Inglewood Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Inglewood, California.
- Location
- 100 S. Hillcrest Blvd, Inglewood, California 90301
- CMS Provider Number
- 055526
- Inspections on file
- 56
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at Inglewood Health Care Center during CMS and state inspections, most recent first.
The facility failed to report an alleged verbal abuse incident to the State agency as required. A resident with morbid obesity, HTN, and intact decision-making capacity had a verbal altercation with the Social Services Director after the director instructed the resident’s family member to wear a mask and told the resident not to worry about an outbreak because the resident was leaving. The resident called the director a derogatory name, the director raised her voice in response, and an RN intervened. The resident later described the director’s behavior as threatening and unprofessional. An RN reported the incident to the ADM, but the ADM did not notify the State agency, despite facility policy and CMS requirements to report all abuse allegations within specified timeframes.
A resident with morbid obesity, HTN, and intact decision-making capacity had a documented verbal altercation with the SSD after the SSD instructed the resident’s family member to wear a mask and declined to disclose details about an outbreak. The resident became upset, yelled at the SSD, and called her a derogatory name; the SSD returned to the room and questioned the resident about the insult. The resident later reported feeling threatened, describing the SSD as yelling, waving her arms, and attempting to re-enter the room. Despite facility policies and federal requirements mandating investigation of all abuse allegations, the ADM acknowledged that no abuse investigation was conducted and that the matter was instead treated as a grievance, with no evidence of a formal investigation or required reporting.
A resident with morbid obesity, hypertension, and intact decision-making capacity became upset after the SSD entered the room to instruct a visiting family member to wear a mask during an Influenza A outbreak and then refused to disclose the type of outbreak, reportedly adding that the resident was leaving anyway. As the SSD exited, the resident called her a derogatory name, and the SSD turned back, re-entered or attempted to re-enter the room, raised her voice, and questioned the resident about the insult, requiring an RN to step between them. The resident later reported feeling threatened and afraid of the SSD, and another resident corroborated that the SSD returned and yelled at the first resident, leading surveyors to find that the SSD failed to meet professional standards of quality in her interaction.
A resident with cerebral infarction, DM, and dementia, who had decision-making capacity, had a documented care plan and widely known preference to refuse ADL care from male CNAs and be assisted only by female CNAs. Despite this, nursing assignments for a night shift placed a male CNA in charge of the resident’s ADL care, contrary to the resident’s expressed wishes and the facility’s dignity policy, which commits to honoring resident choices, preferences, values, and beliefs.
The facility failed to report an influenza A outbreak to the state health department within the required 24-hour timeframe after two residents, both documented as capable of making medical decisions (one cognitively intact and one with moderate cognitive impairment), had positive influenza antigen tests on the same day. The Infection Preventionist acknowledged that, under the county outbreak toolkit, two or more lab-confirmed influenza cases within 72 hours constitute an outbreak that must be reported, and the facility’s Unusual Occurrence Reporting policy and the IP job description required timely reporting of communicable disease outbreaks to appropriate agencies. The Administrator confirmed that the outbreak was not reported within 24 hours, resulting in delayed investigation by the state agency.
A resident with heart failure, stage four CKD, and COPD, who was cognitively intact and self-responsible, tested positive for Influenza A and exhibited fever, vomiting, and cough. An NP gave a verbal order for Tamiflu 75 mg twice daily for five days, but the receiving nurse failed to transcribe the order onto a telephone order form, did not enter it on the MAR, and did not notify the pharmacy, contrary to facility policy. As a result, the Tamiflu order was not reflected in the physician orders or MAR, and the resident missed two doses of the antiviral medication.
A resident with dementia, metabolic encephalopathy, and osteoporosis, who was dependent on staff for ADLs, was kicked in the right shin by a CNA while the CNA was in the room feeding the resident’s roommate. An RN overheard the CNA speaking to the resident, then directly observed the kick, removed the resident from the room, and the resident indicated she had been hit and was in pain. Documentation later that day noted discoloration to the resident’s right leg. This incident occurred despite a facility policy prohibiting abuse, neglect, and exploitation and guaranteeing residents the right to be free from mistreatment.
A resident with dementia, severe cognitive impairment, generalized weakness, and a history of multiple falls was assessed as high risk for elopement and wandering, with care plans calling for a wander guard, bed and wheelchair alarms, visible placement, checking whereabouts, and incremental monitoring. These interventions were described by nursing staff and the DON as vague, were not clearly defined, and were not consistently implemented or documented, including failure to place the resident in a visible area and to carry out incremental monitoring. While the receptionist was on break, an RN briefly assumed responsibility for monitoring the lobby and exit door but left the area to go to the medication room without assigning another staff member, leaving the lobby and exit unsupervised. Shortly thereafter, the wander guard alarm sounded; staff found the resident outside, falling on the sidewalk, with no wheelchair alarm heard, and the resident sustained a closed head injury, intracranial hemorrhage, and fractures of two fingers, which staff and the DON attributed to lack of supervision and failure to follow the fall and wandering care plan.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with moderately impaired cognition, who preferred independent activities such as watching TV, was unable to watch television in her room due to one TV displaying static and another not being plugged in. Both the resident and her family reported issues with the TV, and staff confirmed the lack of a functioning television, contrary to facility policies supporting person-centered care.
A resident with severe cognitive impairment and a history of refusing care was subjected to a blood draw despite expressing refusal, resulting in pain and bruising. Staff did not follow physician orders or facility protocol to contact the family when the resident refused, and proceeded with the procedure against the resident's wishes.
A resident with moderate cognitive impairment and a history of intracerebral hemorrhage and respiratory failure requested partial dentures, but did not receive follow-up dental services or the requested dentures. Despite documentation of the request and facility policies assigning responsibility to social services for dental referrals and follow-up, no further action was taken after the initial dental evaluation.
A resident with severe cognitive impairment and total dependence on staff for care was not changed in a timely manner after episodes of incontinence, as required by their care plan. Family reported the resident was sometimes left wet for extended periods, and staff interviews confirmed the risks associated with such lapses, including skin breakdown and infection.
A resident with dementia, osteoarthritis, and moderate cognitive impairment experienced ongoing pain that was not adequately addressed, as staff failed to complete a pain management evaluation or administer as-needed pain medication despite repeated reports of pain and existing physician orders. Interviews confirmed that a referral to pain management was not completed, and the facility's policy for pain evaluation and referral was not followed.
A resident who was severely cognitively impaired and fully dependent on staff was found to have no soap dispenser in their bathroom, with an un-labeled cup of liquid left on the sink instead. Staff failed to report or address the missing dispenser, and maintenance was unaware of the issue, resulting in a lapse in infection prevention and control practices as required by facility policy.
A resident with recent digestive system surgery and a Jackson Pratt drain was unable to attend a scheduled follow-up appointment with a surgeon due to the facility's failure to arrange transportation, despite physician orders and internal notifications. Documentation showed no evidence of transportation arrangements, and the responsible staff member could not recall or provide proof of arranging the required service.
A facility failed to implement proper infection control practices during wound care for three residents. An LVN was observed not adhering to hand hygiene protocols, such as washing hands between glove changes and removing PPE before leaving the work area. These actions were contrary to the facility's policies, potentially leading to cross-contamination and infection.
A resident with severe cognitive impairment and a no CPR order had a low blood pressure reading, leading to the withholding of medication. The resident's baseline blood pressure was typically low after dialysis. A nurse admitted she could have rechecked the blood pressure and informed the physician. The DON emphasized the importance of monitoring low blood pressure and informing the physician if it remained low.
A resident with cognitive and physical impairments, identified as high risk for falls, was left unattended with a raised bed during wound care by an LVN and CNA. This action was against the facility's policy, which prioritizes resident safety and supervision to prevent accidents.
The facility failed to conduct annual competency assessments for a RN and four CNAs, as required by their policy. The DSD acknowledged the absence of these assessments, which are crucial for validating staff ability to meet resident health and safety needs. The Administrator emphasized the importance of these assessments for compliance with regulations.
The facility failed to meet the nutritional needs and preferences of its residents. A resident who was a vegetarian was served meals containing meat, and incorrect portion sizes were served to residents on mechanical soft and pureed diets. Staff did not adhere to the facility's policies on food preferences and portion control.
The facility failed to properly store and label food items, with unlabeled frozen water and undated opened food found in the refrigerator. An internal fan with black substances was blowing over uncovered produce, risking cross-contamination. Interviews with the DDS and RD confirmed these issues, which were against the facility's policies for food storage and maintenance.
The facility failed to update its Facility Assessment to reflect the accurate resident census, with a discrepancy between the recorded average daily census and the actual number of residents. The Administrator acknowledged the mismatch and the potential risk of not providing quality care due to incorrect documentation. CMS guidance requires regular updates to the Facility Assessment to ensure accurate evaluation of resident needs.
A facility failed to implement its antibiotic stewardship program by not monitoring a resident's antibiotic use for a UTI. The resident, with a history of UTI, sepsis, and diabetes, was readmitted with a prescription for Bactrim DS. The IPN did not complete the required surveillance form, and no lab specimens were drawn post-hospital discharge, contrary to facility policy. The DON noted this could lead to unnecessary antibiotic use and potential harm.
A resident's family filed a grievance about a CNA's loud and rude behavior, but the CNA continued to be assigned to the resident for three days. The resident, who was fully dependent on staff, experienced a lack of dignity and respect. Despite acknowledgment of the grievance, the intervention to remove the CNA was not implemented.
A resident with severe cognitive impairment was not informed when her missing EBT card was found by the Activities Director, causing prolonged distress. The card, valued at $190, was reported missing by a CNA, but the Activities Director did not notify staff or the resident upon finding it, delaying resolution.
A resident with severe cognitive impairment was not offered the opportunity to file a grievance for a missing EBT card, valued at $190, as required by the facility's policy. The Social Services Director and DON were unaware of the issue, and the grievance process was not followed, potentially causing distress to the resident.
The facility failed to accurately complete the MDS for two residents, leading to incorrect data transmission to CMS. One resident's MDS did not acknowledge a schizophrenia diagnosis, while another's MDS was inaccurately coded for schizoaffective disorder. The MDS Nurse confirmed these inaccuracies, which could impact the quality of care. The facility's policy requires certification of MDS accuracy, which was not followed.
The facility failed to resubmit the PASRR for two residents with mental illness, potentially impacting their mental health care. One resident with schizophrenia and dementia did not have a resubmitted PASRR, while another with schizoaffective disorder had an inaccurately completed PASRR level 1 screening, missing the need for a level 11 evaluation. The facility's policy required staff to review PASRRs and determine follow-ups, which was not followed.
The facility failed to create person-centered care plans for two residents, one requiring supervision for smoking and another following grievances about staff behavior. Despite assessments indicating the need for specific care plans, none were documented, potentially affecting the delivery of necessary care.
A resident with visual impairment and fluctuating decision-making capacity experienced frustration due to the facility's failure to clean and provide dentures daily. Despite needing substantial assistance, the resident reported that staff did not clean the dentures or place them within reach before meals. Observations confirmed the dentures were not offered during meals, and a CNA admitted they were not accessible. The facility's policies on denture care were not followed, leading to the resident's inability to use the dentures effectively.
A resident with impaired vision and cognitive issues did not receive a timely ophthalmology appointment for cataracts and glaucoma evaluation. The Social Service Director was unaware of the need for the referral, and there was no documentation or follow-up, contrary to the facility's policies.
A resident at high risk for skin breakdown had their low air loss (LAL) mattress incorrectly set at 400 pounds instead of their actual weight of 101 pounds. This error was identified by an LVN, who confirmed the potential risk for pressure ulcers. The resident's medical history included conditions like dementia and COPD, increasing their vulnerability. The facility's policy emphasized the importance of correct mattress settings for pressure relief.
A resident with blindness and fluctuating decision-making capacity was not provided with the correct diet texture, as they did not wear dentures. Despite being on a low sodium regular diet, the facility did not adjust the food texture, making it difficult for the resident to chew, particularly meat. Interviews with the RD and MDS Nurse highlighted the need for a diet texture adjustment to prevent potential weight loss and ensure proper nutrition.
A resident with PTSD and depression did not receive trauma-informed care as required by facility policy. Despite the resident's traumatic experience of losing his wife, staff failed to provide necessary psychosocial support or offer group therapy, leading to a deficiency in care.
A facility failed to follow physician orders for a resident's oxygen settings, setting the concentrator at three liters per minute instead of the prescribed two liters. The resident, with severe cognitive impairment and multiple health issues, was at risk due to this oversight. Staff acknowledged the error and the importance of adhering to physician orders to prevent potential harm.
A resident grieving the loss of his wife did not receive necessary emotional support and social services, including group therapy and psychological referral, despite expressing ongoing grief and having a care plan in place. The Social Service Director admitted to the lack of interventions, which contradicted the facility's policies on providing appropriate treatment for mental and psychosocial difficulties.
A facility failed to act on a pharmacy consultant's recommendation for a trial reduction of a psychotropic medication for a resident. The consultant pharmacist suggested reducing Seroquel, prescribed for paranoia, but the facility did not inform the resident's physician, and no action was taken. The resident had intact cognitive skills and required setup assistance. The Director of Nursing acknowledged the failure to follow the facility's policy for Medication Regimen Review and Reporting.
A facility failed to label an opened multi-dose tuberculin vial with an expiration date in the medication storage room. During an observation, a nurse found the vial in the refrigerator with a date but no expiration date, acknowledging the potential for medication errors. The facility's policy required refrigerated medications to be labeled, but this was not followed.
A facility failed to date and label an oxygen humidifier for a resident with severe cognitive impairment and multiple health conditions, increasing the risk of respiratory infection. The LVN and DON confirmed that the humidifier should be changed weekly and labeled, but this was not done, violating the facility's infection control policy.
Two residents at risk for falls had care plans that were not individualized to specify the level of staff assistance needed for safe transfer and mobility. Despite being identified as high risk for falls, the care plans did not reflect the assistance levels indicated by physical therapy assessments. Interviews with the RN and DON confirmed that care plans should be individualized, and the lack of specificity could increase fall risks. Facility policies emphasized the need for resident-centered fall prevention plans, which were not met in these cases.
A resident, assessed as needing partial/moderate assistance due to conditions like radiculopathy and spinal stenosis, fell in the bathroom when a CNA failed to provide necessary support. Despite being at high risk for falls, the CNA did not maintain close proximity or physical support, contrary to the facility's safety and fall management policies.
A resident in an LTC facility was physically abused by another resident due to the facility's failure to follow care plans and physician's orders for monitoring aggressive behaviors. The aggressive resident had a history of altercations and was not adequately supervised or separated from the victim, leading to an incident where the victim sustained a hematoma. The facility did not notify the physician or implement effective interventions despite multiple episodes of aggression.
A resident with dementia and other medical conditions left the facility unsupervised due to a failure in following elopement and safety supervision policies. Despite being assessed as at risk for wandering, the resident's wander guard alarm did not sound, and staff did not visually confirm the resident's presence. Interviews revealed lapses in supervision and alarm system functionality, leading to the resident's unsupervised departure.
A resident with acute kidney failure, an automatic cardiac defibrillator, and hypertension frequently left the facility without a required physician order, compromising their safety. The facility's policies mandate a physician order for residents to leave, but this was not followed, as confirmed by the DON.
Failure to Timely Report Alleged Verbal Abuse Incident to State Agency
Penalty
Summary
The facility failed to report to the California Department of Public Health (CDPH) an alleged verbal abuse incident involving the Social Services Director (SSD) and Resident 1, as required by federal and facility policy. Resident 1, who had morbid obesity and hypertension and was assessed as having decision-making capacity and the ability to understand and be understood, was partially dependent on staff for various ADLs. On 2/3/2026, Resident 1’s family member entered the facility without a facemask and went into Resident 1’s room. The SSD saw the family member and requested that a mask be worn. When Resident 1 asked the SSD what the outbreak was, the SSD responded that Resident 1 should not worry because she was leaving the facility. Resident 1 did not like this response and called the SSD a “bitch” as the SSD was stepping out of the room. The SSD then raised her voice and asked Resident 1 why she had to be called that name, and RN 1 intervened by getting between them to calm the situation. Following the incident, Resident 1 reported that the SSD’s behavior was threatening and unprofessional and that the SSD should not be in her room. RN 2 stated she reported the 2/3/2026 verbal altercation to the Administrator (ADM) but did not know if the ADM reported it to CDPH. The ADM later stated that no one, including Resident 1, reported feelings of fear or threat or said they were scared for their life, and that if there had been such a report, she would have reported the incident to CDPH. Facility policies on abuse prevention and prohibition required reporting all abuse allegations to the State agency within required timeframes, and CMS Appendix PP required that all alleged violations involving abuse or mistreatment be reported to the State Survey Agency immediately, but not later than 2 hours after the allegation, with investigation results reported within 5 working days. Despite these requirements, the allegation that the SSD’s behavior was threatening and unprofessional toward Resident 1 was not reported to CDPH, resulting in a failure to timely report suspected abuse and the results of the investigation to the proper authorities.
Failure to Investigate Alleged Verbal Altercation Between SSD and Resident
Penalty
Summary
The deficiency involves the facility’s failure to investigate an alleged verbal altercation between the Social Services Director (SSD) and a resident, as required by the facility’s abuse investigation and reporting policies and federal regulations. The resident was admitted with diagnoses including morbid obesity and hypertension and had documented capacity to understand and make decisions. An MDS assessment showed the resident was cognitively able to understand and be understood, required varying levels of assistance with ADLs, and was dependent for some transfers and ambulation distances. On the date of the incident, a progress note documented that the SSD asked the resident’s family member to put on a face mask upon entering the resident’s room. The resident asked if there was an outbreak, and the SSD responded that she could not disclose other residents’ information. The note indicated the resident became very upset and started yelling at the SSD for not disclosing the information. As the SSD exited the room, she overheard the resident call her a “bitch,” then returned to the room and asked the resident why she had used that term. There was no documentation in the clinical record that any investigation was initiated or conducted regarding this verbal altercation. In subsequent interviews, the resident reported being afraid of the SSD and described the SSD as trying to fight with her at the beginning of the month when the incident occurred. The resident stated the SSD told her not to worry about the outbreak because she was going to leave anyway and that the SSD should not have entered her room due to multiple prior incidents. The resident further stated that during the altercation the SSD was waving her arms, yelling, asking why she was called a “bitch,” and attempting to re-enter the room, which made the resident feel threatened. The Administrator acknowledged that no investigation was conducted into the incident and stated it had been handled as a grievance instead. Facility policies on abuse prevention and prohibition require investigation of any allegations of abuse, and federal guidance in Appendix PP requires that all alleged violations be thoroughly investigated and reported to the State Survey Agency within five working days, which did not occur in this case.
Unprofessional Social Services Interaction During Outbreak Masking Dispute
Penalty
Summary
The deficiency involves the facility’s failure to ensure the Social Services Director (SSD) acted in accordance with professional standards when interacting with a resident during an infectious disease outbreak. Resident 1, who had morbid obesity and hypertension and was assessed as having decision-making capacity and the ability to understand and be understood, required varying levels of assistance with ADLs but was cognitively able to communicate needs and preferences. On the date of the incident, the SSD entered Resident 1’s room after a family member (FM1) entered without a mask during an Influenza A outbreak, and the SSD instructed FM1 to wear a mask. According to progress notes and interviews, when Resident 1 asked the SSD what type of outbreak was occurring, the SSD responded that she could not disclose that information, and per Resident 1 and RN 1, also stated that Resident 1 should not worry because she was going to leave the facility. Resident 1 became upset and, as the SSD was exiting the room, called the SSD a “bitch.” The SSD then turned back, re-entered or attempted to re-enter the room, raised her voice, and questioned Resident 1 about why she had called her that name. RN 1 reported stepping between the SSD and Resident 1 to calm the situation, and Resident 1 later stated she felt threatened by the SSD’s behavior, describing the SSD as waving her arms, yelling, and seeming like she wanted to fight. Resident 1 reported being afraid of the SSD and stated that the SSD was not supposed to enter her room due to prior unspecified incidents and that the SSD’s behavior was unprofessional and disrespectful toward someone who was bedridden. Resident 2 corroborated that Resident 1 had called the SSD a “bitch” as the SSD was leaving and that the SSD then walked back and yelled at Resident 1, asking why she had to be called that. In her own interview, the SSD acknowledged returning to the room after hearing the insult, asking Resident 1 why she had to be called a “bitch,” and later stated she probably should not have gone back into the room and should have allowed RN 1 to deescalate the situation. The surveyors concluded that the SSD’s conduct did not meet professional standards of quality and had the potential to affect Resident 1’s psychosocial well-being, leading to emotional harm.
Failure to Honor Resident Preference for Female CNA During ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly documented preference not to receive ADL care from male CNAs. The resident, who had diagnoses including cerebral infarction, DM, and dementia, was determined in a recent H&P to have the capacity to understand and make decisions. Her care plan, titled “Resident Refuses Male CNA Care,” specified that she would receive required care while maintaining dignity, comfort, and emotional well-being, and directed staff to assign a female CNA for personal care, document refusals of care, and respect her preference for female CNAs. The resident’s MDS showed she required varying levels of assistance with personal hygiene, dressing, bathing, toileting hygiene, footwear, oral hygiene, and eating, indicating she depended on staff for multiple ADLs. Despite this, review of the nursing assignment sheet for a specific night shift showed that a male CNA was assigned to provide ADL care to this resident. Staff interviews confirmed that the resident’s preference to refuse care from male CNAs was widely known among facility staff. The DON acknowledged that the resident’s preference for female CNA care was in the care plan and stated that this preference should have been honored, regardless of staffing changes due to multiple staff calling out sick. The facility’s undated “Quality of Life – Dignity” policy stated that residents will always be treated with dignity and respect and that the facility is committed to honoring resident choices, preferences, values, and beliefs throughout their stay. The assignment of a male CNA in contradiction to the resident’s expressed and care-planned preference constituted the cited deficiency and was noted as having the potential to affect the resident’s psychosocial well-being.
Failure to Timely Report Influenza Outbreak to State Health Department
Penalty
Summary
The facility failed to report an influenza A outbreak to the California Department of Public Health (CDPH) within 24 hours as required by its Unusual Occurrence Reporting policy and the Los Angeles County Department of Public Health (LAC DPH) Influenza and other Respiratory Virus Diseases Outbreak Toolkit. Resident 1, who had diagnoses including heart failure, stage four chronic kidney disease, and COPD, was cognitively intact, self-responsible, and had capacity to make medical decisions per the admission record, history and physical, and MDS. Resident 1 had a positive influenza antigen test result documented on 2/2/2026 at 12:00 p.m. Resident 8, with diagnoses including diabetes mellitus, hypertensive heart disease, and pleural effusion, was documented as capable of understanding and making decisions, with the MDS indicating moderate cognitive impairment, and also had a positive influenza antigen test result on 2/2/2026 at 12:00 p.m. During interview and record review with the Infection Preventionist (IP), it was confirmed that the LAC DPH toolkit defined an outbreak as two or more laboratory-confirmed influenza cases identified within 72 hours of each other and required such outbreaks, as well as sudden increases in acute respiratory illness cases, to be reported. The facility’s Unusual Occurrence Reporting policy required epidemic outbreaks or prevalence of communicable disease to be reported via telephone to appropriate agencies within 24 hours, and the IP job description required reporting all reportable diseases to the state health department. Despite having two confirmed influenza cases that met the outbreak definition on 2/2/2026, the facility did not report the outbreak to CDPH within 24 hours, as acknowledged by both the IP and the Administrator, resulting in delayed investigation by CDPH.
Failure to Transcribe and Implement Verbal Tamiflu Order for Influenza-Positive Resident
Penalty
Summary
The facility failed to ensure that a nurse practitioner’s verbal order for Tamiflu was properly processed and implemented for a resident who tested positive for influenza. The resident, who had diagnoses including heart failure, stage four chronic kidney disease, and COPD, was cognitively intact and self-responsible, with documented capacity to make medical decisions. On 2/2/2026 around noon, the resident’s influenza antigen test was positive for Influenza A, and an SBAR documented fever of 103°F, vomiting, and coughing. The infection preventionist reported that the nurse practitioner was notified of the positive test and verbally ordered Tamiflu 75 mg twice daily for five days to treat the influenza. However, the infection preventionist stated she forgot to carry out the order and did not notify the pharmacy. Review of the resident’s physician orders and MAR for February 2026 showed no entry for Tamiflu, and nursing staff confirmed that there was no Tamiflu order documented. The nurse practitioner later confirmed that Tamiflu 75 mg had been ordered to treat Influenza A and that he was not notified that the resident did not receive the medication. The facility’s policy titled “Physician Orders” required that when receiving a telephone or verbal order, the licensed nurse must repeat the order to clarify, transcribe all components onto a telephone order form with time, date, and signature, transcribe the order onto the MAR, and notify the pharmacy of the new order. These required steps were not completed, resulting in the resident missing two doses of Tamiflu on the evening of 2/2/2026 and the morning of 2/3/2026.
Resident Kicked by CNA Resulting in Pain and Leg Discoloration
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA kicked the resident’s right shin while providing care. The resident, who had diagnoses including metabolic encephalopathy, osteoporosis, and dementia, had been assessed as lacking capacity to make decisions and having severely impaired cognitive skills for daily decision-making. The resident was dependent on staff for ADLs such as toileting and showering and required partial assistance for eating, oral hygiene, dressing, and positioning. While the CNA was in the room feeding the resident’s roommate, an RN overheard the CNA speaking to the resident and then directly observed the CNA kick the resident’s right leg. Following the observed kick, the RN immediately removed the resident from the room and the resident pointed to the right leg and stated she had been hit and was in pain. An SBAR form documented that the RN supervisor witnessed the CNA kick the resident and that the resident reported pain. A Resident Data Collection form completed later the same day documented discoloration to the resident’s right leg. The facility’s abuse, neglect, and exploitation prohibition policy stated that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property, but the observed conduct of the CNA and resulting pain and purplish discoloration to the resident’s right shin demonstrated that this policy was not followed in this instance.
Failure to Supervise High-Risk Wanderer Resulting in Elopement and Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and monitoring for a resident assessed as high risk for elopement and falls. The resident had dementia, Alzheimer’s disease, generalized muscle weakness, severe cognitive impairment, and a documented history of multiple prior falls. Assessments and care plans identified the resident as at risk for elopement and wandering without purpose, with exit-seeking and searching behaviors, and at high risk for falls due to poor decision making, incontinence, gait/balance problems, multiple medications, and multiple medical conditions. The care plans included interventions such as allowing safe movement in hallways, gently redirecting the resident back to supervised areas, checking the resident’s whereabouts, using a wander guard bracelet with function and placement checks every shift, providing bed and wheelchair alarms, placing the resident in visible areas after activities, providing individualized activities, encouraging the resident to ask for help, and implementing incremental monitoring for safety. Despite these identified risks and planned interventions, staff did not consistently implement or clearly define the required monitoring and supervision. The fall care plan intervention to “check resident’s whereabouts” and to provide “incremental monitoring” was described by nursing staff and the DON as vague and unclear, and there was no documentation or proof that incremental monitoring was carried out. The DON stated that the intervention for incremental monitoring was not documented and that a written log was not in place to verify implementation. The DON also acknowledged that the fall care plan intervention to place the resident in a visible area was not implemented. The RN and DON both indicated that the resident’s fall care plan interventions to prevent falls and injuries were not followed because the resident was outside the facility and unsupervised at the time of the incident. On the day of the event, the resident, who required supervision/touching assistance for transfers and ambulation and 24-hour staff assistance with mobility and daily care tasks, was able to move independently in a wheelchair around the unit. The receptionist asked an RN to observe the front door and lobby to ensure resident safety and prevent residents from leaving while the receptionist went on break. The RN reported that she did not see any residents in the lobby and left the lobby area to go to the medication room, from which the lobby and exit door could not be viewed. She did not assign another staff member to supervise the lobby and exit door. Shortly after entering the medication room, the RN heard the wander guard alarm activate at the front door. When she responded, she did not see any residents in the lobby or near the door, then ran outside and observed the resident falling on the sidewalk. Staff reported that they did not hear the resident’s wheelchair alarm prior to the fall, and the DON confirmed that the lobby and exit door were unsupervised when the wander guard alarm sounded. The resident sustained a closed head injury, left frontal scalp hematoma, intracranial hemorrhage, and fractures of the left hand fourth and fifth fingers as a result of the unwitnessed fall outside the facility after eloping without staff knowledge or supervision. Interviews with multiple staff members corroborated that the resident was not to leave the building without staff supervision and assistance, that the resident had unsteady gait and weakness, and that alarms such as wander guard and wheelchair alarms were in use but did not replace the need for active staff supervision. The Administrator acknowledged that a system-wide approach to prevent elopements and falls required active supervision of the lobby and exit door whenever the automatic-opening exit was unlocked. The facility’s own policies on Safety Supervision of Residents, Comprehensive Care Plan, and Fall Management required identification of individual risks, implementation of targeted interventions including adequate supervision, consistent implementation and evaluation of interventions, and updating care plans when falls recurred. However, the DON stated that these interventions were not correctly and consistently implemented for this resident, and that the resident’s fall and injuries were a major accident caused by lack of staff supervision and assistance when the resident exited the facility unsupervised.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Resident Unable to Access Functioning Television for Preferred Activities
Penalty
Summary
A deficiency was identified when a resident, who enjoyed watching TV as part of her preferred activities, did not have access to a functioning television in her room. The resident's care plan and activity assessment documented her interest in independent activities such as watching TV, and her medical records indicated she had moderately impaired cognition but was able to make her own decisions. During interviews and observations, it was found that the TV mounted on the wall in her room displayed static and unclear channels, making it difficult to watch. Additionally, a second TV on the nightstand was not plugged in, further limiting her ability to watch TV. The resident's family member reported that the TV was always fuzzy and unclear, and the resident herself confirmed that the TV was sometimes very unclear and difficult to watch. Staff, including an LVN, verified that both TVs in the room were either not functioning or not set up for use. Facility policies reviewed indicated an expectation for person-centered care and activities tailored to residents' interests, but these were not met in this instance, resulting in the resident being unable to enjoy watching TV as she preferred.
Failure to Honor Resident's Right to Refuse Blood Draw
Penalty
Summary
The facility failed to honor a resident's right to refuse treatment when staff attempted to draw blood from a resident who had previously indicated refusal. The resident, who had diagnoses including dementia, anxiety, and osteoarthritis, was assessed as having severely impaired cognition and was dependent on staff for daily activities. Despite physician orders and signage above the resident's bed instructing staff to call the family if the resident refused a blood draw, staff proceeded with the procedure after the resident expressed refusal. Observations and interviews revealed that the resident verbally told staff to stop during the blood draw, but staff continued and completed the procedure. The resident reported that staff held her down and did not listen to her refusal, resulting in pain and bruising on both wrists. Documentation showed that the resident had a history of refusing care, and the care plan included interventions to encourage the resident to verbalize feelings and offer understanding and empathy. Staff interviews confirmed that the protocol was to call the family if the resident refused a blood draw, and that residents should not be forced to accept care. However, the staff involved were either unaware of the signage or did not follow the established protocol. Facility policies reviewed indicated that residents have the right to refuse treatment and should not be compelled by force, but these policies were not followed in this instance.
Failure to Provide Follow-Up Dental Services for Resident Requesting Partial Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who requested partial dentures. The resident, who had a history of intracerebral hemorrhage and respiratory failure, was observed to have a large gap in the upper row of teeth and expressed feeling embarrassed and self-conscious due to missing teeth. Documentation showed that the resident had moderate cognitive impairment and required assistance with eating and oral hygiene. The physician had referred the resident for annual and as-needed dental consultations, and dental notes indicated the resident requested partial dentures. However, social services notes from the same date stated no recommendations were given, and there was no evidence of follow-up or provision of dentures after the resident's request. Interviews with the Social Services Director and the DON confirmed that the social services department was responsible for following up on dental evaluations and resident needs, but no follow-up dental services or dentures were provided after the initial request. The facility's policies required social services staff to make referrals, secure dental care, and document interactions, but these steps were not completed for this resident. The DON acknowledged that the lack of dentures could potentially result in weight loss and swallowing issues for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease and severe cognitive impairment, who was fully dependent on staff for all activities of daily living and always incontinent of bowel and bladder, was not provided timely incontinence care. The resident's care plan required staff to clean and dry the resident after each incontinent episode and to observe for skin irritation and redness. However, according to a family member, the resident was sometimes only changed once per shift instead of the expected twice, and on one occasion was found wet with urine in both the incontinence brief and gown, indicating the brief had not been changed since the morning. Interviews with staff confirmed that leaving a resident in a wet brief can result in rashes, skin breakdown, and urinary tract infections. The Director of Nursing acknowledged that residents are to be changed at the beginning of the shift and as needed, and that failure to do so puts residents at risk. The facility's policy on bladder and bowel incontinence emphasized the importance of preventive measures for infection control, but the observed and reported practices did not align with these standards.
Failure to Provide Pain Management Evaluation
Penalty
Summary
The facility failed to provide a pain management evaluation for a resident with multiple diagnoses, including unspecified dementia, anxiety, primary osteoarthritis of both knees, and hypertension. The resident was noted to have moderate cognitive impairment and was dependent on staff for most activities of daily living. Physician orders included scheduled and as-needed pain medications, and the care plan directed staff to acknowledge pain, use non-pharmacological interventions, administer pain medication as ordered, and notify the provider if pain was not adequately controlled. Despite these orders, pain monitoring records showed the resident repeatedly reported moderate pain levels in the knees, with no documented administration of as-needed acetaminophen during the month reviewed. Progress notes indicated a referral to pain management was planned, but interviews with staff revealed that the referral was not completed and the resident had not been evaluated by a pain specialist. The DON confirmed that the resident should have been seen for pain management but was unsure why this had not occurred. The facility's policy required pain screening, evaluation, and referral to other disciplines as needed, but this process was not followed for the resident, resulting in unaddressed and unmanaged pain.
Failure to Provide Soap Dispenser in Resident Bathroom Creates Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident's bathroom was found to be lacking a soap dispenser, with an un-labeled plastic cup containing yellow liquid placed on the sink instead. The resident in question was admitted with Alzheimer's disease and anxiety, was severely cognitively impaired, and fully dependent on staff for all activities of daily living, including hygiene and toileting. The resident was also always incontinent and at risk for developing pressure ulcers. The absence of a soap dispenser was confirmed during an observation and interview, with the resident's family member stating that there had never been soap available in the restroom. Staff interviews revealed that the Certified Nurse Aide (CNA) did not report the missing soap dispenser to the charge nurse as required, and the maintenance team was unaware of the issue, as there was no entry in the maintenance log regarding the missing dispenser. The Infection Preventionist Nurse and Director of Nursing both acknowledged that the lack of a soap dispenser and the use of a cup for soap constituted an infection control problem and a safety issue. Facility policies required regular inspection of resident rooms and bathrooms to ensure all dispensers were functioning, but this was not followed in this instance.
Failure to Arrange Transportation for Post-Surgical Follow-Up
Penalty
Summary
The facility failed to arrange transportation for a resident who required a follow-up appointment with a surgeon regarding a Jackson Pratt drain. The resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, left bundle branch block, and acute on chronic systolic heart failure. The resident's Minimum Data Set indicated the ability to communicate needs and required partial to moderate assistance with personal care. A physician's order and progress notes documented the need for a follow-up appointment, and the surgeon's office communicated the appointment date to the facility. The Social Service Designee was notified to arrange transportation. However, a review of the Social Service Designee's calendar showed no documentation of transportation arrangements for the resident's appointment. On the scheduled date, the resident was unable to attend the appointment due to transportation difficulties, and the appointment was subsequently rescheduled. During an interview, the Social Service Assistant, responsible for arranging transportation, could not recall making the arrangements and was unable to provide documentation to support that transportation had been arranged. The facility's policy indicated that the Social Service Assistant is responsible for assisting with residents' transportation needs.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during wound care for three residents. During an observation, a Licensed Vocational Nurse (LVN) was seen performing wound care on Resident 2 without adhering to proper hand hygiene protocols. The LVN cleaned the bedside table, applied a plastic cover, and changed gloves multiple times without washing hands in between. Additionally, the LVN applied ointment and dressed the wound without ensuring the cleanliness of the heel protector boots, which had dried flaky skin particles inside. In another instance, the same LVN was observed conducting wound care for Resident 3. The LVN prepared the wound care supplies and donned personal protective equipment (PPE) but failed to remove the PPE before leaving the room to retrieve additional supplies. This action was contrary to the facility's policy, which requires the removal of PPE before exiting the work area. The LVN continued the wound care procedure without washing hands after changing gloves, which could lead to cross-contamination and infection. Similarly, during wound care for Resident 4, the LVN did not follow proper hand hygiene practices. The LVN left the room wearing PPE to get more supplies, which is against the facility's guidelines. The Director of Nursing confirmed that the LVN should have washed hands every time gloves were changed to prevent contamination. The facility's policy mandates handwashing after glove removal and before applying new gloves, which was not adhered to during these observations.
Failure to Recheck Low Blood Pressure in Resident
Penalty
Summary
The facility failed to recheck the blood pressure of a resident who had a physician's order of no Cardiopulmonary Resuscitation and a low blood pressure reading. The resident, who had severe cognitive impairment and was on palliative care, had a history of low blood pressure after dialysis. On a specific date, the resident's blood pressure was recorded at 93/55 mmHg with a heart rate of 53 beats per minute, leading to the withholding of blood pressure medication. During interviews, a Licensed Vocational Nurse acknowledged that the resident's baseline blood pressure was typically low after dialysis and admitted that she could have rechecked the blood pressure after 15 minutes and informed the physician. The Director of Nursing emphasized the importance of monitoring residents with low blood pressure and stated that even if the baseline was low, the blood pressure should have been rechecked and the physician informed if it remained low.
Failure to Provide Safe Environment During Wound Care
Penalty
Summary
The facility failed to provide a safe environment for a resident during wound care, which had the potential to result in a fall and injury. The resident, who was admitted with a diagnosis of a pressure ulcer in the sacral region, was identified as having cognitive impairment and one-sided impairment in both upper and lower extremities. The resident was also dependent on assistance for movement and was assessed as being at high risk for falls. During an observation, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) raised the resident's bed to provide wound care. However, both staff members left the resident unattended with the bed raised, which was against the facility's policy for residents at high risk for falls. Interviews with the LVN and CNA confirmed that they were aware that residents should not be left alone with the bed raised, especially those at high risk for falls. The Director of Nursing (DON) also reviewed the resident's fall risk assessment and acknowledged that the resident should not have been left unattended during care. The facility's policy emphasized the importance of resident safety and supervision to prevent accidents, highlighting a failure in adhering to these guidelines in this instance.
Failure to Conduct Annual Competency Assessments
Penalty
Summary
The facility failed to ensure that a competency assessment skills check was performed upon hire and annually for two out of five randomly selected staff members. During an interview and record review, it was found that the Director of Staff Development (DSD) did not have an annual skills competency assessment check on file for a Registered Nurse (RN 1) and four Certified Nurse Assistants (CNA 1, CNA 2, CNA 3, and CNA 4). The DSD acknowledged that these assessments were necessary to validate the ability of the nursing staff and CNAs to meet the health and safety needs of the residents. The Administrator confirmed the importance of performing annual competency assessments to ensure compliance with state and federal regulations. The facility's policy and procedure indicated that competency skills evaluations should be completed upon orientation and annually thereafter. Additionally, the Facility Assessment stated that the DSD would provide ongoing training and assess competencies upon hire, annually, as needed, and on demand. The lack of these assessments had the potential to impact the facility's ability to provide nursing services while ensuring resident safety and well-being.
Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of its residents, as evidenced by several deficiencies in meal preparation and service. Resident 33, who identified as a vegetarian, was served meals containing meat, contrary to her dietary preferences. Despite being aware of Resident 33's vegetarian preference, the facility's staff, including the Certified Nursing Assistant and the Director of Dietary Services, did not ensure that her meals were appropriately adjusted. The facility's policy required food preferences to be reviewed quarterly, but this was not adhered to, leading to the resident receiving non-preferred food. Additionally, the facility did not follow standardized recipes and portion sizes for residents on mechanical soft and pureed diets. Observations revealed that 25 residents on mechanical soft diets and 20 residents on pureed diets were served incorrect portion sizes of ground meat and squash. The Registered Dietician confirmed that the portions were incorrect, which could potentially affect the residents' nutritional intake. The facility's policy on portion control was not followed, as the staff used incorrect scoop sizes due to damaged equipment, leading to improper serving sizes.
Improper Food Storage and Sanitation in Facility
Penalty
Summary
The facility failed to ensure the safe and proper storage of food items in the refrigerator, as observed during a survey. Specifically, a frozen bottled water was found unlabeled in the freezer, and several opened food items, including a bag of white sliced bread, oatmeal, grits, hot sauce, cornstarch, pickle relish, and mayonnaise, were found without open or use-by dates. Additionally, the internal fan in one of the refrigerators, which was blowing air over uncovered fresh produce, had black substances on its blades, indicating improper sanitation. Interviews with the Director of Dietary Services (DDS) and the Registered Dietician (RD) confirmed the presence of dirt on the fan and the uncovered fresh produce, which could potentially lead to cross-contamination and food poisoning. The facility's policies and procedures for food storage and maintenance were reviewed, revealing requirements for labeling food with expiration dates and maintaining clean and efficient cold storage areas. However, these policies were not adhered to, as evidenced by the observations and interviews conducted during the survey.
Inaccurate Facility Assessment and Resident Census
Penalty
Summary
The facility failed to revise and provide an updated and accurate resident census in its Facility Assessment, which is a process for evaluating the resident population and identifying the resources needed to provide care and services. During a review of the facility census on October 15, 2024, it was found that 94 residents were residing in the facility. However, during a concurrent interview and record review on October 18, 2024, with the Administrator, it was revealed that the Facility's Assessment was last updated on September 7, 2024, and indicated an average daily census of 88 to 91 residents. This discrepancy between the recorded census and the actual number of residents was acknowledged by the Administrator, who admitted that the Facility Assessment did not match the current census and that some residents were not accounted for in the assessment. The Administrator stated that she was responsible for updating the Facility Assessment, which serves as an overview of the services provided by the facility to the resident population. The incorrect documentation on the Facility Assessment could potentially result in not providing quality and standard care to residents. The Centers for Medicare and Medicaid Services (CMS) guidance, referenced as QSO-24-13-NH, requires that the facility assessment include an evaluation of the resident population's diseases, conditions, and limitations, and be updated as necessary and at least annually. The failure to maintain an accurate and updated Facility Assessment could place residents at risk for delays in care and treatment services.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not monitoring and addressing antibiotic use for a resident who was on antibiotics for a urinary tract infection (UTI). The resident, who had a history of UTI, sepsis, and diabetes mellitus, was readmitted to the facility from a hospital with a prescription for Bactrim DS to treat the UTI. Despite the facility's policy requiring infection surveillance within three days of admission, the Infection Preventionist Nurse (IPN) did not complete the surveillance form for the resident, and no laboratory specimens were drawn at the facility after the resident's discharge from the hospital. The Director of Nursing (DON) acknowledged that the lack of surveillance could lead to unnecessary antibiotic use, potentially causing harm such as antibiotic resistance or adverse reactions. The facility's policy on the Antibiotic Stewardship Program outlined specific steps for infection surveillance, including monitoring the type of antibiotic ordered, the route of administration, and whether a culture was obtained before ordering the antibiotic. However, these steps were not followed for the resident, leading to the deficiency identified in the report.
Failure to Reassign CNA After Grievance
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 5) was not assigned to a resident (Resident 195) after a grievance was filed by the resident's family member regarding the CNA's loud and rude behavior. Resident 195, who was admitted with multiple fractures and was fully dependent on staff for daily activities, experienced a lack of dignity and respect from CNA 5, as reported by the resident and confirmed by the family member's grievance. Despite the grievance, CNA 5 continued to be assigned to Resident 195 for three days after the grievance was filed. Interviews with the Social Services Director, Registered Nurse Supervisor, Director of Staff Development, and Human Resources Staffing Coordinator revealed that the grievance was acknowledged, and it was agreed that CNA 5 should have been removed from providing care to Resident 195. However, the intervention to remove CNA 5 was not implemented, leading to continued interaction between CNA 5 and Resident 195. The facility's policy on dignity, which requires staff to speak respectfully to residents, was not adhered to in this case.
Failure to Notify Resident of Found EBT Card
Penalty
Summary
The facility failed to notify a resident, her doctor, and a family member when her missing Electronic Benefit Transfer (EBT) card was found. The resident, who was admitted with diagnoses including metabolic encephalopathy, chronic kidney disease, and dementia, had a severely impaired cognitive ability and required substantial assistance from staff. The EBT card, valued at $190, was reported missing by a Certified Nursing Assistant (CNA) to the resident's responsible party, who was informed during a visit. The resident expressed worry about the missing card, and the CNA reported the issue to the registered nurse supervisor. The Activities Director later found the EBT card in the activity room but failed to notify the staff or the resident, which prolonged the resident's distress. The registered nurse stated that the lack of communication among staff delayed the resolution of the issue and increased the resident's distress. The facility's policy on residents and personal property requires reports of misappropriation or mistreatment of resident property to be investigated and documented, but this process was not followed in this instance.
Failure to Address Resident's Grievance for Missing EBT Card
Penalty
Summary
The facility failed to ensure that a resident was offered the opportunity to file a grievance regarding a missing Electronic Benefit Transfer (EBT) card. The resident, who was admitted with diagnoses including metabolic encephalopathy, chronic kidney disease, and dementia, had a severely impaired cognitive ability and required substantial assistance from staff. The resident's EBT card, valued at $190, was noted as missing by a Certified Nursing Assistant and reported to the resident's responsible party. However, the Social Services Director and the Director of Nursing were not aware of the missing card, and the grievance process was not initiated as required by the facility's policy. The facility's policy mandates that grievances be actively resolved and communicated to the resident or their family in a timely manner. Despite this, the grievance process was not followed, and the resident was not given the opportunity to file a grievance for the missing EBT card. This oversight had the potential to cause distress for the resident, as acknowledged by both the Social Services Director and the Director of Nursing during their interviews. The facility's failure to adhere to its grievance policy resulted in a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Inaccurate MDS Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Section A for the level II Preadmission Screening and Resident Review (PASRR) condition for two residents. Resident 42's admission record indicated diagnoses including schizophrenia, dementia, osteoarthritis, and anemia. However, the MDS did not acknowledge the schizophrenia diagnosis, which was confirmed by the MDS Nurse during an interview. The nurse admitted that the MDS was inaccurate and emphasized that such inaccuracies could lead to poor quality of care. Similarly, Resident 85's MDS assessment was completed inaccurately. The resident's diagnoses included schizoaffective disorder, chronic kidney disease, and dysphagia. The MDS Nurse noted that the cognitive skills for daily decision-making were severely impaired, and the PASRR sections A1500 and A1510 were incorrectly coded. The nurse stated that the assessment should have indicated a serious mental illness due to the schizoaffective disorder diagnosis. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, which was not adhered to in these cases.
Failure to Resubmit PASRR for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was resubmitted for two residents, leading to a potential deficiency in their mental health care. Resident 42, who was admitted with diagnoses including schizophrenia and dementia, had a severely impaired cognitive ability and was dependent on staff for daily activities. Despite these conditions, the PASRR was not resubmitted, which could have resulted in a lack of necessary mental health resources and services. The MDS Nurse acknowledged that the PASRR should have been resubmitted due to the resident's mental illness diagnosis. Similarly, Resident 85, diagnosed with schizoaffective disorder and receiving psychotropic medication, had an inaccurately completed PASRR level 1 screening by the general acute care hospital. The screening failed to recognize the serious mental illness and the use of psychotropic medication, which should have triggered a PASRR level 11 evaluation. The MDS Nurse confirmed that the facility should have completed and resubmitted a new PASRR level 1 screening to ensure the resident received appropriate treatment recommendations. The facility's policy indicated that designated staff should review PASRRs from acute hospitals and determine necessary follow-ups, which was not adhered to in these cases.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. For Resident 83, who was diagnosed with major depressive disorder, anxiety disorder, and a mental disorder, the facility did not create a comprehensive care plan to address the resident's smoking habits. Despite the resident's intact cognitive skills and the need for supervision while smoking, as indicated in the smoking assessment and evaluation, no care plan was documented. The MDS Nurse acknowledged the absence of a care plan and emphasized its importance for the safety of staff and other residents. For Resident 195, who was fully dependent on staff for daily activities and had intact cognitive skills, the facility failed to develop a care plan following grievances filed by the resident's family member. The grievances involved a CNA being loud and rude during care. Despite the grievances being logged, no care plan was created to address the incident. RN 1 confirmed the lack of a care plan related to the grievance, which could potentially delay adequate care for the resident. The facility's policy requires comprehensive care plans to be developed and evaluated in response to changes in a resident's status, but this was not adhered to in these cases.
Failure to Clean and Provide Dentures to Resident
Penalty
Summary
The facility failed to ensure that a resident's dentures were cleaned daily, which led to the resident feeling frustrated. The resident, who was blind and had fluctuating capacity to understand and make decisions, required substantial assistance from staff for personal hygiene and showering. Despite this need, the resident reported that staff did not clean the dentures daily nor place them within reach before meals, making it difficult for the resident to determine if the dentures were clean. This lack of assistance was confirmed during interviews with the resident and observations by surveyors, where it was noted that the dentures were not offered during meals and were not within reach. The Director of Nursing (DON) acknowledged that certified nursing assistants (CNAs) were responsible for soaking the dentures at night, cleaning them in the morning, and placing them within reach. However, this procedure was not followed, as confirmed by a CNA who admitted the dentures were in a drawer and not accessible to the resident. The facility's policy and procedure for denture care emphasized the importance of cleaning dentures to remove plaque and odor, and to encourage residents to wear them to facilitate eating and speaking. Despite these guidelines, the facility did not adhere to its own policies, resulting in the resident's frustration and inability to use the dentures effectively.
Failure to Schedule Ophthalmology Appointment for Resident
Penalty
Summary
The facility failed to schedule a follow-up ophthalmology appointment for a resident who required evaluation for cataracts and glaucoma. The resident, who was admitted with diagnoses including schizoaffective disorder, chronic kidney disease, and dysphagia, was found to have impaired vision and lacked the capacity for medical decision-making. An eye consultation indicated the need for a referral to an ophthalmologist, but this was not scheduled. During interviews, the resident expressed concerns about worsening vision and the delay in receiving new eyeglasses. The Social Service Director, responsible for scheduling such appointments, was unaware of the need for the ophthalmology referral and acknowledged the absence of documentation or follow-up. The facility's policies indicated that social services should manage referrals for vision care, but this was not adhered to, potentially delaying necessary treatment for the resident.
Incorrect LAL Mattress Setting for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident had the correct low air loss (LAL) mattress setting, which is crucial for preventing pressure ulcer development. The resident, who was at high risk for skin breakdown due to severe cognitive impairment and dependency on staff for personal care, had their LAL mattress set incorrectly at 400 pounds instead of their actual weight of 101 pounds. This incorrect setting was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the error and its potential risk for skin breakdown. The resident's medical history included conditions such as failure to thrive, dementia, and chronic obstructive pulmonary disease, which further increased their vulnerability to pressure ulcers. The facility's policy on low air loss therapy beds emphasized the importance of setting the mattress to specific pressures based on the patient's height and weight. Interviews with the LVN and the Minimum Data Set (MDS) Nurse confirmed the significance of correct mattress settings in maintaining skin integrity and preventing pressure ulcers, highlighting the deficiency in care provided to the resident.
Failure to Provide Correct Diet Texture for Resident Without Dentures
Penalty
Summary
The facility failed to provide the correct diet texture for a resident who did not wear dentures, which could potentially affect the resident's ability to chew food properly. The resident, who was blind and had fluctuating capacity to understand and make decisions, was on a low sodium regular diet. Despite the resident's inability to wear dentures due to difficulty in putting them in, the facility did not adjust the food texture to accommodate this, leading to challenges in chewing, especially with meat. Interviews with the Registered Dietitian and the Minimum Data Set Nurse revealed that the resident's diet should have been adjusted to a texture suitable for someone not wearing dentures. The Registered Dietitian emphasized the importance of assisting the resident with wearing dentures due to his blindness and the risk of weight loss if the food texture was too hard. The facility's policy and procedure indicated the need for special nutritional requirements and equipment, but these were not adequately implemented for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety disorder. The resident, who had experienced a traumatic event with the loss of his wife to cancer, was not given the necessary psychosocial support as outlined in the facility's policies. Despite the resident's cognitive skills being intact and his ability to make medical decisions, the care plan did not address his trauma-related needs, and staff did not offer group therapy or other interventions to help manage his emotional distress. The Social Service Director acknowledged the importance of screening residents for trauma history to prevent re-traumatization and improve their quality of life. However, the facility did not implement any interventions to address the resident's past traumatic experience. The facility's policies emphasized the need for trauma-informed care and psychosocial support, but these were not provided to the resident, leading to a deficiency in care.
Failure to Follow Physician Orders for Oxygen Settings
Penalty
Summary
The facility failed to ensure that staff followed physician orders for the correct oxygen settings for Resident 12, who was admitted with diagnoses including emphysema, end-stage renal disease, and heart failure. The resident's Minimum Data Set indicated severe cognitive impairment, requiring substantial assistance from staff. During an observation, it was noted that the resident's oxygen concentrator was set at three liters per minute, contrary to the physician's order of two liters via nasal cannula. Licensed Vocational Nurse (LVN) 1 confirmed that the oxygen setting was incorrect and acknowledged the importance of adhering to physician orders to prevent potential harm, such as exacerbating the resident's emphysema. The Minimum Data Set Nurse also emphasized that oxygen settings are considered a medication and must be administered as per the physician's orders. The facility's policies on physician orders and medication pass guidelines were reviewed, highlighting the necessity for accurate implementation of physician orders to ensure proper resident care.
Failure to Provide Emotional Support and Social Services to Grieving Resident
Penalty
Summary
The facility failed to provide medically related social services and emotional support to a resident, identified as Resident 83, who was grieving the loss of his wife. Resident 83 was admitted to the facility with diagnoses including major depressive disorder and anxiety disorder. Despite having intact cognitive skills and the capacity for medical decision-making, the resident expressed ongoing grief and a desire to participate in group therapy to share his experiences. However, the facility did not offer daily supportive visits, emotional support, or group therapy, nor was the resident referred to a psychologist since his admission. The Social Service Director (SSD) acknowledged the lack of documentation and interventions provided to Resident 83, admitting there was no reason for the failure to refer the resident to a psychologist. The SSD recognized that this oversight could lead the resident to feel neglected and at risk for further depression. The facility's policies indicated that residents displaying mental or psychosocial adjustment difficulties should receive appropriate treatment and services, which were not provided in this case.
Failure to Act on Pharmacy Consultant's Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's recommendation for a trial reduction of a psychotropic medication was acknowledged and acted upon for Resident 83. The consultant pharmacist had recommended a trial reduction of Seroquel, a medication prescribed for paranoia, during a Medication Regimen Review. However, the facility did not inform Resident 83's physician of this recommendation, and no action was taken to address the suggestion. This oversight was identified during a review of Resident 83's clinical records, where it was noted that the pharmacy consultant's recommendation note was not signed or dated by the physician. Resident 83, who was admitted to the facility with diagnoses including major depressive disorder and anxiety disorder, had intact cognitive skills for daily decision-making and required setup assistance for certain activities. Despite the consultant pharmacist's recommendation, the facility's Director of Nursing acknowledged that the facility failed to follow its policy and procedure for Medication Regimen Review and Reporting, which mandates that recommendations be documented and acted upon within 30 days. This deficiency had the potential to result in Resident 83 receiving unnecessary medication.
Failure to Label Expiration Date on Tuberculin Vial
Penalty
Summary
The facility failed to ensure that an opened multi-dose tuberculin vial was labeled with an expiration date in the medication storage room. During an observation and interview, a multidose vial of tuberculin purified protein derivative was found in the refrigerator with a date but no expiration date. A registered nurse acknowledged that the vial was just opened and should have been labeled with an expiration date. The nurse also noted that the date on the vial box could be confusing and mistaken for an expiration date instead of an open date. This oversight had the potential to lead to administering expired medication or a medication error. The facility's policy and procedures for medication storage, which were undated, indicated that refrigerated medications should be kept in closed and labeled containers. However, the observed practice did not align with this policy, as the tuberculin vial was not properly labeled with an expiration date.
Failure to Date and Label Oxygen Humidifier
Penalty
Summary
The facility failed to ensure that the oxygen humidifier for one of the residents was properly dated and labeled, which is a critical step in infection prevention and control. During an observation and interview, it was noted that the oxygen humidifier in the resident's room was neither dated nor labeled. The Licensed Vocational Nurse (LVN) acknowledged this oversight and stated that the humidifier should be changed weekly. The absence of a date and label on the humidifier posed a risk of bacterial contamination, potentially leading to a respiratory infection for the resident. The resident in question had significant medical conditions, including emphysema, end-stage renal disease, and heart failure, and was severely cognitively impaired, requiring substantial assistance from staff for personal care. The Director of Nursing (DON) confirmed that the facility's policy required humidifiers to be changed every seven days or as needed, and that they should be labeled and dated upon opening. The failure to adhere to this policy meant that staff could not determine when the humidifier was last changed, increasing the risk of infection for the resident.
Failure to Individualize Care Plans for Fall Risk Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents at risk for falls were revised and individualized to include the level of staff assistance needed for safe transfer and mobility. Resident 1, who was admitted with conditions such as osteopenia, bradycardia, and syncope, had a care plan that did not specify the level of assistance required for transfers and mobility, despite being identified as high risk for falls. The physical therapist's discharge summary indicated that Resident 1 needed contact guard assistance for transfers, but this was not reflected in the care plan. Additionally, Resident 1 experienced a fall incident, and the risk meeting notes highlighted the need for assistance with toileting and unstable gait and balance. Similarly, Resident 3, admitted with diagnoses including radiculopathy, spinal stenosis, and neuralgia, had a care plan that failed to specify the level of assistance needed for transfer and mobility. The care plan identified Resident 3 as high risk for falls due to muscle weakness and balance problems. The MDS indicated that Resident 3 required substantial assistance with activities of daily living, and the physical therapist's treatment notes specified the need for partial/moderate assistance for transfers and ambulation. However, these details were not included in the care plan. Interviews with the RN and DON revealed that care plans should be individualized based on residents' needs for assistance, and the lack of specificity in the care plans could lead to increased fall risks. The facility's policies emphasized the importance of a resident-centered fall prevention plan and comprehensive care plans that address individual needs and prevent avoidable decline. However, the care plans for Residents 1 and 3 did not meet these standards, resulting in a deficiency.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident 3, who was assessed as needing partial/moderate assistance after toileting and while ambulating. Resident 3, who had medical conditions including radiculopathy, spinal stenosis, and neuralgia, was at high risk for falls due to muscle weakness and balance problems. Despite this, the resident's care plan and Minimum Data Set indicated a need for substantial assistance with activities of daily living. On the day of the incident, a Certified Nurse Assistant (CNA) took Resident 3 to the bathroom with a walker, but did not maintain the required close proximity and physical support, resulting in the resident losing balance and falling. Interviews with the resident, CNA, Rehabilitation Supervisor, and Director of Nursing revealed that the CNA was not in the correct position to provide the necessary support, as she was in front of the resident and not holding her. The facility's policies on safety supervision and fall management emphasized the importance of providing adequate supervision and assistance to prevent accidents, which was not adhered to in this case. The failure to follow these protocols led to the resident's fall, highlighting a deficiency in the facility's adherence to its own safety and fall prevention policies.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in an incident where one resident was pushed to the floor and sustained a hematoma on the forehead. The facility did not follow the care plan and physician's orders for monitoring and addressing aggressive behaviors of the resident who committed the abuse. This resident had a history of physical aggression, including a previous altercation with the same resident, but the facility did not ensure they were separated or supervised adequately. The care plan for the aggressive resident was not individualized to address specific triggers and behaviors, such as not receiving what the resident wanted immediately. Despite multiple episodes of agitation and aggression, the facility failed to notify the physician or implement effective interventions. The facility's policies and procedures for abuse prevention and behavior monitoring were not followed, as there was no documentation of physician notification or other interventions when redirection was ineffective. Interviews with staff revealed that the aggressive resident was known to be physically aggressive and had previously hit staff members. The Director of Nursing acknowledged that the residents should have been kept separated and that the care plan should have been individualized to include specific triggers and supervision needs. The facility's policies emphasized the importance of individualized interventions and immediate safety strategies to protect residents, but these were not implemented effectively in this case.
Failure in Resident Supervision and Elopement Prevention
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding resident elopement and safety supervision, resulting in a resident leaving the facility unsupervised. The resident, who had a history of dementia, anxiety disorder, hypertension, and osteoarthritis, was assessed to be at risk for wandering and elopement. Despite this, the resident was able to leave the facility without supervision. The resident's care plan included interventions to check the resident's whereabouts, and a wander guard was ordered and placed on the resident to prevent elopement. However, on the day of the incident, staff members did not hear the alarm from the wander guard, indicating a failure in the system designed to prevent such occurrences. Interviews with staff revealed that the resident was not accounted for at the beginning of a shift, and the alarm system did not function as expected. A CNA admitted to not visually confirming the resident's presence, and an LVN acknowledged the importance of supervising residents at risk for elopement but did not recall hearing the alarm. The Director of Nursing confirmed that the wander guard should have alarmed when the resident approached an exit, but no alarm was heard. This oversight in supervision and failure of the alarm system contributed to the resident's unsupervised departure from the facility.
Failure to Obtain Physician Order for Resident's Out on Pass
Penalty
Summary
The facility failed to obtain a physician order to allow a resident to leave the facility on out on pass. This deficiency was identified during an interview and record review, where it was found that the resident, who had a history of acute kidney failure, an automatic cardiac defibrillator, and hypertension, had been leaving the facility frequently without a physician's order. The resident's Minimum Data Set indicated that they were independent in certain activities but had a care plan noting the risk of injury due to medical conditions such as hypertension and venous ulcers. Despite this, the resident signed out and left the facility multiple times from January to March 2024 without the required physician order. During a review of the facility's policies, it was noted that all residents leaving the facility must have a physician order indicating they are medically stable to go out on pass. However, the physician order reports from January to April 2024 did not include any such order for the resident. The Director of Nursing acknowledged that the resident's safety might have been compromised due to this oversight. The facility's policy on physician orders also emphasized the need for clear direction in the care of residents, which was not followed in this case.
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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