienced a decline in mobility, becoming increasingly bedbound and eventually requiring a wheelchair and mechanical lift for transfers. Despite a physician's order dated 10/23/2024 for PT/OT evaluation and a wheelchair, there was no documented evidence that the order was communicated to or carried out by the therapy department. Interviews with therapy staff revealed they were unaware of the order and had not reassessed the resident after the initial therapy discharge. Nursing staff also confirmed that the order was not implemented or communicated, and the resident's decline in function was not addressed with appropriate therapy referrals or interventions. The facility's own policies and job descriptions required that physician orders be carried out promptly and that referrals to other departments, such as therapy, be completed as needed. However, the failure to implement the physician's order resulted in delayed treatment and services for the resident, as confirmed by multiple staff interviews and record reviews.
Failure to Account for Resident's Personal Wheelchair
Penalty
Summary
The facility failed to ensure that a resident's personal wheelchair was accounted for in the resident's inventory list, as required by the facility's policy and procedure. The resident, who was admitted with a diagnosis of hemiplegia following a stroke, had the capacity to understand and make decisions. During an observation, the resident's identifying information was found on a tag attached to the wheelchair, confirming it as the resident's personal property. However, the inventory list did not reflect the presence of the wheelchair, and it lacked the necessary signature from the resident or their representative. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Rehabilitation, revealed that the inventory list should have been updated to include the wheelchair. The facility's policy indicated that all durable medical equipment must be listed and signed for, but this was not done. The Social Services Director confirmed that the inventory list should have been updated when the resident received the wheelchair, as indicated by a Standard Written Order. The failure to update the inventory list had the potential to result in the wheelchair being lost or stolen, as it was not documented as the resident's property within the facility.
Failure to Implement Comprehensive Fall Prevention Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who was admitted with a high risk for falls. The resident experienced three falls over a five-month period, which were not adequately addressed in the care plan. The initial care plan included interventions such as assessing toileting needs, encouraging the use of a call light, and providing non-skid footwear, but did not include continuous monitoring or supervision, which was crucial given the resident's condition. The resident's history included falls, muscle weakness, impaired gait, and forgetfulness of limitations, indicating a high fall risk. Despite these risk factors, the care plan was not updated to include necessary monitoring or supervision after the first fall, which resulted in a bump and abrasion on the head. The interdisciplinary team recommended continued use of non-skid footwear and reminders to use the call light, but these measures were insufficient to prevent further falls. Subsequent falls occurred at an outside clinic and within the facility, with the resident attempting to ambulate without assistance. The facility's policy on fall prevention emphasized the need for individualized care plans and supervision for high-risk residents, but these were not implemented effectively. Interviews with staff revealed that the care plan lacked interventions for monitoring, and the Director of Nursing acknowledged that continuous monitoring might not have been considered necessary, despite the resident's high fall risk.
Call Lights Not Within Reach for Multiple Residents
Penalty
Summary
The facility did not ensure that the call lights were within reach for five residents, increasing the risk of residents being unable to call for staff assistance or express their needs. Resident 27, who was admitted with generalized muscle weakness and osteoarthritis, was observed multiple times with the call light on the floor, out of reach. Despite calling out for help, no staff were present to assist. CNA 1 confirmed that the call light should have been within reach to prevent the resident from attempting to get up unassisted and potentially falling. Resident 70, admitted with generalized muscle weakness and difficulty walking, was also found with the call light on the floor, out of reach. Similarly, Resident 7, who has muscle weakness and spina bifida, was observed with the call light under the pillow and later on the floor, unable to call for assistance. Resident 7 was calling for help and asking for water but could not locate the call light. Resident 9, diagnosed with Alzheimer's disease and other conditions, was observed with the call light under the bed and out of reach on two separate occasions. LVN 1 confirmed that the call lights should be within reach to prevent delays in resident care and reduce the risk of falls. Resident 79, with hemiplegia and a history of falls, was found in a wheelchair leaning to one side and unable to reach the call light. The Infection Preventionist Nurse confirmed that the call light should have been within reach. The Director of Nursing reiterated that call lights should always be within reach to ensure resident safety.
Failure to Provide ROM and Mobility Services
Penalty
Summary
The facility failed to provide treatments and services to prevent and/or limit a decline in range of motion (ROM) and mobility for two residents with identified concerns. For Resident 78, the facility did not provide a right knee extension splint as recommended by Physical Therapy (PT) and did not implement a Restorative Nursing Program (RNP) to maintain mobility and ROM after discharge from PT services. This led to a decline in Resident 78's mobility and left knee ROM, with the resident experiencing stiffness and an inability to straighten both knees. The Director of Rehabilitation (DOR) confirmed that there was no monitoring system in place to detect changes in a resident's ROM and mobility, and the rehabilitation department was unaware of Resident 78's functional decline because they were not notified by nursing staff. For Resident 29, the facility failed to implement the RNP for ambulation five times a week as recommended by PT upon discharge from PT services. The RNA Documentation Survey Reports for February, March, and April 2024 indicated multiple days where Resident 29 did not receive the scheduled RNA services. The Director of Staff Development (DSD) confirmed that Resident 29 missed several days of scheduled RNA services and stated that missed sessions could place residents at risk for a functional decline. The Director of Nursing (DON) acknowledged that the purpose of the RNA program was to maintain a resident's current level of function and that missed RNA treatments could potentially cause a decline in overall function, mobility, and ROM. The facility's policies and procedures indicated that assistive devices and RNA services should be provided to maintain or improve a resident's abilities. However, the facility did not have policies and procedures specifically for maintaining a resident's ROM and mobility and contracture management. The lack of adherence to PT recommendations and the failure to implement RNA services as established led to the decline in physical functioning and quality of life for Residents 78 and 29.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary psychotropic medications. Lorazepam was administered to the resident for behaviors not indicated in the physician order or care plan. The resident's care plan specified that lorazepam should be administered for repetitive motions, but the resident did not exhibit this behavior during the months reviewed. Despite this, the resident received lorazepam multiple times over several months without the appropriate behavioral indications being documented. Certified Nursing Assistant (CNA) observations were improperly used for clinical justification in determining whether to attempt a gradual dose reduction (GDR) for the resident's lorazepam order. The facility's Director of Nursing (DON) confirmed that CNA observations should not be used for clinical justification, as it is outside their scope of practice. The Psychotropic Behavior Summary GDR Form used to review the resident's lorazepam orders included general mood/behavior episodes without specifying the behaviors relevant to the medication's administration. The resident's attending physician did not document the risk-benefit analysis for the continued administration of lorazepam beyond the federal guideline of 14 days. The facility's policy requires that PRN psychotropic drug orders be limited to 14 days unless accompanied by supporting documentation from the prescribing practitioner. The physician's progress notes lacked this necessary documentation, leading to the continued use of lorazepam without proper justification.
Failure to Properly Manage and Store Medications
Penalty
Summary
The facility failed to ensure expired Ozempic was removed and discarded for one resident. Resident 51, who had Type 2 diabetes mellitus and chronic kidney disease, had an Ozempic pen that was used beyond its 56-day expiration period. The medication was last administered on a date that exceeded the manufacturer's recommended usage period, and the Licensed Vocational Nurse (LVN) acknowledged that the medication should have been discarded and reordered. The Director of Nursing (DON) was unaware of the specific expiration guidelines for Ozempic, and the facility's policy indicated that outdated medications should be immediately removed and disposed of properly. The facility also failed to remove and securely store medications for two residents who were discharged. Medications for Resident 55 and Resident 88 were found mixed with current residents' medications in the Middle Station Medication Cart. Resident 55 had been transferred to a hospital and was on bedhold, while Resident 88 had been discharged from the facility. The LVN stated that there were no markings on the medication packs to indicate the residents were transferred, and she was not instructed on how to store bedhold medications. The DON confirmed that the medications should have been removed from the cart and stored in a designated location in the medication room. The facility's policy on discontinued medications indicated that medications should be marked as discontinued and destroyed when a resident is transferred or discharged. However, the facility did not have a specific policy for handling bedhold medications. The DON stated that controlled medications should be given to the DON as soon as possible when orders are changed or residents are discharged. The failure to properly store and manage medications for discharged residents created a potential for medication errors and drug diversion.
Failure to Label and Date Food Items in Kitchen and Storage
Penalty
Summary
The facility failed to ensure all food items stored in the kitchen and dry food storage room were labeled and dated, and did not follow safe food preparation practices. During an initial tour of the kitchen, surveyors observed multiple food items in the refrigerator, including glasses of milk and juice, containers of cooked beans and apple sauce, and cartons of milk, all without dates. Additionally, a large box of margarine and bags of uncooked sausages were found without dates. On the kitchen table, containers of previously cooked rice were also undated, and in the dry storage room, a container of dry uncooked beans was found unlabeled and undated. During an interview, Cook 1 admitted to not knowing when the undated food items were prepared and acknowledged the importance of labeling and dating food for safety and quality. Cook 1 mentioned that the margarine and sausages were delivered the previous week but were not labeled due to being busy. The Dietary Staff Manager confirmed that all foods should be labeled and dated to prevent cross-contamination and ensure food safety. The facility's policy on food safety in receiving and storage requires food containers to be labeled with the contents and the date they were transferred to the container.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for 16 residents, increasing the risk of transmission of multidrug-resistant organisms (MDROs). Observations revealed that there was no signage indicating EBP, and no personal protective equipment (PPE) was available outside or near the rooms of the affected residents. This was noted for residents with various conditions, including cellulitis, pressure ulcers, surgical incisions, end-stage renal disease, and dependence on renal dialysis, among others. These residents had wounds, indwelling medical devices, or were receiving treatments that required EBP according to the facility's policy and procedure (P&P) dated March 2023. For instance, Resident 59 had a Stage II pressure ulcer and cellulitis but did not have orders for EBP, and no PPE was observed outside their room. Similarly, Resident 70, who had a surgical incision on the left foot, also lacked EBP orders and PPE outside their room. Resident 94, with end-stage renal disease and extended spectrum beta-lactamase resistance, was observed without EBP signage or PPE outside their room. These observations were consistent across multiple dates and times, indicating a systemic issue in the facility's infection control practices. The Infection Preventionist Nurse (IPN) confirmed that EBP was not being implemented for any facility residents, despite the facility's P&P requiring it for residents with wounds and indwelling medical devices. The IPN acknowledged that the lack of EBP could increase the risk of infection within the facility. The facility's P&P clearly stated that PPE should be available immediately near or outside the resident's room and that orders for EBP should be obtained for residents with specific conditions, which was not adhered to in these cases.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to offer advance directives to Resident 44, who was admitted with diagnoses including metabolic encephalopathy and dementia. A review of Resident 44's records indicated severe cognitive impairment and a complete dependence on assistance for daily activities. Despite these conditions, there was no documentation in the resident's electronic medical record indicating that advance directives were offered or acknowledged. Interviews with the Social Services Director and the Administrator confirmed that the process of offering advance directives and documenting them was not followed in this case. The facility's policy and procedure, dated November 2016, required informing new residents of their right to establish an advance directive and having them or their responsible party sign an acknowledgment form. However, this procedure was not adhered to for Resident 44, as evidenced by the lack of documentation in the resident's chart. This oversight had the potential to cause conflict with Resident 44's healthcare wishes, as the resident's severe cognitive impairment necessitated clear documentation of their healthcare preferences.
Improper Bed Positioning Leading to Entrapment Risk
Penalty
Summary
The facility failed to ensure that two residents' beds were not positioned against the wall, which restricted their ability to get out of bed freely and increased the risk of entrapment and injury. Resident 37, who had severe cognitive impairment and required maximal assistance for repositioning, was observed with her bed against the wall without any documented preference or care plan indicating this arrangement. The resident's family member confirmed that the bed had been against the wall for a while and was not informed that it should not be positioned that way. The facility's policy indicated that such positioning is considered a physical restraint. Similarly, Resident 41, who had moderate cognitive impairment and required partial assistance for repositioning, was also observed with her bed against the wall. The resident's care plan did not indicate any preference for this arrangement. The Director of Nursing confirmed that beds should not be placed against the wall unless documented as a resident's preference, and acknowledged that this practice posed a high risk for entrapment and was considered a restraint. The facility's policy on a restraint-free environment supported this stance.
Failure to Develop and Implement Individualized Care Plan for Resident with Mobility and ROM Limitations
Penalty
Summary
The facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for a resident identified as having decreased mobility and range of motion (ROM) limitations in the right leg. The resident, who was admitted with diagnoses including an acquired absence of the right leg below the knee, right knee contracture, and a chronic left ankle ulcer with necrosis, did not have a care plan addressing these issues. The resident's Minimum Data Set (MDS) indicated functional limitations in ROM in one leg and required extensive assistance for various activities of daily living, yet no care plan was created to address these needs. During an observation and interview, the resident was found lying in bed with both knees bent and unable to straighten them. The resident reported not having received help with leg exercises for about a year and never having had a splint for the right leg. The MDS Director confirmed that a care plan should have been created to include interventions such as physical therapy, occupational therapy, and/or restorative nursing assistant services to maintain or prevent a decline in the resident's mobility and ROM. The lack of a care plan meant that the resident did not receive the appropriate treatment and services required. The Director of Nursing (DON) also confirmed that comprehensive care plans should be developed for all residents identified as having ROM and mobility limitations. The facility's policy and procedure indicated that care plans should be individualized, realistic, and have measurable goals and timeframes. However, in this case, the facility failed to adhere to its own policy, resulting in the resident not receiving the necessary care to maintain or improve their physical functioning.
Failure to Accurately Monitor and Record Enteral Feeding
Penalty
Summary
The facility failed to accurately monitor and record the total amount of calories received via enteral feeding for Resident 2. Resident 2, who was diagnosed with dementia, gastrostomy, and dysphagia, was dependent on staff for all activities of daily living, including eating. The physician's orders specified that Resident 2 was to receive Jevity 1.2 at a rate of 50 ml per hour for 20 hours daily, starting at 2 p.m. However, observations and interviews revealed discrepancies in the administration and recording of the enteral feeding, leading to Resident 2 not receiving the prescribed amount of nutrition. On multiple occasions, the enteral feeding pump was turned off earlier than the prescribed time, and the total volume fed did not match the physician's orders. For instance, on 4/29/2024, the pump was turned off at 10:00 a.m., and Resident 2 had only received 786 ml of Jevity 1.2 since the previous day. Similar discrepancies were observed on 4/30/2024 and 5/1/2024, where the total volume fed did not align with the prescribed 1000 ml. The nurses involved were unsure of the total amount of nutrition Resident 2 actually received, and the documentation in the medication administration record (MAR) did not reflect the actual times the feedings were administered. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the enteral feeding orders were not being followed accurately. The DON stated that the total volume fed and the rate of feeding should be set on the pump by the nurse and reset after the total volume was administered. However, the discrepancies in the total volume fed and the timing of the feedings indicated that Resident 2 was at risk of not receiving adequate nutrition, potentially leading to weight loss. The facility's policy on enteral nutritional therapy required documentation of the date, time, type, and amount of feeding administered, which was not consistently followed in this case.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of one resident, identified as Resident 65, who had specific dietary needs due to gastro-esophageal reflux disease (GERD), constipation, and chronic gastritis. Despite Resident 65's clear communication to the Dietary Staff Manager (DSM) about avoiding bell peppers and spicy foods due to stomach irritation, the resident was served Spanish rice containing bell peppers. This occurred even though the DSM had updated the resident's food preferences, which were supposed to be reflected on the tray tickets. However, the dietary aide and cook did not ensure that these preferences were followed, leading to the resident experiencing discomfort and potential digestive irritation. During interviews, the DSM acknowledged that Resident 65 had requested to avoid bell peppers and spicy foods, and that the Spanish rice served should have been replaced with an alternative. Cook 1 confirmed that the diet slip did not specify no bell peppers, only no spicy foods, and did not consider bell peppers as spicy. The facility's policy required the Food and Dining Services Manager to document specific food preferences within 48 hours of admission and ensure that dining staff were aware of these preferences. The failure to accurately document and honor Resident 65's food preferences led to the deficiency identified in the report.
Failure to Provide Necessary Occupational Therapy Services
Penalty
Summary
The facility failed to provide necessary Occupational Therapy (OT) services to a resident who had significant activities of daily living (ADL) and functional mobility concerns. The resident, who had an amputation below the right knee, a right knee contracture, and a chronic left ankle ulcer, was admitted with a requirement for OT services. Despite an OT evaluation indicating the resident's need for therapy to address a decline in strength, balance, activity tolerance, and safety awareness, the resident was discharged from OT services when insurance coverage ended, without exploring alternative means to continue the therapy. This discharge occurred despite the resident's continued need for skilled OT services to prevent further decline and immobility, as noted in the OT evaluation and discharge summary. The Director of Rehabilitation (DOR) and Occupational Therapist (OT 1) confirmed that the resident was discharged from OT services due to the end of insurance coverage, even though the resident still required skilled therapy. OT 1 admitted that she did not inform the DOR, case manager, or business office to request re-authorization or explore alternate ways of obtaining services. The Social Services Director (SSD) and the Director of Nursing (DON) both stated that the facility should have ensured the resident received the necessary services regardless of payment source, by requesting re-authorization or exploring alternative means of providing the services. The Administrator (ADM) also acknowledged that the facility was responsible for providing the required care and services regardless of payment source. The failure to continue OT services for the resident, despite the clear need and potential for further decline, highlights a significant deficiency in the facility's process for managing therapy services when insurance coverage ends. The facility did not have policies in place for Rehabilitation Services, maintaining ADLs, and maintaining mobility, which contributed to the oversight and subsequent deficiency in care for the resident.
Failure to Provide Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to ensure that a resident (Resident 74) understood and received the arbitration agreement in a language he could understand when entering a binding contract. Resident 74, who only speaks, reads, and writes in Spanish, signed an arbitration agreement in English. The Admission Coordinator acknowledged that the arbitration agreement should have been provided in Spanish. The resident did not remember signing the agreement and stated he was probably not fully aware when he signed it. Resident 74 was admitted to the facility with diagnoses including stage renal disease and dependence on renal dialysis. The resident had the capacity to understand and make decisions, as indicated in his History and Physical. The facility's policy required that arbitration agreements be presented in a language the resident understands, but this was not followed in Resident 74's case, leading to a potential waiver of his right to a jury trial without his knowledge.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to provide privacy to Resident 2 during a right foot wound care procedure. Resident 2, who was admitted with a diagnosis that included surgical wound dressing changes and diabetes, had the mental capacity to understand and make medical decisions. During an observation, a Licensed Vocational Nurse (LVN) was seen performing wound care on Resident 2 without completely closing the curtains, thereby exposing the procedure to staff and visitors passing by. This lack of privacy was confirmed by Resident 2, who expressed discomfort about the situation. Interviews with the Social Services Department and the Assistant Director of Nursing (ADON) confirmed that the facility's policy required providing privacy during resident care. The ADON acknowledged that failing to close the curtains during the procedure was a dignity issue and could make Resident 2 feel embarrassed and disrespected. The facility's policy on promoting and maintaining resident dignity emphasized the importance of protecting resident rights and treating each resident with respect and dignity.
Failure to Revise Care Plan for Resident with Osteoporosis
Penalty
Summary
The facility failed to revise the care plan to reflect safety measures for a resident at risk for spontaneous fractures due to brittle bones. The resident, diagnosed with dementia, age-related osteoporosis, and unilateral primary osteoarthritis of the right knee, required substantial assistance with activities of daily living (ADLs) and was dependent on staff for transfers and bed mobility. Despite these needs, the care plan did not include specific interventions to ensure the resident's safety and prevent injuries, such as gentle handling during transfers and ADL care. This omission was highlighted during an interview with the resident, who recounted an incident where a CNA moved their knee too hard, resulting in pain and the need for a splint. Interviews with the facility's staff, including a registered nurse and the assistant director of nursing, confirmed that the care plan should have included safety interventions tailored to the resident's condition. The facility's policy on comprehensive care plans mandates the development of person-centered care plans that address the resident's medical, nursing, and psychosocial needs. However, the care plan for this resident did not meet these requirements, as it lacked specific measures to prevent injuries related to osteoporosis.
Inaccurate Assessment of Resident's Lower Extremities
Penalty
Summary
The facility failed to ensure an accurate assessment was conducted on the lower extremities for one resident. The resident was admitted with diagnoses including fractures of both femurs and osteoporosis. The Minimum Data Set (MDS) indicated the resident had impairments on both lower extremities and was dependent on staff for various movements. However, subsequent evaluations showed inconsistencies, with some indicating no impairments and others indicating impairments or even an amputation, which was not accurate according to the Director of Nursing (DON). The MDS nurse confirmed that the documentation was inconsistent and based on whoever assessed the resident at the time. During interviews, both the MDS nurse and the DON acknowledged the inconsistencies in the assessments. The DON specifically noted that the incorrect evaluations could lead to improper interventions for the resident. The facility's policy and procedure for care planning emphasized the importance of accurate assessments to develop individualized care plans. The failure to ensure accurate assessments had the potential to result in poor quality care for the resident.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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