Inland Christian Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ontario, California.
- Location
- 1950 S Mountain Ave, Ontario, California 91762
- CMS Provider Number
- 555108
- Inspections on file
- 23
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Inland Christian Home during CMS and state inspections, most recent first.
A resident's barrier cream was found left open and unsanitarily on a bedside table, contrary to facility policy requiring clean and safe medication storage. Additionally, expired hydrogel gauze packets were discovered in a treatment cart, with staff confirming these items should have been removed according to policy.
Surveyors found that food items in the kitchen, including BBQ sauce and shredded Parmesan cheese, were stored without required labels or dates, and a tray of tomatoes was kept past its expiration date. Review of cooling logs showed improper cooling practices, with food not reaching required temperatures within policy timeframes and temperature checks performed too early. The Director of Kitchen acknowledged these lapses and confirmed that facility policies for food storage, labeling, and cooling were not followed.
Essential kitchen equipment, including a stove, griddle, and grill, were found with significant accumulations of grease, burnt food, and grime during a survey. The Director of Kitchen confirmed that cleaning had not been performed according to facility policy, leading to unsanitary conditions.
Two residents with complex medical conditions did not have their required RAI/MDS assessments completed within the mandated timeframes. The DON confirmed that both annual and quarterly assessments were significantly overdue, and facility policy regarding timely assessments was not followed.
Two residents did not have their required MDS assessments completed and transmitted within the mandated timeframes, resulting in significant delays. One resident with multiple chronic conditions had an annual comprehensive assessment completed over four months late, while another with diabetes and kidney disease had a quarterly assessment completed more than three months late. The DON confirmed that facility policy requiring timely assessments was not followed, leading to inadequate monitoring and delayed reporting to CMS.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, was allowed to sign a POLST form instead of the legally recognized decisionmaker, despite facility policy requiring the representative's signature when the resident lacks capacity. The DON and Social Services Director confirmed the error during interviews and record review.
A resident with multiple medical conditions was found with an uncovered and undated yankauer suction device and suction canister in their room. Staff interviews revealed inconsistent knowledge about proper infection control practices, and the facility could not provide a policy for handling this equipment.
A resident with dementia, Type 2 diabetes, and dysphagia did not receive the influenza vaccine despite providing consent, as there was no documented evidence of administration. The facility's policy and CDC guidelines required vaccination, but the process was not followed after the resident's request.
The facility failed to store food properly, with uncovered and undated items like pudding, cut melon, hot dogs with mold, and leftover pork found in the refrigerator. Interviews confirmed that these items should have been discarded or properly stored, as per facility policy.
The facility failed to maintain a sanitary kitchen environment, with grease and food crumbs behind the cooking line and under dry storage shelves. Thawing meat in the walk-in refrigerator was unlabeled and undated, and the ice machine had a brown slime build-up. These issues were acknowledged by the Nutrition Care Manager and Dining Services Director, indicating lapses in routine maintenance and adherence to facility policies.
The facility failed to maintain an effective pest control program when a roll-up door in the paper goods storage closet had a gap where light could be seen coming through. The Dining Service Director acknowledged the issue, and the facility's policy indicated that such gaps should be repaired or sealed to prevent pest entry.
The facility failed to administer the correct amount of enteral feeding nutrition as ordered for two residents. Observations and interviews revealed that the feeding pumps were not on, and significant amounts of the formula remained in the bottles. The DON confirmed that the facility's policy on enteral nutrition was not followed, and there was no documentation explaining the deviations.
The facility did not follow the menu when residents on a CCHO diet received a 1/4 cup serving of Yukon whipped potatoes instead of the prescribed 1/2 cup, and residents on a regular diet received 2.6 ounces of baked ham instead of 3 ounces. This affected 29 of 52 medically compromised residents. The Dining Service Director and Registered Dietitian confirmed the discrepancy.
A resident was administered Tramadol 50 mg by mouth instead of through their G-tube as prescribed, resulting in a medication error. Interviews with the DON and DD confirmed that staff are required to follow physician's orders for medication administration routes.
The facility failed to ensure that pharmacist recommendations made during monthly Medication Regimen Reviews (MRR) were communicated to the physician for two residents. For one resident, recommendations included assessing the risk versus benefits of antipsychotic therapy, evaluating dual antipsychotic therapy, and considering an antidepressant. For another resident, the recommendation was to request laboratory testing of her Thyroid Stimulating Hormone (TSH). The Director of Nursing (DON) acknowledged that there was no documented evidence indicating the physician was made aware of these recommendations.
An expired bottle of [brand name] docusate sodium was found in the medication supply room during an observation with the Director of Staff Development. The Director of Nursing confirmed that nursing staff are responsible for removing expired medications, as per the facility's policy.
The facility failed to ensure a resident's medical record was complete and accurate when an LVN did not document a physician's telephone order regarding a change in the route of medication. This resulted in an incomplete medical record, potentially affecting the resident's care.
A used syringe was left on a resident's bedside table, contrary to the facility's policy on sharps disposal. The LVN was uncertain about the syringe's use, and the DON confirmed that the policy was not followed.
The facility failed to maintain the walk-in refrigerator in safe operating condition, resulting in ice build-up on the bottom portion of one wall. The Nutrition Care Manager acknowledged the issue but stated that no work order had been submitted. The Dining Service Director confirmed that ice build-up should not occur. According to the FDA Federal Food Code, equipment must be properly maintained to ensure safe food temperatures.
The facility failed to provide three residents with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS-10055) when their Medicare Part A benefits were ending. The Social Services Director was unaware of the requirement, and the Director of Nursing confirmed that the facility's policy was not followed, resulting in residents not being informed of their financial responsibility and right to appeal.
The facility failed to post Direct Care Service Hours Per Patient Day (DHPPD) in a prominent place readily accessible to residents and visitors. The staffing information was found to be outdated by five days, and the Director of Nursing (DON) and the Director of Staff Development (DD) acknowledged the lapse. The facility's policy required daily updates, but the information had not been updated due to the DD's absence and the DON's oversight.
Improper Storage of Barrier Cream and Expired Wound Care Supplies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications and biologicals in two separate instances. For one resident with a history of multi-system degeneration of the autonomic nervous system, neuromuscular dysfunction of the bladder, and muscle weakness, a medication cup containing barrier cream and opened packets of zinc oxide barrier cream were found left open and unsanitarily on the bedside table. The resident had physician orders for daily wound care involving the application of barrier cream to areas of moisture-associated skin damage. Interviews with nursing staff and the infection preventionist confirmed that leaving medication cups with barrier cream at the bedside was not acceptable and not in accordance with facility policy, which requires medication storage and preparation areas to be maintained in a clean, safe, and sanitary manner. In a separate incident, five expired packets of hydrogel saturated gauze were found in the treatment cart in front of the nurse's station. The gauze had expired over a month prior to the observation. Facility policy requires that all expired medications be removed from active supply and destroyed. Interviews with nursing staff and the DON confirmed that the expired items should have been removed and that the policy was not followed. A nurse acknowledged responsibility for checking the treatment cart weekly to ensure all items were within expiration dates.
Failure to Follow Food Storage, Labeling, and Cooling Procedures
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices as observed during a kitchen inspection. Two food items, a bottle of BBQ sauce and a bag of shredded Parmesan cheese, were found in the refrigerator without labels or dates indicating when they were placed there. Additionally, a tray of tomatoes was discovered in the refrigerator past its labeled expiration date, with the label indicating they should have been discarded the previous day. The Director of Kitchen (DOK) acknowledged that these items should have been labeled, dated, and discarded according to the facility's policy and procedure, but was unsure why this was not done. A review of the facility's cooling logs for May and June revealed improper cooling practices. Several entries showed that food items, such as chicken and pork, were not cooled to the required temperature of 70°F within two hours, as stipulated by the facility's policy. In some cases, temperature checks were performed before the two-hour mark, resulting in inaccurate documentation of the cooling process. The DOK admitted to checking temperatures too early and not following the policy's requirements for cooling and documentation. The facility's policies and procedures, which were reviewed with the DOK, clearly state that all food items must be labeled, dated, and discarded when expired, and that proper cooling techniques must be followed and documented. The DOK confirmed that these policies were not followed in the instances identified during the survey.
Failure to Maintain Kitchen Equipment in Sanitary Condition
Penalty
Summary
During an inspection of the facility's kitchen, surveyors observed that essential cooking equipment, including a 4-burner stove, flat top griddle, and grill, were not maintained in a sanitary condition. The stove had a buildup of oil, burnt food particles, and grime on, around, and underneath the burners. The flat top griddle displayed visible layers of grease stains and dark discoloration across its cooking surface, while the grill had old burnt food particles sticking to it. These observations were made during the initial kitchen tour. Interviews with the Director of Kitchen (DOK) and a review of the facility's cleaning logs and policy revealed that the equipment had last been cleaned four days prior, and that deep cleaning was scheduled weekly. The facility's policy required that food contact surfaces be kept free of encrusted grease and accumulated soil, and that non-food contact surfaces be cleaned as often as necessary to prevent buildup. The DOK acknowledged that the policy was not followed, resulting in the unsanitary conditions found during the inspection.
Failure to Complete Timely Resident Assessments
Penalty
Summary
The facility failed to ensure that the required Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed within the federally mandated timeframes for two residents. For one resident with chronic obstructive pulmonary disease, heart failure, mild cognitive impairment, and acute on chronic respiratory failure, the annual comprehensive assessment was completed 146 days late. The Director of Nursing (DON) confirmed that the last quarterly assessment for this resident was completed on January 23, 2025, and the annual comprehensive assessment, which was due on April 26, 2025, was not completed until June 18, 2025. For another resident with type 2 diabetes mellitus, chronic kidney disease, hypertension, and anemia, the quarterly MDS assessment was not completed within the required 92-day interval. The last quarterly assessment was completed on February 16, 2025, and the subsequent assessment, due on May 19, 2025, was not completed until June 18, 2025, making it 122 days late. The DON acknowledged that the facility's policy and procedure, which requires timely completion of these assessments, was not followed.
Failure to Complete and Submit Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that required Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed and transmitted to the State within the federally mandated timeframes for two residents. For one resident with chronic obstructive pulmonary disease, heart failure, mild cognitive impairment, and acute on chronic respiratory failure, the annual comprehensive MDS assessment was completed 146 days late. For another resident with type 2 diabetes mellitus, chronic kidney disease, hypertension, and anemia, the quarterly MDS assessment was completed 122 days late. These delays were confirmed through record review and interviews with the Director of Nursing (DON), who acknowledged responsibility for timely completion of MDS assessments and stated that the assessments were not completed within the required 92-day interval. Facility policy and procedure documents, reviewed during the survey, specified that the resident assessment coordinator and interdisciplinary team are responsible for ensuring timely and appropriate assessments, including quarterly and annual assessments as required by OBRA regulations. The DON confirmed that these policies were not followed, resulting in the late completion and submission of the assessments. The failure to adhere to these requirements led to inadequate monitoring of the residents' progress or decline and the lack of timely resident-specific information being submitted to CMS for payment and quality measure monitoring.
Failure to Ensure Proper Completion of POLST for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) form was appropriately completed for a resident with severe cognitive impairment. The resident, who had a BIMS score of 00 indicating severe decision-making impairment, was admitted with diagnoses including dementia, diabetes type 2, and dysphagia. Despite the resident's lack of capacity, as documented in the Minimum Data Set (MDS), the POLST form was signed by the resident rather than the legally recognized decisionmaker, contrary to facility policy and professional standards. Interviews with the Director of Nursing (DON) and Social Services Director confirmed that the POLST should have been signed by the resident's legal representative, not the resident, due to the resident's incapacity. The facility's policy explicitly states that the form must be signed by the resident with capacity or by the resident representative when the resident lacks capacity. The DON acknowledged that the policy was not followed in this instance, and the documentation review supported this finding.
Failure to Maintain Proper Infection Control for Suction Equipment
Penalty
Summary
During an observation in a resident's room, a yankauer suction device was found uncovered and exposed to air, resting on top of the suction machine. Additionally, both the yankauer and the suction canister were not dated. The resident involved had a medical history including dementia, acute respiratory failure with hypoxia, and hemiplegia. These findings were based on direct observation, interview, and record review. Interviews with facility staff revealed inconsistent knowledge regarding the appropriate frequency for changing and covering the yankauer and suction canister. One LVN was unsure of the required change interval, while the Infection Preventionist Nurse stated the yankauer should be changed every seven days, covered, and labeled. The DON indicated the yankauer should be changed after each use and not left open to air. The facility was unable to provide a policy and procedure regarding infection control practices for the yankauer, indicating a lack of established protocol.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to ensure that one of five sampled residents received the influenza vaccination, despite the resident having requested the vaccine and provided consent on November 14, 2024. Review of the resident's face sheet indicated diagnoses of dementia, Type 2 diabetes, and dysphagia. Examination of the immunization dashboard revealed no documented evidence that the influenza vaccine was administered to the resident in 2024. The Infection Preventionist confirmed that the facility should have followed up with the vaccination after consent was obtained. Further review of the facility's policy and procedure for influenza vaccination, as well as CDC guidelines, indicated that administration of the vaccine should occur in accordance with current recommendations. The Director of Nursing acknowledged that the policy was not followed, and the resident, who was in a high-risk environment, did not receive the required vaccination as per facility policy and CDC guidelines.
Improper Food Storage in Refrigerator
Penalty
Summary
The facility failed to store food by methods that conserve nutritive value, flavor, and appearance. During an observation, a tray of pudding and cut melon was found in the refrigerator uncovered and undated. Additionally, a bag of hot dogs with a mold-like substance, uncovered tortillas, and leftover pork from May 4 were stored in the refrigerator drawer, ready for use. These items were not properly stored, which could affect the palatability and safety of the food served to 52 of 53 vulnerable residents who receive food from the kitchen. Interviews with the Nutrition Care Manager and the Dining Service Director confirmed that the hot dogs and tortillas should have been discarded and that no food should be left uncovered in the refrigerator. The Dining Service Director also stated that leftovers should only be kept for three days. A review of the facility's policy on Production, Purchasing, Storage indicated that all food should be covered, labeled, and dated to prevent contamination and maintain safety and wholesomeness for human consumption.
Sanitary Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed by surveyors. The floor behind the cooking line had a significant build-up of grease and food crumbs, which the Nutrition Care Manager acknowledged should be kept clean. The Dining Services Director admitted that the area had been cleaned about two weeks prior but was not on the regular cleaning schedule, indicating a lapse in routine maintenance. Additionally, the floor under the shelves in the dry storage area also had a build-up of food crumbs, which the Dining Services Director confirmed should not be present in hard-to-reach areas. Both observations highlight a failure to adhere to the facility's policy on sanitation and infection prevention/control, which mandates that nonfood contact surfaces be cleaned as often as necessary to prevent the attraction of pests and the accumulation of pathogenic microorganisms. In the walk-in refrigerator, several pieces of meat, including steak, beef, ground beef, and chicken, were found unlabeled and undated while thawing. The AM Cook and the Dining Services Director both acknowledged that the meat should be labeled and dated when placed in the refrigerator to thaw, as per the facility's policy. This failure to properly label and date the meat poses a risk of foodborne illness due to improper tracking of the thawing process and potential for the meat to be used beyond its safe consumption period. The ice machine in the kitchen was found to have a brown slime build-up on the underside of the icemaker and a slimy substance on a stainless-steel plate inside the top portion of the ice bin. The Dining Services Director admitted to cleaning the ice machine but not the specific areas where the build-up and slime were found. This oversight contradicts the facility's policy, which requires routine cleaning of the ice machine to prevent the development of slime, mold, or soil residues that could contribute to an accumulation of microorganisms. The Infection Preventionist Nurse confirmed that there had been no documented cases of norovirus in the last six months, but the presence of slime and build-up in the ice machine still poses a potential risk for contamination.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program when a roll-up door in the paper goods storage closet had a gap where light could be seen coming through. This gap was observed on two separate occasions, and the floor was noted to be partially wet. During interviews, the Dining Service Director acknowledged that there should be no gap that could allow pest entry and that the gap needed to be closed. A review of the facility's policy indicated that all holes and cracks where pests could gain entry should be repaired or sealed, and exterior department doors should have less than a 1/4-inch gap to prevent pest entry.
Failure to Administer Correct Amount of Enteral Nutrition
Penalty
Summary
The facility failed to administer the correct amount of enteral feeding nutrition as ordered for two residents, Resident 45 and Resident 13. For Resident 45, the nursing staff did not administer the full 1000 milliliters of enteral nutrition as prescribed. Observations revealed that the feeding pump was not on, and 300 milliliters of the formula remained in the bottle. Interviews with the LVN and RD confirmed that Resident 45 did not receive the full amount of nutrition, which was her primary source of diet. The resident experienced a significant weight loss of 6 pounds within a week, and the facility's policy on enteral nutrition was not followed, as acknowledged by the DON. Similarly, Resident 13 did not receive the full prescribed dose of enteral nutrition. Observations showed that the feeding pump was not administering nutrition, and 400 milliliters of the formula remained in the bag, which should have contained only 160 milliliters after the prescribed dose. The DON confirmed that there was no documentation or evidence in Resident 13's medical record to explain why the full dose was not administered. The DON emphasized the importance of following physician orders and documenting any deviations. Both residents had specific medical conditions requiring enteral feeding, such as dysphagia and poor oral intake. The failure to administer the correct amount of enteral nutrition as ordered had the potential to negatively impact their nutritional status and overall health. The facility's policy and procedure on enteral nutrition were not adhered to, leading to these deficiencies.
Menu Portions Not Followed for CCHO and Regular Diets
Penalty
Summary
The facility did not follow the menu when residents on a Consistent Carbohydrate Order (CCHO) diet received a 1/4 cup serving of Yukon whipped potatoes instead of the prescribed 1/2 cup serving, and residents on a regular diet received 2.6 ounces of baked ham instead of the 3 ounces indicated by the menu for lunch on May 6, 2024. This discrepancy affected 29 of 52 medically compromised residents who received food from the kitchen. During an observation and interview with the Dining Service Director (DSD), it was confirmed that the portions served did not match the menu requirements. The Registered Dietitian (RD) also confirmed that residents should receive the correct portions according to the menu. A review of the lunch menu for May 6, 2024, indicated that the prescribed portions were not followed.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident received medications in the route prescribed by the physician. Specifically, a Licensed Vocational Nurse (LVN) administered Tramadol 50 mg by mouth to a resident instead of through the resident's gastrostomy tube (G-tube) as ordered by the physician. This incident was observed during a medication administration on May 8, 2024, and there was no documentation indicating physician approval to change the route of administration. The resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, pancreatic cancer, chest pain, and difficulty swallowing. Interviews with the Director of Nursing (DON) and the Director of Staff Development (DD) confirmed that staff are required to administer medications as prescribed by the physician. A review of the facility's policy on medication administration, dated October 2012, also indicated that medications should be administered in a safe and effective manner, following the five rights of medication administration. The failure to follow these protocols resulted in a medication error, placing the resident at risk for adverse outcomes.
Failure to Communicate Pharmacist Recommendations to Physician
Penalty
Summary
The facility failed to ensure that pharmacist recommendations made during monthly Medication Regimen Reviews (MRR) were communicated to the physician for two residents. For Resident 41, there was no indication that a physician was notified regarding the pharmacist's MRR recommendations dated October 18, 2023. These recommendations included assessing the risk versus benefits of antipsychotic therapy, evaluating the continued use of dual antipsychotic therapy, and considering the adjunctive use of an antidepressant medication. The Director of Nursing (DON) acknowledged that the Physician/Prescriber Response section was blank and that there was no documented evidence indicating the physician was made aware of the pharmacist's recommendations. For Resident 43, there was no indication that a physician was notified regarding the pharmacist's MRR recommendations dated October 18, 2023, to request laboratory testing of her Thyroid Stimulating Hormone (TSH). The DON acknowledged that the follow-through section was left blank and that there was no documented evidence indicating the physician was made aware of the pharmacist's recommendation to obtain a TSH level. The DON also confirmed that there was no documented evidence that Resident 43's TSH level was assessed between the date of the pharmacist's recommendation and the current date of the interview. The facility's policy and procedure titled 'Consultant Pharmacist Reports' indicated that the consultant pharmacist's observations and recommendations regarding residents' medication therapy should be communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion. However, the facility failed to follow this policy, resulting in a delay of notification to the physician to evaluate residents' medication regimens, which had the potential to increase residents' risk of harm and injury without proper dosing adjustment and monitoring.
Expired Medication Found in Supply Room
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication supply room. During an observation and interview with the Director of Staff Development (DD), an expired bottle of [brand name] docusate sodium was found in the medication cabinet. The expiration date on the bottle was September 2023, and the DD confirmed that expired medications were supposed to be removed and discarded. This observation took place on May 9, 2024, at 9:00 AM. In a subsequent interview with the Director of Nursing (DON), it was stated that it was the responsibility of the nursing staff to ensure expired medications were removed from the medication supply room. A review of the facility's policy and procedure on Medication Labeling and Storage, revised in February 2023, indicated that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner, and that outdated medications should be returned or destroyed as per the dispensing pharmacy's instructions.
Failure to Document Physician's Telephone Order
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurate when staff did not document a physician's telephone order regarding a change in the route of medication in the resident's clinical record. This failure resulted in the resident's medical record being incomplete regarding physician's orders, which had the potential for staff to not provide care as specified by the physician. A review of the resident's admission record indicated the resident was initially admitted with diagnoses including surgical aftercare following surgery on the digestive system, pancreatic cancer, and difficulty swallowing. During an interview, an LVN stated he changed the route of multiple medications to be administered by gastrostomy tube instead of by mouth after receiving a telephone order from the physician but did not document the order. The Director of Nursing and the Director of Staff Development confirmed that nurses were supposed to document physician's orders in the resident's medical record, as per the facility's policies and procedures.
Used Syringe Left on Bedside Table
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment when a used syringe was left on the bedside table of Resident 251. Resident 251 was admitted with diagnoses including a urinary tract infection, altered mental status, and hydronephrosis. During an observation, an unlabeled, unpackaged, used syringe containing approximately 2 milliliters of unknown fluid was found on the bedside table next to a pitcher of water and a box of tissues. This observation was made on May 6, 2024, at 11:18 AM. During a concurrent observation and interview with an LVN, the nurse was uncertain about the syringe's use and why it was on the bedside table. The LVN acknowledged that the syringe should not have been left there and should have been discarded in the sharps container immediately after use. A review of the facility's policy and procedure on sharps disposal confirmed that used syringes and needles must be discarded immediately. The Director of Nursing confirmed that the facility's policy was not followed in this instance.
Ice Build-Up in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure the walk-in refrigerator was in safe operating condition, as evidenced by ice build-up across the bottom portion of one wall. During an observation on May 6, 2024, ice build-up was noted on the bottom six inches of the wall behind the shelves. The Nutrition Care Manager (NCM) acknowledged the issue, stating that they try to undo the ice build-up occasionally, but it accumulates quickly. The Dining Service Director (DSD) confirmed that there should not be ice build-up in the walk-in refrigerator. Additionally, the NCM admitted that no work order had been previously submitted for the ice build-up. According to the FDA Federal Food Code, equipment must be maintained in a state of repair and condition that meets specified requirements, and failure to do so could compromise the equipment's ability to properly cool or hold time/temperature control for safety foods at safe temperatures.
Failure to Provide SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide three residents with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS-10055) when their Medicare Part A benefits were ending. This document is essential as it informs residents about skilled services that may no longer be covered by Medicare Part A, their claim appeal rights, and their potential financial liability. During interviews and record reviews, it was found that Residents 8, 17, and 23 were not given the SNF ABN form prior to the termination of their Medicare Part A services. The Social Services Director (SSD) admitted to being unaware of the requirement to provide this form, indicating a gap in knowledge and adherence to the facility's policies and procedures. Further review with the Director of Nursing (DON) revealed that the facility's policy and procedure titled 'Advance Beneficiary Notices' was not followed. The policy clearly states that the facility must provide timely notices regarding Medicare eligibility and coverage, using the current CMS-approved version of the forms. The DON acknowledged that the facility failed to inform the residents of their financial responsibility and right to appeal, as mandated by the policy. This oversight resulted in the facility not meeting its obligation to notify the residents of their choices regarding their claim appeal rights and financial liability for services no longer covered by Medicare Part A.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post Direct Care Service Hours Per Patient Day (DHPPD) in a prominent place readily accessible to residents and visitors. During an observation and record review, it was found that the staffing information posted at the nursing station was dated five days prior to the current date. The Director of Nursing (DON) and the Director of Staff Development (DD) acknowledged that the DHPPD information had not been updated daily as required. The DD stated that the information had not been updated because she had been out of the facility, and the DON admitted that it was her responsibility to ensure the information was posted in the DD's absence. There was no other location in the facility where the DHPPD staffing information was posted. The facility's policy and procedure titled 'Staffing, Sufficient and Competent Nursing' indicated that direct care daily staffing numbers should be posted for every shift. Additionally, a review of the National Healthcare Safety Network (NHSN) document titled 'Nurse Staffing Hours Indicator' emphasized the importance of the Nursing Hours per Patient Day (NHPPD) as a tool to assess the value nursing staff provides around patient safety and care quality. The failure to update and post the DHPPD staffing information daily resulted in the facility's nurse staffing information not being readily available for review by residents and visitors as required by regulations.
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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