Imperial Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Mirada, California.
- Location
- 11926 La Mirada Blvd, La Mirada, California 90638
- CMS Provider Number
- 056115
- Inspections on file
- 31
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Imperial Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced new onset confusion following dialysis, but nursing staff did not notify the physician or document a comprehensive assessment or monitoring. Facility policy required prompt physician notification and assessment for such changes, but these actions were not taken or recorded.
A resident reported and surveyors observed a protruding nail from a water drain securement clip and a cracked, jagged plastic tabletop on the patio. The Maintenance Supervisor, responsible for daily safety checks, was unaware of how long these hazards had existed. The Administrator confirmed that such safety concerns should be addressed immediately, and facility policies require a safe, clean, and comfortable environment.
A resident with cognitive impairment and lacking decision-making capacity received Lexapro, a psychotropic medication, without proper informed consent from their responsible party. The consent form was signed only by a PA and an LVN, and the responsible party reported not being informed of the medication's risks or providing consent, contrary to facility policy.
Two residents with significant physical and cognitive impairments, including one with legal blindness and another with severe cognitive decline, were found without their call lights within reach. In both cases, the call lights were either placed on the bed or wrapped around a side rail, making them inaccessible. Staff confirmed that call lights should always be within easy reach, as required by the residents' care plans and facility policy.
A resident with no cognitive impairment and full decision-making capacity was not provided with the required NOMNC and SNFABN notices regarding the end of Medicare coverage for skilled services. Instead, the facility gave these notices to the resident's son, who was not involved in care decisions, resulting in the forfeiture of the resident's appeal rights and discontinuation of rehabilitative services.
Two residents with significant physical and cognitive impairments used side rails as mobility aids, but the facility did not develop or implement person-centered care plans with measurable objectives and interventions for their safe use. Staff and record reviews confirmed the absence of these care plans, despite physician orders and facility policy requiring them.
A resident with dementia and moderate cognitive impairment was involved in an altercation that led to a hospital transfer. Following the incident, the IDT did not address the event or develop a care plan to manage the resident's aggressive behavior, despite facility policy requiring such action after a change in condition.
Two residents with hearing impairments were not provided with necessary communication tools, such as communication boards, despite expressing difficulty hearing and a desire for assistance. Staff assessments failed to document the residents' hearing deficits, and both the AD and DON were unaware of the impairments until interviewed. This failure to follow facility policy placed the residents at risk of unmet needs and negatively affected their ability to communicate.
A resident with severe cognitive impairment and a history of pressure ulcers was observed lying on a low air loss mattress (LALM) that was set for a much higher weight than the resident's actual weight. Despite care plans and orders specifying the use of a LALM for skin management, staff did not adjust the mattress setting to match the resident's weight, as confirmed by interviews and documentation. This failure to follow proper protocol for pressure ulcer prevention was identified through observation, record review, and staff interviews.
Two residents with dementia and high fall risk were not adequately protected due to staff failing to respond promptly to bed alarms, not ensuring a Wander Guard alarm prevented unsupervised exit, and not maintaining a functioning bed alarm. One resident was able to exit and re-enter the building without staff supervision despite alarms sounding, and another had a non-functioning bed alarm, with staff unaware of how to check or replace it. These lapses occurred despite care plans and physician orders requiring these safety interventions.
Two residents were found to have bed mobility devices installed without proper adherence to assessment, physician orders, and informed consent protocols. One resident with severe mobility impairment had half side rails installed instead of the ordered grab bars, while another had grab bars in use without a physician's order or timely informed consent from the responsible party. Staff and the DON confirmed these lapses, which were contrary to facility policy.
Two residents were given medications—metoprolol and aspirin—without food as ordered by their physicians, resulting in a medication error rate of 6.67%. The LVN did not verify if the residents had eaten or offer snacks before administering the medications, and later acknowledged not following the specific order instructions. The DON confirmed that all medication orders, including those specifying administration with food, must be followed.
A resident with intact cognitive skills and multiple diagnoses was found storing and self-administering prescription medications, including Adderall, Atarax, and Diovan, at the bedside without authorization or a care plan for self-administration. Nursing staff and the DON confirmed that facility policy prohibits residents from keeping medications at their bedside, and there was no documentation supporting self-administration for this resident.
A resident with intact cognitive skills and no chewing or swallowing difficulties was served ground meat intended for a mechanical soft diet, despite having physician orders and dietary documentation for a regular diet with regular texture. The resident expressed dissatisfaction and confusion, and staff confirmed the error, noting that all food is supposed to be checked against dietary cards by dietary, nursing, and CNA staff.
Two residents with cognitive impairments and lacking decision-making capacity were presented with and signed binding arbitration agreements without involvement of their responsible parties. Staff did not review medical records to confirm capacity before obtaining signatures, contrary to facility policy requiring informed consent from residents or their representatives.
A resident with an infected amputation stump and a PICC line was not placed on Enhanced Barrier Precautions (EBP) as required, despite documented risk factors and facility policy. Staff did not use gowns or gloves during direct care, and the required EBP signage was missing, resulting in a lapse in infection control for approximately 19 days.
A resident with moderate cognitive impairment and a history of tobacco use was repeatedly observed smoking unsupervised outside of the designated smoking area, despite facility policy and care plan requirements for staff supervision and restricted access to smoking materials. Staff interviews and record reviews confirmed that the resident was able to keep a lighter at bedside and smoke without supervision, in violation of established safety protocols.
A resident with a pacemaker was admitted to an LTC facility without essential pacemaker information, such as the insertion date, type, and cardiologist details. Despite multiple hospitalizations due to syncopal episodes and hypotension, the facility did not obtain the missing information or consult a cardiologist. Staff interviews confirmed awareness of the issue, but no documented efforts were made to rectify it, leading to a significant deficiency in care.
A CNA at a facility was found sleeping at the nurses' station and using a cell phone excessively, leading to delayed responses to call lights for two residents. One resident, with COPD and diabetes, was dependent on staff for personal care, while another, with metabolic encephalopathy, required assistance. Both reported the CNA's neglectful behavior, which was confirmed by disciplinary records. The DON deemed such actions unacceptable and against the facility's dignity policy.
A resident with a history of serious injuries fell and was sent to a GACH, but the facility failed to promptly notify the family. The LVN on duty did not inform the family due to the early hour and intended to notify them later, but the task was passed to the incoming nurse, resulting in a delay. The facility's policy requires immediate notification of changes in a resident's condition.
During a COVID-19 outbreak, a resident was unnecessarily exposed to the virus due to a room change to a high-risk area without proper approval. The facility also failed to stock face shields in isolation carts, leading staff to enter COVID-19 positive rooms without adequate protection. Additionally, improper doffing and disposal of PPE increased the risk of virus spread.
The facility failed to ensure a complete set of vital signs were taken, documented, and monitored as ordered by the physician for a resident with severe medical conditions. The lack of vital sign entries for three consecutive days led to a delay in identifying the resident's deteriorating condition, resulting in hospitalization for acute renal failure, hyperkalemia, and sepsis.
The facility failed to develop and implement individualized care plans for two residents. One resident was not consistently turned and repositioned, leading to an unstageable pressure ulcer. Another resident's multiple refusals of RNA services were not addressed in a care plan, risking functional decline. Staff acknowledged the importance of adhering to care plans to prevent harm.
The facility failed to ensure that IDT meeting records were completed, organized, and readily accessible for three residents. This deficiency resulted in staff being unaware of the location of the medical records, potentially delaying and negatively affecting the delivery of necessary care and services. The disorganization and improper filing of medical records, including IDT meeting notes, were acknowledged by the DON and the DSD, who admitted that this issue had led to lost or misplaced documents in the past.
A facility failed to maintain infection control procedures when an RNA did not clean and disinfect a shared FWW after use and before placing it in the Utility Room. The RNA, IPN, and DON confirmed the importance of disinfecting shared equipment to prevent infection spread. The facility's policy also required decontamination of reusable equipment between residents.
The facility failed to ensure the therapy mat in the rehabilitation room was clear of miscellaneous items, limiting its availability for resident use during therapy treatments. The Director of Rehabilitation confirmed the mat should be free of items, but storage space issues led to the clutter.
The facility failed to obtain informed consent for psychotropic medications for three residents. One resident, unable to make medical decisions, was given Mirtazapine without a signed consent from her responsible party. Another resident, capable of making decisions, was prescribed Sertraline without a verification signature, and neither he nor his wife were informed about the medication. A third resident was administered Duloxetine without an informed consent form due to the facility's policy on off-label use.
A facility failed to maintain the dignity and privacy of a resident when a CNA left the privacy curtain open while the resident was exposed in only a diaper. The resident, who has intact cognition and requires various levels of assistance, expressed a preference for being covered with a blanket and having the curtain or door closed for privacy. Interviews with staff confirmed the importance of maintaining resident privacy, as outlined in the facility's policy on dignity.
A resident developed a stage II pressure ulcer due to the facility's failure to follow the care plan for turning and repositioning every 2 hours. Staff did not report the skin breakdown to the charge nurse and treatment nurse, and no change of condition note was initiated, leading to the deficiency.
The facility failed to implement fall prevention measures for two residents, leading to significant injuries. Despite being identified as high risk for falls, necessary precautions such as fall mats and falling star stickers were not in place. Staff interviews and observations confirmed these deficiencies, which were not in line with the facility's policies and procedures.
The facility failed to change a resident's oxygen tubing and humidifier within the required timeframe and did not document the resident's refusal of care to promote lung expansion, despite the resident's history of recurring pneumonia.
The facility failed to ensure that doors remained closed to rooms of residents who tested positive for COVID-19, potentially exposing all residents, staff, and visitors to the virus. Observations showed that doors to COVID-19 positive rooms were left open, and some residents in hallways were not wearing masks. Staff interviews confirmed awareness of the protocol but revealed lapses in adherence.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely physician notification for a significant change in condition for one of three sampled residents. The resident, who had multiple complex diagnoses including acute and chronic respiratory failure, COPD, congestive heart failure, acute pulmonary edema, pleural effusion, type 2 diabetes, hypertension, end stage renal disease, and a history of renal transplant, was readmitted to the facility from a hospital stay. Upon readmission, assessments indicated the resident was alert, oriented, and able to make decisions independently. On two separate occasions, nursing progress notes documented that the resident was alert but experiencing new onset confusion following dialysis. Despite this change in mental status, there was no documentation that the resident's physician was notified, nor was there evidence of a comprehensive nursing assessment or monitoring related to the confusion. The facility's care plan for the resident specifically required monitoring for changes such as altered mentation and prompt reporting to the physician, but these interventions were not carried out as documented. Interviews with the attending physician and a registered nurse confirmed that the new onset confusion represented a significant change in condition that warranted immediate physician notification and further assessment. The physician stated that, had he been notified, he would have sent the resident to the emergency room for evaluation. Review of facility policy indicated that such changes required physician notification, assessment, documentation, and ongoing monitoring, none of which were completed or documented in this case.
Failure to Maintain Safe and Functional Patio Environment
Penalty
Summary
The facility failed to maintain the outside patio in a safe and functional condition, as evidenced by a nail protruding from the water drain securement clip and a cracked plastic tabletop with jagged edges. During an observation and interview, a resident reported that the tabletop had been cracked since their admission and that the water pipe was not properly secured, resulting in the nail pointing toward the door used by residents to enter and exit the patio. The resident expressed concern that these conditions could cause injury to anyone using the patio. The Maintenance Supervisor confirmed responsibility for daily cleaning and safety checks of the patio but was unaware of how long the hazards had been present. The Administrator acknowledged that both indoor and outdoor areas should be well-kept and that safety concerns should be addressed immediately. Review of facility policies and job descriptions indicated an expectation for a safe, clean, and comfortable environment, with ongoing inspections to identify and repair hazards.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Lexapro, for one resident. The resident, who had diagnoses including dementia, cognitive communication deficit, generalized muscle weakness, and major depressive disorder, was assessed as lacking the capacity to understand and make decisions. Despite this, the medical record showed that only the physician assistant and a licensed vocational nurse signed the informed consent form, with no signature or date from the resident's responsible party, who was designated to make medical decisions on the resident's behalf. The responsible party later confirmed that she had not provided informed consent and had not been adequately informed about the medication's potential side effects or complications by a qualified medical provider. The resident received Lexapro daily over several months, as documented in the medication administration records. Interviews with facility staff, including the LVN and the Director of Nursing, confirmed that the facility's policy required written informed consent for psychotropic medications and that this consent was not obtained from the responsible party. The failure to secure proper informed consent was acknowledged by staff and was not in accordance with the facility's established procedures.
Failure to Keep Call Lights Within Reach for Residents with Impairments
Penalty
Summary
The facility failed to ensure that call lights were kept within reach for two residents, both of whom had significant physical and cognitive impairments and were at risk for falls. In one instance, a resident with severe cognitive impairment, generalized muscle weakness, lower extremity impairments, and a history of falls was observed sitting in a wheelchair at the foot of her bed with her call light placed on the bed, out of her reach. Her care plan specifically required that the call light be kept within easy reach to allow her to request assistance, but this intervention was not followed. In another case, a resident with moderate cognitive impairment, severe vision loss (legal blindness), generalized muscle weakness, and upper and lower extremity impairments was observed in a wheelchair with the call light cord and button wrapped around the bed's side rail, behind him and not accessible. This resident was heard calling out for a nurse, indicating he could not use the call light to request help. Both residents had care plans and fall risk assessments that required staff to keep call lights within reach, and staff interviews confirmed that this standard was not met at the time of observation.
Failure to Provide Required Medicare Coverage Notices to Resident with Decision-Making Capacity
Penalty
Summary
The facility failed to provide a resident with the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), which are documents intended to inform Medicare beneficiaries when their covered services are ending and when they may be liable for payment for non-covered services. The resident in question was admitted with diagnoses including generalized muscle weakness, abnormal gait, and lack of coordination, and was assessed as having no cognitive impairment and the capacity to make his own decisions. Despite this, the facility provided the NOMNC and SNFABN to the resident's son, who was not involved in the resident's care and was not authorized to make healthcare decisions on his behalf. The son made the decision to forfeit the appeal process for continued Medicare coverage, resulting in the discontinuation of the resident's rehabilitative services and transition to custodial care. Interviews and record reviews confirmed that the resident was not aware of the forfeiture of his appeal rights and would have wanted to make the decision himself. The facility's own policy required that residents or their representatives be informed in advance of changes to their billing and coverage, and that they be given the opportunity to assume financial responsibility for continued skilled services. The failure to provide the required notices directly to the resident, who was capable of understanding and making decisions, resulted in the resident losing the opportunity to appeal the termination of Medicare coverage for his rehabilitative services.
Failure to Develop Care Plans for Residents Using Side Rails
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable objectives and interventions for two residents who utilized side rails as mobility aids. For one resident with a history of traumatic brain injury and functional quadriplegia, records indicated severe cognitive impairment and total dependence on staff for daily activities. Despite physician orders and assessments recommending bilateral grab bars for mobility, there was no care plan in place to address the use of side rails, as confirmed by both observation and staff interviews. Similarly, another resident with generalized muscle weakness, bilateral hand contractures, and dementia required maximal assistance with daily activities and had an order for bilateral grab bars to aid in bed mobility and provide a sense of security. Observations and interviews confirmed the presence and use of grab bars, but a review of the electronic health record revealed that no care plan had been developed to address their use. Staff acknowledged the absence of care plans for both residents regarding side rail use. The Director of Nursing confirmed that care plans should have been developed for both residents to address their use of side rails as mobility aids. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables for each resident, but this was not followed for the two residents in question.
Failure to Develop Care Plan After Resident Altercation
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) conference and develop a care plan for a resident following a resident-to-resident altercation. The resident involved had a history of dementia, restlessness, agitation, Alzheimer's disease, and other mental and behavioral disorders, and was noted to have moderate cognitive impairments. After the altercation, which resulted in the resident being transferred to the hospital, there was no documentation that the IDT addressed the incident or created a care plan to manage the resident's behavior, specifically the behavior of kicking others that was alleged to have initiated the altercation. Facility policy required the IDT to review and update care plans when a change of condition occurred, such as a resident-to-resident altercation. Additionally, policies on safety, supervision, and resident-to-resident altercations required staff to analyze incidents, identify risks, and make necessary changes to care plans. Despite these requirements, the IDT conference notes did not reflect any discussion or intervention planning related to the altercation, and there was no care plan in place to address the resident's aggressive behavior.
Failure to Provide Communication Tools for Residents with Hearing Impairments
Penalty
Summary
The facility failed to provide necessary communication tools to two residents with hearing impairments, resulting in a deficiency related to access to vision and hearing services. For one resident with hemiplegia and diabetes mellitus, records initially indicated adequate hearing, but during interviews, the resident reported recent hearing loss in one ear and difficulty understanding staff. Both the Activity Director (AD) and Director of Nursing (DON) were unaware of the resident's hearing impairment, and the AD acknowledged that a communication board would be beneficial, but this need was not documented in the activity review assessment. Another resident, diagnosed with hepatomegaly and dysphagia, was also found to have difficulty hearing, particularly in certain environments. Although the care plan included interventions for alternative communication tools, the activity review assessment did not document the hearing impairment, and no communication tools were observed in the resident's room. During interviews, the resident expressed difficulty hearing and a desire for a communication board, which had not been provided. Both the AD and DON were unaware of the resident's hearing impairment until the time of the survey. The facility's policy on care for hearing-impaired residents required staff to assist with effective communication and to evaluate adaptive needs regularly. However, staff failed to identify and document the residents' hearing impairments and did not provide the necessary communication tools, such as communication boards, as required by policy. This lack of action placed the residents at risk of unmet needs and potential negative effects on their psychosocial well-being.
Failure to Set Low Air Loss Mattress to Resident's Weight
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM) for a resident was set according to the resident's actual weight, as required for proper pressure ulcer prevention. The resident, who had diagnoses including metabolic encephalopathy, cerebral infarction, and dementia, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's care plan and physician orders specified the use of a LALM for skin management, and the Braden Scale assessment indicated the resident was at risk for developing pressure sores. Despite this, observations over multiple days revealed that the LALM was set for approximately 200 pounds, while the resident's actual weight was 104 pounds, as confirmed by the treatment nurse and documentation. Interviews with the treatment nurse and DON confirmed that the LALM should have been set within the 100-150 pound range, as indicated on the pump and by a note attached to it. Both staff members acknowledged that setting the LALM outside the appropriate weight range would make the mattress too firm, which could contribute to the development of pressure ulcers. Review of the manufacturer's user manual also confirmed that the pressure setting should be adjusted according to the resident's weight. The failure to set the LALM correctly represented a lapse in following established protocols for pressure ulcer prevention for a resident with a history of fragile skin and previous pressure ulcers.
Failure to Maintain Hazard-Free Environment and Supervision to Prevent Accidents
Penalty
Summary
Staff failed to maintain a hazard-free environment for two residents by not responding promptly to bed alarms, not ensuring a Wander Guard alarm prevented unsupervised exit, and not maintaining a functioning bed alarm. One resident, with diagnoses including dementia, muscle weakness, and abnormal gait, was identified as high risk for falls and had a history of multiple falls. Despite physician orders and care plans requiring bed and wheelchair alarms, staff did not respond in a timely manner when the resident's bed alarm sounded, and multiple staff walked past the room without intervening. Additionally, a CNA was observed not knowing how to turn off the alarm, and interviews confirmed that staff were expected to respond immediately to such alarms to prevent falls. The same resident, who had a Wander Guard alarm to prevent unsupervised wandering, was observed entering the building through an emergency exit without staff supervision on two occasions. The Wander Guard and emergency exit alarms were both sounding, but staff did not respond or supervise the resident as required by physician orders and facility policy. The resident was able to be outside and re-enter the building without staff knowledge or intervention, and there were no cameras monitoring the area. Interviews with staff confirmed that the resident should have been supervised when outside due to the risk of elopement and accidents. A second resident, also with dementia and a history of falls, was observed in bed with a bed alarm monitor that was not functioning, as indicated by the lack of indicator lights. The resident's care plan and physician orders required a functioning bed alarm for safety, but the CNA was unsure if the alarm was working and did not know how to check it. The DON confirmed the alarm was not functioning and needed replacement, acknowledging that this posed a fall risk. Facility policy required implementation and monitoring of fall prevention interventions for residents at risk, which was not followed in this case.
Failure to Ensure Proper Assessment, Orders, and Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure the proper use of side rails for two residents by not following established protocols for assessment, installation, and consent. For one resident with traumatic brain injury and functional quadriplegia, the care plan and physician's order specified the use of grab bars to assist with turning and repositioning in bed. However, observations and staff interviews confirmed that half side rails, rather than the ordered grab bars, were installed. Staff acknowledged that the installed side rails were not appropriate for the resident's needs and did not allow optimal use for mobility assistance as intended by the order and assessment. For another resident with generalized muscle weakness, hand contractures, and dementia, grab bars were installed on the bed without a corresponding physician's order at the time of observation. The order for grab bars was only entered after the issue was identified during the survey. Staff confirmed that an assessment had been completed recommending grab bars, but the required physician's order was missing until the day of the survey review. Additionally, the facility did not obtain informed consent from the responsible party for the use of grab bars immediately upon the resident's readmission, despite the grab bars being in use. The Director of Nursing confirmed that informed consent should have been obtained on the day of readmission to ensure the responsible party was aware of and agreed to the use of the device. The facility's own policy required assessment, order, and informed consent prior to the use of bed rails or grab bars.
Medication Error Rate Exceeds 5% Due to Failure to Administer Medications With Food
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, when a Licensed Vocational Nurse (LVN) did not administer medications according to physician orders for two out of five randomly selected residents. Specifically, the LVN did not ensure that metoprolol for one resident and aspirin for another were given with food, as directed by the prescribers. This resulted in two medication errors out of 30 opportunities, yielding a medication administration error rate of 6.67%. For the first resident, who had diagnoses including hypertensive heart disease with heart failure and paroxysmal atrial fibrillation, the physician's order specified that metoprolol should be administered with food or after meals. During medication administration, the LVN checked the resident's vital signs but did not ask if the resident had eaten or offer a snack before giving the medication. The LVN later acknowledged not following the order to give the medication with food, which could help prevent stomach discomfort. For the second resident, who had a history of stroke, hemiplegia, and malignant neoplasm of the brain, the order for aspirin also specified administration with food. The LVN did not verify if the resident had eaten or offer a snack prior to giving the medication. The LVN confirmed during an interview that the order was not followed. The Director of Nursing stated that nurses are responsible for reviewing and carrying out all medication order instructions, including ensuring medications ordered with food are administered accordingly.
Unauthorized Resident Medication Storage and Self-Administration
Penalty
Summary
A resident with diagnoses of ADHD, anxiety, and hypertension was found to have multiple prescription medication bottles, including Adderall, Atarax, and Diovan, stored at the bedside and inside a dresser drawer. The resident was observed self-administering medication without staff supervision, stating that he took his medications as needed and that staff were aware of this practice. The resident's medical records indicated he had intact cognitive skills and was independent in most activities of daily living, but there was no documentation of an order or care plan allowing self-administration of medications. Interviews with nursing staff, including an LVN and an RN, confirmed that facility policy prohibits residents from keeping medications at their bedside, regardless of whether the medications are prescription or over-the-counter. Staff stated that this practice is unsafe due to the risk of overdose, medication errors, and potential for other residents to access the medications. Both the LVN and RN indicated that medications found at the bedside should be removed immediately and that all staff are responsible for ensuring compliance with medication storage policies. The Director of Nursing confirmed that the resident had not been authorized to self-administer medications and that there was no request or assessment for self-administration on file. Facility policies reviewed indicated that only licensed personnel or authorized staff may access medication supplies, and self-administration is only permitted following a determination by the physician and care planning team. The presence of multiple medication bottles at the resident's bedside and the lack of staff awareness or intervention constituted a failure to follow established medication storage and administration protocols.
Resident Served Incorrect Food Texture Despite Regular Diet Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertensive heart disease and malignant neoplasm of the colon, who was cognitively intact and able to make decisions, was not provided with the correct diet as ordered. The resident was assessed to require a regular diet with regular texture, and this was documented in the admission record, order summary, and nutritional assessment. Despite these clear orders, the resident was served ground meat, which is intended for a mechanical soft diet, rather than the regular texture diet that was ordered. During mealtime, the resident received a tray with ground meat and expressed confusion and dissatisfaction, stating a preference for regular texture food and questioning whether there had been a change in her diet that she was not informed about. The resident confirmed she had no issues with chewing or swallowing and did not want the ground meat, which she associated with residents who have such difficulties. Staff interviews and observations confirmed that the dietary card indicated a regular diet with regular texture, and both the CNA and Dietary Supervisor acknowledged that the resident had been served the wrong food texture due to a mistake. Further interviews with nursing staff, including an LVN and RN, revealed that all food delivered to residents is supposed to be checked by dietary staff, licensed nurses, and CNAs to ensure it matches the dietary card, including diet type, texture, and allergies. The DON also confirmed that serving a mechanical soft diet to a resident ordered for a regular texture diet was not acceptable and could affect the resident's psychosocial well-being. The facility's policy indicated that therapeutic diets are to be provided according to physician orders and resident preferences.
Failure to Ensure Arbitration Agreements Signed by Authorized Decision-Makers
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were provided to and signed by individuals with decision-making capacity for two residents. For one resident with diagnoses including dementia, depression, and bipolar disorder, the Minimum Data Set (MDS) and History & Physical (H&P) indicated moderate cognitive impairment and a lack of mental capacity to make decisions. Despite this, the admissions assistant did not review the H&P prior to presenting the arbitration agreement and relied solely on a brief conversation to assess alertness. The resident signed the agreement, even though the admissions assistant later acknowledged that the responsible party should have been involved due to the resident's incapacity. Similarly, another resident with metabolic encephalopathy, cognitive communication deficit, and dementia was assessed as moderately impaired and unable to make medical decisions. The admissions assistant explained the arbitration agreement directly to the resident, who signed it, despite the H&P indicating that decisions should be made by the responsible party. The administrator confirmed that the proper procedure was not followed, as the H&P should have been reviewed to determine decision-making capacity before presenting the arbitration agreement. The facility's policy required that residents or their representatives be fully informed to make an informed decision regarding such agreements.
Failure to Implement Enhanced Barrier Precautions for Resident with Infected Wound and PICC Line
Penalty
Summary
A deficiency occurred when the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who was admitted with an infected right above-the-knee amputation stump and a peripherally inserted central catheter (PICC) line for long-term intravenous antibiotics. The resident required maximal assistance with several activities of daily living and had an open, infected wound with serous drainage. Despite these risk factors, which were documented in the resident's admission records and assessments, EBP was not initiated upon admission as required by facility policy. The resident's name tag outside the room did not display the orange sticker indicating EBP status, and staff did not wear gowns or gloves when providing direct care. Interviews with the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) confirmed that the resident met the criteria for EBP due to the presence of a PICC line and an infected wound. The IPN acknowledged that the resident was not placed on EBP for approximately 19 days because the need for precautions was overlooked. Facility policy required the use of gowns and gloves for residents with indwelling medical devices or open, non-healing wounds, and the absence of proper signage and staff adherence led to the failure in implementing necessary infection control measures.
Failure to Supervise Resident Smoking and Enforce Smoking Policies
Penalty
Summary
Facility staff failed to ensure safe smoking practices for one resident who had a history of tobacco use, moderate cognitive impairment, and required partial to moderate assistance with daily activities. The resident's care plan and facility documentation indicated that staff supervision was required during smoking, and that smoking was only permitted in designated areas. Despite these requirements, the resident was observed multiple times smoking unsupervised outside of the designated smoking patio, in areas not visible to staff. During these unsupervised smoking incidents, the resident was able to access and use a lighter kept at his bedside and obtain cigarettes from other residents. Staff interviews confirmed that the resident was not permitted to keep smoking materials and required supervision for safety reasons. Staff members, including a CNA, RN, and activity staff, acknowledged that the resident was not being supervised as required and that the areas where the resident was observed smoking were not approved smoking locations. Record reviews and interviews with the Director of Nursing confirmed that facility policy prohibited unsupervised smoking for residents requiring supervision and restricted smoking to designated areas. The policy also prohibited residents from keeping smoking items in their possession. The failure to follow these policies resulted in the resident smoking unsupervised in unauthorized areas and maintaining access to a lighter, contrary to the care plan and facility procedures.
Failure to Monitor and Document Pacemaker Information
Penalty
Summary
The facility failed to provide adequate care and monitoring for a resident with a pacemaker, as evidenced by the lack of essential pacemaker information upon the resident's admission and subsequent readmissions. The resident, who had a history of an implanted cardiac pacemaker, sick sinus syndrome, and hypertension, was admitted without documentation of the pacemaker's insertion date, type, model, serial number, or the cardiologist's details. This information was not obtained or documented in the resident's care plan or physician orders, contrary to the facility's policy. The resident experienced multiple syncopal episodes and hypotension, leading to hospitalizations, yet the facility did not take effective steps to manage the resident's pacemaker and blood pressure medications. There was no evidence of attempts to obtain the missing pacemaker information or to consult with a cardiologist, despite the resident's severe cognitive impairment and dependency on staff for daily activities. The facility's failure to act on these critical omissions placed the resident at risk for further health complications. Interviews with facility staff, including a registered nurse and the director of nursing, revealed an awareness of the missing pacemaker information and the importance of obtaining it. However, there were no documented efforts to contact the medical director or arrange for a cardiology consult. The facility's policy required documentation of pacemaker details and regular monitoring, which was not adhered to, resulting in a significant deficiency in the resident's care.
CNA Sleeping and Cell Phone Use Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) did not sleep at the nurses' station, use a cellular device while working, and ensure call lights were answered promptly for two out of three sampled residents. Resident 2, who was admitted with chronic obstructive pulmonary disease, diabetes, and myasthenia gravis, was dependent on staff for dressing, toileting, and personal hygiene. Resident 3, admitted with metabolic encephalopathy and heart failure, required supervision or assistance for similar activities. Both residents reported that CNA 1 was often seen sleeping at the nurses' station and using a cellular device excessively, which led to delays in responding to their needs. CNA 1 had a history of disciplinary actions for failing to change residents' briefs in a timely manner and for excessive use of a cellular device and headphones while working. Resident 2 recounted instances where CNA 1 would turn off the call light without addressing his needs, while Resident 3 witnessed CNA 1 sleeping and not responding to call lights. The Director of Nursing stated that such behavior was unacceptable and disrespectful, as it was visible to the residents and did not align with the facility's policy on promoting residents' dignity and well-being.
Failure to Notify Family of Resident's Hospitalization
Penalty
Summary
The facility failed to notify both designated emergency contacts for a resident who suffered a fall and was sent to a General Acute Care Hospital (GACH). The incident involved a resident with a history of traumatic subarachnoid hemorrhage, skull fractures, and other serious injuries, who was dependent on staff for daily activities. Despite the resident's cognitive skills being intact according to the Minimum Data Set, the History and Physical indicated a lack of capacity to understand and make decisions. The resident fell at around 2:20 a.m., sustained skin tears, and was transported to the hospital at 3:28 a.m. However, the responsible party was not informed until after the resident returned to the facility, leading to distress and upset. Licensed Vocational Nurse (LVN) 1, who was responsible for the resident during the night shift, acknowledged the failure to notify the responsible party promptly. The LVN stated that she did not want to wake the family member during the early hours and intended to notify them closer to the end of her shift. However, due to being busy, she endorsed the task to the incoming nurse, which resulted in the notification being delayed. The facility's policy and procedure require prompt notification of the resident's representative in case of a change in condition or status, which was not adhered to in this instance.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention measures during a COVID-19 outbreak, resulting in the unnecessary exposure of Resident 1 to the virus. Resident 1, who had severe cognitive impairment and was dependent on staff for daily activities, was moved from a clean area to Room B, which was near several COVID-19 positive rooms. This room change was not communicated to the Infection Prevention Nurse (IPN) due to her absence, and the Director of Nurses (DON) acknowledged that the move was unsafe. The facility's census and COVID-19 tracking map indicated that a safer, vacant room was available, but this option was not utilized. The facility also failed to ensure that face shields were stocked in isolation carts outside COVID-19 positive and exposed rooms. Observations revealed that eight isolation carts lacked face shields, despite the facility having an adequate supply. Staff members, including a Certified Nursing Assistant (CNA) and an Activities Assistant (AA), entered COVID-19 positive rooms without wearing face shields, contrary to the facility's policy. The IPN and DON confirmed that face shields were necessary to protect staff from respiratory droplets and that their absence increased the risk of virus transmission. Additionally, the facility did not ensure proper doffing and disposal of personal protective equipment (PPE). The AA was observed doffing PPE outside Resident 3's room and disposing of it in a hallway trash cart, rather than inside the room as required. This improper procedure was acknowledged by the IPN and DON, who stated that it increased the risk of spreading COVID-19 to other residents and staff. The facility's failure to adhere to PPE protocols and room assignment procedures contributed to the potential spread of the virus within the facility.
Failure to Monitor and Document Vital Signs
Penalty
Summary
The facility failed to ensure a complete set of vital signs were taken, documented, and monitored as ordered by the physician for one resident. This resident, who had multiple severe medical conditions including acute respiratory failure, hypertension, heart failure, and sepsis, was supposed to have their vital signs monitored every night shift. However, there were no vital sign entries for three consecutive days, which led to a delay in identifying the resident's deteriorating condition. The resident was eventually sent to the hospital and diagnosed with acute renal failure, hyperkalemia, and sepsis. Interviews with the facility's staff, including a Licensed Vocational Nurse (LVN), a Nurse Practitioner (NP), and a Registered Nurse (RN), confirmed that the vital signs were not taken as required. The LVN admitted that the vital signs should have been taken and that the failure to do so could have delayed care. The NP emphasized the importance of taking vital signs to monitor the resident's condition, especially since the resident was unable to communicate their needs. The RN also acknowledged that the lack of vital signs could have led to a delay in identifying the resident's change in condition. The Director of Nursing (DON) stated that the vital signs were not documented because the electronic medical record (EMR) system did not populate the necessary documentation boxes. Despite this, the LVNs should have noticed the missing vital signs and documented them manually. The facility's policy and procedure, as well as job descriptions for RNs and LVNs, clearly indicated the importance of taking and documenting vital signs as ordered by the physician.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of eight sampled residents. For Resident 74, the facility did not consistently turn and reposition the resident every two hours as indicated in the pressure ulcer care plan. This failure led to the development of an unstageable pressure ulcer on Resident 74's right medial lower leg. The documentation showed multiple instances where the resident was not repositioned for extended periods, contrary to the care plan and facility policy. Interviews with staff confirmed the importance of regular repositioning to prevent pressure ulcers and acknowledged that the lack of adherence to the care plan likely contributed to the development of the ulcer. For Resident 78, the facility did not develop and implement a care plan to address the resident's multiple and consecutive refusals of Restorative Nursing Aide (RNA) services. Despite the resident's refusals being documented, there was no care plan in place to manage these refusals and ensure the resident maintained their level of function. The resident was cognitively intact and required RNA services for ambulation exercises using a single-point cane. The lack of a care plan for these refusals was confirmed during interviews with staff, who emphasized the importance of having a comprehensive care plan to prevent functional decline. The facility's policies and procedures for repositioning and care plans were not followed, leading to deficiencies in the care provided to Residents 74 and 78. The Director of Nursing and other staff members acknowledged the importance of adhering to care plans and the potential negative outcomes of failing to do so. The facility's failure to implement these care plans as required resulted in harm to Resident 74 and had the potential to negatively affect the care and services provided to Resident 78.
Failure to Maintain and Organize IDT Meeting Records
Penalty
Summary
The facility failed to ensure that Interdisciplinary Team Meeting (IDT) records were completed, organized, and readily accessible for three sampled residents. This deficiency resulted in staff being unaware of the location of the medical records for these residents, potentially delaying and negatively affecting the delivery of necessary care and services. Specifically, the IDT records for Residents 64, 78, and 194 were not properly maintained and were found in various locations, including the Medical Records Department, a separate binder at the Nurses' Station, and in unorganized piles in the Director of Staff Development's (DSD) office. Resident 194, who had multiple serious diagnoses including traumatic subarachnoid hemorrhage, end-stage renal disease, and type 2 diabetes mellitus, had an unwitnessed fall that resulted in a laceration above his left eyebrow. Despite the severity of his condition and the high risk for falls, the IDT meeting records related to his care were not readily accessible. Similarly, Resident 64, who had a history of falls and severe cognitive impairment, also experienced an unwitnessed fall and was sent to the hospital. The IDT meeting records for Resident 64 were not properly filed and were found in different locations, making it difficult for staff to access them. Resident 78, who was cognitively intact and had been receiving Restorative Nursing Aide (RNA) services, was discharged from these services without an IDT meeting note being properly documented in his medical record. The Director of Rehabilitation (DOR) and the Medical Records Director (MRD) were unable to locate the IDT meeting note initially, and it was later found in a stack of papers in the DSD's office. The disorganization and improper filing of medical records, including IDT meeting notes, were acknowledged by the Director of Nursing (DON) and the DSD, who admitted that this issue had led to lost or misplaced documents in the past, potentially resulting in incomplete medical records and delays in care and services.
Failure to Disinfect Shared Equipment
Penalty
Summary
The facility failed to implement and maintain infection control procedures for a resident when a Restorative Nursing Aide (RNA) did not clean and disinfect a shared front wheeled walker (FWW) after use and before placing it into the Utility Room with other clean equipment. This incident was observed during a walking exercise session with the resident, where the RNA folded the FWW and placed it in the Utility Room without cleaning it. The RNA acknowledged the failure to disinfect the FWW and recognized the importance of cleaning shared equipment to prevent the spread of infection. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) confirmed that all shared resident equipment should be cleaned and disinfected between uses and before being stored in the Utility Room. The facility's policy and procedure also indicated that reusable resident care equipment must be decontaminated between residents. The failure to follow these procedures was identified as a potential risk for spreading infections among staff, residents, and visitors.
Therapy Mat Cluttered with Miscellaneous Items
Penalty
Summary
The facility failed to ensure the therapy mat in the rehabilitation room was clear of miscellaneous items, including a black bag, office supplies, a large black mat, a large therapy ball, a graded rainbow arc, two bins containing multiple balls, a foam roller, a backpack, two large cardboard boxes, and four plastic bins containing various items. This deficiency was observed during a recertification survey, where the therapy mat was cluttered with these items, limiting its availability for resident use during therapy treatments. During an interview, the Director of Rehabilitation (DOR) confirmed that the therapy mat should not have any items on it as it is used for residents who have trouble standing and sitting. The DOR acknowledged that the items were on the therapy mat due to a lack of storage space in the rehabilitation gym and the designated storage area outside the gym being full. The facility's Policy and Procedures, revised in February 2009, indicated that therapy equipment must be ready for use and properly stored in designated locations, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to the administration of psychotropic medications for three residents. Resident 3, who could not make medical decisions, was administered Mirtazapine without a signed informed consent from her responsible party. The facility's practice did not require the resident or their representative to sign the consent form, leading to the administration of medication without proper consent documentation. Interviews with the DON and RN confirmed that the facility's long-standing practice did not align with regulatory requirements for obtaining informed consent signatures from residents or their representatives. Resident 48, who was cognitively intact and capable of making decisions, was prescribed Sertraline without a verification signature on the informed consent form. The resident and his wife were not informed about the medication's risks and benefits, as confirmed by their statements. The facility's documentation practices failed to ensure that the resident or his responsible party was adequately informed and had provided consent for the psychotropic medication. Resident 149, who had the capacity to understand and make decisions, was administered Duloxetine for neuropathy without an informed consent form. The facility's policy did not require informed consent for off-label use of psychotropic medications, which led to the administration of the medication without proper consent. Interviews with the DON and RN revealed that the facility did not obtain signatures for informed consent, relying instead on the physician to explain the risks and benefits. This practice was inconsistent with regulatory requirements, as highlighted by the California Department of Public Health's directive for written informed consent for psychotherapeutic drugs.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure dignity was maintained for Resident 86 when the privacy curtain was left open while the resident was exposed, wearing only a diaper. This incident was observed during a visit to Resident 86's room with a Certified Nursing Assistant (CNA 4), who opened the privacy curtain, leaving the resident uncovered on the bed. Resident 86, who has diagnoses including anoxic brain damage, major depressive disorder, and benign prostatic hyperplasia, was admitted to the facility on a previous date and has intact cognition, requiring various levels of assistance for daily activities. The resident expressed a preference for being covered with a blanket when in bed and exposed in a diaper, and stated a desire for the curtain or door to be closed for privacy during such times. Interviews with CNA 4, Resident 86, a Registered Nurse (RN 2), and the Director of Nursing (DON) confirmed that the privacy curtain should have been closed to maintain the resident's dignity. CNA 4 acknowledged the importance of closing the curtain when a resident is exposed in a diaper, and RN 2 and the DON reiterated that staff are responsible for treating residents with respect and maintaining their privacy. The facility's policy on dignity emphasizes the importance of promoting and protecting resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Prevent Pressure Ulcer
Penalty
Summary
The facility failed to prevent an avoidable pressure ulcer for one resident, resulting in the development of a stage II pressure ulcer on the resident's sacrum. The resident, who was moderately cognitively impaired and non-ambulatory, required moderate to maximal assistance for repositioning and getting out of bed. Despite the care plan indicating the need for turning and repositioning every 2 hours, the resident developed a pressure ulcer between 5/10/2024 and 5/12/2024. Interviews with staff revealed that the resident's skin was intact on 5/10/2024, but a new pressure ulcer was observed on 5/12/2024. The staff failed to report the skin breakdown to the charge nurse and treatment nurse, and no change of condition note was initiated as required by the facility's policy. The facility's policy on pressure ulcers indicated that an avoidable pressure ulcer means that the resident developed a pressure ulcer due to the failure to evaluate the resident's clinical conditions or risk factors, implement consistent interventions, monitor the impact of the interventions, or revise the interventions as appropriate. The Director of Nursing confirmed that any observed skin changes should have been reported and documented, which did not occur in this case. The lack of proper monitoring and reporting led to the resident developing a stage II pressure ulcer, highlighting a deficiency in the facility's care practices.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention measures for two residents, leading to significant injuries. Resident 64, who had a history of falls and multiple medical conditions including hemiplegia and epilepsy, fell on 4/10/2024 and sustained a broken left hip, requiring surgery. Despite being identified as high risk for falls, the facility did not place bilateral fall mats or a falling star sticker in her room, as observed on multiple occasions in May 2024. Staff interviews confirmed that these measures were necessary to prevent further falls and injuries, but they were not implemented in a timely manner. Similarly, Resident 194, who had a traumatic subarachnoid hemorrhage from a fall on 5/4/2024, was also identified as high risk for falls. The facility's care plan included placing a falling star sticker to indicate his fall risk status, but observations on 5/13/2024 and 5/14/2024 revealed that no such sticker was placed. Staff interviews corroborated that the absence of the sticker could lead to inadequate monitoring and increased risk of further falls. The facility's policies and procedures, including the Falling Star Program and fall risk management guidelines, were not followed. The Director of Nursing acknowledged that fall interventions should have been implemented immediately after the residents' falls to prevent further incidents. The failure to adhere to these protocols resulted in a lack of necessary precautions and increased the risk of additional falls and injuries for both residents.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards for a resident by not changing the resident's oxygen tubing and humidifier within one week as per facility policy. The resident, who had a history of recurring pneumonia, was observed with oxygen tubing dated 4/26/2024 and a humidifier dated 4/30/2024, which were not changed within the required timeframe. Interviews with the RN and DON confirmed that the facility policy mandates changing these items at least once a week to prevent infection, especially for residents with a history of pneumonia. Additionally, the facility did not provide adequate care or treatment to strengthen the resident's lungs despite the resident's history of recurring pneumonia. The DON mentioned that the resident was encouraged to get out of bed to promote lung expansion but often refused. However, there was no documentation of the resident's refusal of care. The facility's policy requires that if a resident refuses care, the charge nurse or interdisciplinary team should meet with the resident to address concerns and discuss alternative options, which was not documented in this case.
Failure to Maintain COVID-19 Isolation Protocols
Penalty
Summary
The facility did not ensure that doors remained closed to residents' rooms who tested positive for COVID-19, which had the potential to expose all residents, staff, and visitors to the virus. Observations revealed that doors to COVID-19 positive rooms were left open, and some residents in the hallways were not wearing masks. The Infection Preventionist Nurse (IPN) confirmed that there were currently eight residents who tested positive for COVID-19 and two residents who were exposed but had not converted to a positive status. The IPN stated that doors should be kept closed at all times to prevent airborne particles from spreading, but this protocol was not followed. During an interview, the IPN mentioned that there was no designated staff to care for COVID-19 positive residents only, and staff were instructed to change N95 masks when leaving COVID-19 positive rooms. However, observations showed that staff did not always close the doors after leaving these rooms. The IPN also stated that residents were encouraged to wear masks in hallways and public areas, but compliance was not enforced. The Outbreak Nurse (OBN) confirmed that the facility was not following some of the recommendations provided, including keeping doors closed and having dedicated CNAs for COVID-19 positive residents. Further observations and interviews with staff, including a Physical Therapy Assistant (PTA) and an Occupational Therapy Assistant (OTA), revealed that they were aware of the protocol to keep doors closed but failed to do so. Licensed Vocational Nurse (LVN) 2 and Certified Nursing Assistant (CNA) 3 also acknowledged that leaving doors open could spread COVID-19 to other residents. The facility's Policy and Procedure (P&P) indicated that residents suspected or confirmed with COVID-19 infection should be placed on transmission-based precautions, including keeping doors closed, but this was not adhered to.
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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