Kei-ai Los Angeles Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 2221 Lincoln Park Ave, Los Angeles, California 90031
- CMS Provider Number
- 555438
- Inspections on file
- 116
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Kei-ai Los Angeles Healthcare Center during CMS and state inspections, most recent first.
Two residents with intact decision-making capacity reported that a contracted phlebotomist entered their shared room in the early morning without properly identifying himself, used a rough, stabbing technique during venipuncture, ignored one resident’s verbal requests to stop, and caused significant pain and bruising. One resident, recovering from joint replacement, stated the phlebotomist continued inserting the needle despite her yelling for him to stop, while the roommate, who has spinal stenosis and prior phlebotomy experience, described previous and repeated rough blood draws, arm bruising, and the phlebotomist holding her arm down and telling her to “cool off” despite her complaints of pain. Both residents reported the conduct to nursing staff; however, although an RN supervisor, CN, CM, and DSD became aware of the complaints, there was no documented immediate action to protect residents, no identification of the phlebotomist, and no investigation or notification of the contracted lab, contrary to facility policies on resident rights and refusal of treatment.
Two residents with intact cognition reported that a contracted phlebotomist entered their room in the early morning without proper identification, used a rough, stabbing technique during venipuncture, ignored a resident’s verbal requests to stop, and caused significant pain and bruising, leading one resident to leave AMA and the other to refuse further blood draws, delaying needed labs and treatment. Multiple staff, including an RN supervisor, CM, CN, and DSD, were informed of the complaints and documented awareness of the concerns, but they did not initiate or document an abuse investigation, did not promptly identify or report the phlebotomist to the lab vendor, and did not implement measures to prevent further incidents, contrary to the facility’s abuse and neglect policy requiring investigation of alleged abuse.
A resident with chronic kidney disease and decision-making capacity repeatedly requested discharge home and participated in an IDT meeting where the team documented that the resident would remain until full recovery and that the MD would be notified to determine discharge safety. Despite a care plan calling for evaluation of prognosis, pre-discharge planning, and monitoring for distress, staff did not notify the physician, obtain MD orders or progress notes regarding discharge appropriateness, or document specific safety concerns preventing discharge. The resident reported not seeing a doctor since admission and feeling distressed and uninformed about discharge goals, while SS and the DON acknowledged that discharge goals, rationale, and required physician notification were not documented or completed.
A resident with chronic kidney disease and decision-making capacity repeatedly expressed a desire to return home, but the facility failed to develop and document specific discharge goals or a clear rationale for why discharge was not feasible. Although the care plan contained general language about evaluating discharge potential and arranging community resources, the record lacked resident-specific discharge planning interventions, measurable objectives, or exploration of community supports. Progress notes referenced an IDT meeting that concluded the resident would remain until deemed safe by the MD, yet there was no documented assessment of discharge needs, no ongoing communication with the resident about next steps, and no physician documentation explaining why community discharge was not possible, contrary to facility policy.
A resident with encephalopathy, epilepsy, dysphagia post-CVA, severe cognitive impairment, and high ADL dependence was admitted for rehab with a documented goal to discharge home with family. After becoming combative and being placed on 1:1, the resident was transferred to a GACH on a 5150 hold. Over subsequent months, the hospital CM repeatedly faxed referrals and updated clinicals and reported the resident was calm, off restraints, and ready for discharge, but the facility’s admissions staff and DON declined readmission based on the prior 5150 and did not contact the hospital to clarify current status. Despite policies requiring priority readmission of hospitalized residents and comprehensive discharge planning focused on discharge goals and transition to post-discharge care, the facility did not revise or implement an effective discharge plan or facilitate the resident’s return or alternative placement, resulting in the resident remaining in the hospital long after being cleared for discharge.
A resident with intact cognition and multiple medical conditions repeatedly complained of inadequate assistance from CNAs, housekeeping, and nursing staff, as well as unresolved diarrhea and confusion about his medications. Staff, including an LVN, ADON, and social worker, acknowledged that the resident frequently voiced complaints about care and staff behavior, but no grievance form was completed, no grievance was formally filed, and no documentation was produced to show that his concerns were recorded or resolved. This conflicted with the facility’s grievance policy, which requires grievances to be documented, logged, and followed up by the grievance official while keeping the resident informed.
A resident with severe cognitive impairment and high risk for pressure ulcers was found with new MASD and skin tears. An LVN assessed the area and applied zinc oxide ointment without obtaining a physician's order, following a common practice in the facility. Review of facility policies confirmed that a physician's order is required for such topical treatments, and this protocol was not followed.
Two residents with complex medical conditions were discharged to other facilities without documentation of required nurse-to-nurse reports in their medical records, despite physician orders and staff confirmation that the reports were given. This resulted in incomplete and inaccurate records, contrary to facility policy.
A CNA wrapped a sheet around a resident's legs and tied it to the bedframe, restricting movement without a physician's order or care plan authorization. The resident, who had severe cognitive impairment and was fully dependent on staff, was found by multiple staff members with his legs immobilized. Facility policy prohibits such restraints, and the action was confirmed as unauthorized and not in line with professional standards.
A resident with severe cognitive impairment and multiple medical conditions was found with a sheet tied around their legs and bedframe by a CNA, constituting an unauthorized restraint. Multiple staff recognized this as abuse and removed the restraint, but the administrator did not report the incident to CDPH and the ombudsman within the required two-hour window, citing the absence of serious bodily injury. This delay violated mandated reporting requirements.
During a COVID-19 outbreak, staff failed to consistently wear N95 masks as required, with some not wearing them at all and one LVN wearing an N95 over a surgical mask, compromising its effectiveness. A CNA was observed not removing gloves between tasks, and the facility did not follow local health department guidelines such as social distancing, separating laundry, and keeping doors closed for exposed residents. These actions were not in accordance with the facility's infection control policies.
A resident's discharge was delayed due to transportation issues, but the responsible party was not notified of the changes and was unable to reach staff despite leaving multiple voicemails. Staff interviews revealed that no one was assigned to check or knew how to retrieve voicemail messages, resulting in the responsible party waiting and becoming worried, and the resident feeling anxious.
A resident with anxiety and other health conditions had their care plan include Alprazolam administration and monitoring. After a physician discontinued the Alprazolam, the care plan was not updated to reflect this change, resulting in an inaccurate care plan that did not match the resident's current treatment.
Five used oxygen concentrators were found unsanitized and uncovered in the supply room alongside clean supplies. Staff confirmed the devices had not been disinfected after resident use and were awaiting hospice pickup, in violation of facility policy requiring cleaning, disinfection, and separate storage of reusable equipment.
A medication cup with pills was left unattended on the bedside table of a resident who required moderate assistance, after an LVN failed to remain with the resident to ensure medication was taken, contrary to facility policy and professional standards. Staff interviews and policy review confirmed that medications should not be left at the bedside and that staff are required to observe residents take their medications.
A resident with chronic kidney disease, heart failure, and dementia had a care plan requiring intake and output monitoring to prevent renal complications. Despite this, staff were unable to provide documentation that intake and output were monitored, as confirmed by both an LVN and an RN supervisor. The resident was totally dependent, incontinent, and received nutrition via a gastrostomy tube, yet the care plan intervention was not implemented as required.
A resident with multiple complex medical conditions had a physician's order for GT feeding and water flush to be administered over 16 hours, but the order and MAR documented a 12-hour administration period instead. Both a registered dietitian and an LVN confirmed the documentation was incorrect, resulting in inaccurate medical records.
A call light system malfunction occurred when staff failed to properly reset a bathroom call light switch, causing the entire second floor's call system to become nonfunctional. This affected 71 residents, including a resident with significant care needs who was unable to use the call light and had to rely on a hand bell to request assistance. The deficiency was confirmed by staff interviews and review of facility records.
A resident with dementia and a history of falls did not have a floor mat placed as required by their care plan, increasing the risk of injury. Staff confirmed the absence of the mat, which was necessary to prevent injury, despite the facility's policy to implement comprehensive care plans.
The facility failed to ensure a CNA maintained current BLS certification, as required by the facility's policy. The CNA's BLS certificate had expired, and the DSD stated that only licensed staff were required to have BLS certification. This deficiency had the potential for the CNA not to recognize residents needing immediate emergency intervention.
A resident with dementia and a history of falls experienced multiple unwitnessed falls due to the facility's failure to ensure the sensor pad alarm was monitored and functioning. Staff interviews revealed inconsistencies in checking the alarm's placement and responding promptly when triggered, despite the resident's high fall risk and facility policies emphasizing safety and supervision.
A resident with chronic kidney disease stage five did not receive the required weekly blood tests as ordered by the physician. The facility failed to conduct the tests on a specified date, and there was no documentation explaining the omission. The oversight was confirmed by the registered nurse supervisor and the director of nursing, who noted the absence of records indicating a refusal by the resident.
A facility failed to provide adequate supervision and care for a cognitively impaired resident with a history of falls. Despite physician orders for 30-minute visual checks, these were not consistently implemented, and the care plan was not updated after multiple falls. The resident, with multiple health issues, experienced a third fall resulting in hospitalization for a hematoma and shoulder fracture. Staff interviews revealed lapses in supervision, contributing to the resident's repeated falls and injuries.
A resident was discharged without a proper order from their primary physician, leading to inaccurate documentation. Despite the resident's need for assistance with daily activities, the facility failed to confirm the discharge order source, violating professional standards.
A resident was administered psychotropic medications without obtaining informed consent, as required by the facility's policy. The resident, who was cognitively intact, did not sign the consent forms, nor did a responsible party. The forms were only signed by the physician, and the facility's policy required either the resident or a responsible party to sign, with two nurses witnessing the consent if the resident was unable to sign. The oversight was confirmed by the registered nurse supervisor and the director of nursing.
A resident in an LTC facility, who was frequently incontinent and dependent on assistance for daily activities, consistently refused personal and toileting hygiene. The facility failed to involve the resident's responsible party or notify the physician about the refusals, despite care plans indicating the need for such actions. Interviews with staff revealed the resident often refused care, leading to poor hygiene and potential health risks.
The facility failed to ensure call lights were within reach for five residents, preventing them from calling for assistance. Observations confirmed that residents with various impairments had their call lights out of reach, contrary to their care plans and facility policy. Staff acknowledged the oversight and the importance of accessible call lights.
A resident with limited mobility experienced a significant change in condition, but the facility failed to notify the physician directly. The resident's RNA services were discontinued based on hospice company orders without direct physician communication, potentially leading to a sacro-coccyx wound. Facility staff did not document or communicate the change of condition as required by policy.
A resident was prescribed psychotropic medications without proper diagnoses documented in their medical record, leading to an increased risk of unnecessary medication administration. Despite having a history of dementia, alcohol dependency, and opioid dependency, the resident had not seen a psychiatrist since readmission, and the facility failed to conduct a necessary psych consult. Facility staff acknowledged the oversight, which was against the facility's policy requiring diagnoses for psychotropic medication orders.
A facility failed to implement person-centered care plans for three residents, leading to a deficiency. One resident's care plan did not include their preferred activities like reading, another resident's request to listen to music was not updated in their care plan, and a third resident lacked an activity care plan altogether, resulting in isolation. The Activities Director and DON acknowledged these oversights, highlighting the importance of updating care plans to reflect residents' preferences.
The facility failed to provide consistent activities for three residents, impacting their physical, cognitive, and emotional health. One resident with dementia was observed without activity engagement, another with depression reported inconsistent staff visits, and a third with schizophrenia had limited access to preferred activities like bingo and religious services. The facility's policy required sufficient staffing for activities, but this was not met.
The facility failed to provide prescribed range of motion (ROM) and mobility services to several residents, as per physician orders. Residents did not receive active or passive ROM exercises, nor the application of prescribed splints and orthotic devices. Documentation was incomplete, and residents reported not receiving the necessary care. The Director of Staff Development confirmed the deficiencies, which could lead to a decline in ROM and mobility.
A resident with mobility concerns did not receive prescribed OT and PT services for 20 days due to the facility waiting for insurance authorization, despite having physician orders. This delay potentially contributed to further ROM limitations. Observations showed the resident's condition had deteriorated, with bent hips and knees and complaints of pain during repositioning.
A facility failed to complete therapy discharge summaries for several residents, impacting their follow-up care. Residents with conditions like schizophrenia, Alzheimer's, and B-cell lymphoma did not have their PT and OT discharge summaries completed, as confirmed by therapists and the Director of Rehabilitation. The facility's policy emphasized the importance of these summaries for ensuring continued care.
A resident with severe cognitive impairment and a preference for Mandarin was not provided with adequate translation services, despite the facility's policy and care plan interventions. Instead, an LVN used a personal phone to communicate, contrary to the facility's procedures, potentially affecting the resident's psychosocial wellbeing.
A resident's care plan for 'Alteration in Comfort' was not updated quarterly as required, despite the facility's policy. Staff interviews revealed that the care plan, last revised several months ago, was not reviewed to assess its effectiveness or the resident's progress, contrary to the facility's procedures.
A resident at risk for seizures did not have the physician-ordered bilateral padded side rails on their bed, as confirmed by staff. The resident, with severe cognitive impairment and dependency on staff, was admitted with epilepsy and other conditions. Despite the care plan and physician's order, only one padded side rail was present, increasing the risk of injury during seizures.
A resident with emphysema and other health conditions was found receiving oxygen therapy without a physician's order, a practice admitted by an LVN as common in the facility. The DON confirmed the necessity of physician orders for such treatments, highlighting a lapse in following the facility's oxygen administration policy.
The facility failed to complete annual performance evaluations for two LVNs and one RN, and an annual competency evaluation for another RN. Additionally, a CNA was found with an expired certification. These deficiencies were confirmed by the DSD and DON, who emphasized the importance of evaluations and certifications for staff performance and resident safety.
The facility did not complete an annual performance evaluation for a CNA hired in 2022, as required by policy. The DSD and DON confirmed the importance of these evaluations for addressing performance issues. The facility's policy mandates annual evaluations.
Two residents in the facility experienced medication administration errors. One resident did not have Lidocaine patches removed and reapplied as scheduled, and psyllium husk powder was not given with the correct amount of water. Another resident's aspirin was held without a physician's order due to a reported nosebleed, and the frequency of certain medications was not clarified. These actions led to potential adverse effects and risks.
The facility exceeded the acceptable medication error rate with errors involving two residents. One resident received psyllium husk with an incorrect amount of water due to lack of proper measuring equipment, while another resident's aspirin was withheld without a physician's order due to a complaint of nosebleeds. These errors were identified through observations and interviews, highlighting failures in following physician orders and proper medication administration procedures.
A resident did not receive their lidocaine patch as ordered, leading to a significant medication error. The LVN failed to remove old patches and apply new ones on schedule, resulting in prolonged exposure to the medication. The DON confirmed that this could lead to adverse effects, and the facility's medication administration policy was not followed.
The facility failed to properly store, label, and remove expired and discontinued medications, affecting several residents. Inspections revealed expired insulin, improperly stored refrigerated medications, and unlabeled medications, compromising their safety and effectiveness. The DON confirmed that these deficiencies could lead to adverse health consequences for residents.
The facility failed to ensure safe food storage and preparation practices, leading to deficiencies. Expired food items were found in the refrigerator, and food taken from the freezer lacked thaw dates, contrary to policy and manufacturer instructions. Additionally, improper sanitation practices were observed, with kitchen staff using towels stored in water without sanitizer to clean surfaces, risking cross-contamination. An open tube feeding bag was also found in the resident refrigerator without a label or date.
The facility failed to maintain sanitary conditions in the dumpster area, with one dumpster overfilled and uncovered, and trash littering the surrounding floor. Interviews with staff confirmed that the dumpster lids should be covered and the area kept clean to prevent pest attraction. The facility's policy and FDA Food Code require covered receptacles to prevent access by pests.
The facility failed to ensure proper infection control practices for residents under COVID-19 observation. Staff and a family member were observed not wearing required eye protection, violating facility protocols and CDC guidelines. This involved residents with histories of falling, respiratory failure, and dementia, highlighting a significant lapse in infection prevention measures.
A resident fell in the bathroom due to unstable toilet seat side rails in the facility. The side rails were loose and wobbly, failing to provide adequate support. Maintenance staff confirmed the instability, and the DON acknowledged the risk of falls and injury. Facility policies lacked guidelines for stable toilet seats with side rails.
The facility failed to complete timely MDS assessments for two residents, leading to potential delays in care planning and Federal database submission. One resident's significant change in status MDS was completed 40 days after admission to hospice, while another resident's Admission MDS was completed 35 days post-admission. Delays were due to staff performing additional duties and the absence of a DON.
The facility failed to complete the Quarterly MDS assessments on time for two residents, resulting in delayed submission to the Federal database. One resident with a history of falling and adult failure to thrive had their MDS completed 28 days after the ARD, while another resident with hemiplegia had theirs completed 21 days after the ARD. The delays were due to MDS staff performing additional duties in the absence of a DON.
Failure to Honor Residents’ Right to Refuse Rough Phlebotomy and Ensure Respectful Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity and that their right to refuse care from a contracted phlebotomist was honored during early-morning blood draws at the bedside. On the date in question at approximately 4:00 AM, a male phlebotomist from an outside laboratory company entered the shared room of two cognitively intact residents without introducing himself, wearing a visible name badge, or adequately responding when asked for his name. One resident, admitted with a left artificial knee joint following joint replacement surgery and assessed on the MDS as having cognitive skills for daily decision-making and needing varying levels of assistance with ADLs, reported that the phlebotomist stated he was going to draw her blood but did not explain who he was or why the blood draw was needed. She stated he proceeded to insert the needle in a forceful, stabbing manner without using a tourniquet, causing significant pain. According to the resident’s account and nursing progress notes, she verbally told the phlebotomist to stop the procedure and yelled at him to stop, but he continued to re-insert the needle to draw her blood. She reported feeling that her rights were violated and that the incident caused her anguish and anxiety, contributing to her desire to leave the facility against medical advice. Her roommate, who also had cognitive skills for daily decision-making and was admitted with spinal stenosis requiring extensive assistance with ADLs, corroborated hearing the interaction, including the resident’s repeated requests for the phlebotomist to stop and her screams of pain. The roommate stated that the phlebotomist did not knock, did not identify himself, and pulled the curtain open when entering the room. The second resident also reported having previously experienced rough and unprofessional blood draws by the same phlebotomist, including an earlier incident after which her arm was bruised for a week. She stated that he held her arm down despite her telling him it hurt, told her to “cool off,” and used a stabbing technique that caused significant pain, despite her informing him she had small veins and was a hard stick. On the later date, when he again entered around 4:00 AM without identifying himself, she told him to get out and refused to allow him to draw her blood, even when a male nurse accompanied him and asked her to permit the blood draw. Nursing progress notes documented that she adamantly refused the blood draw and that the CN attempted to convince her to proceed, but there was no documentation of honoring her refusal through appropriate follow-up per policy. Facility staff were aware of both residents’ complaints about the phlebotomist’s rude, harsh, and rough conduct, as reflected in nursing progress notes and staff interviews. The RN Supervisor, CN, Case Manager, and Director of Staff Development all acknowledged being informed of concerns about the phlebotomist’s behavior and the residents’ reports that he did not identify himself and caused pain. Despite this, there was no documented evidence that the facility took immediate action to ensure resident safety, to prevent the phlebotomist from continuing to provide services to other residents, or to initiate an investigation to identify the phlebotomist and notify the contracted laboratory company. The RN Supervisor stated she attempted but was unable to reach the core lab to identify the phlebotomist and did not document or thoroughly follow up, and the CN did not report or investigate the incident after hearing the second resident’s complaint. As of the survey date, no investigation or interventions had been implemented, despite facility policies stating that residents are to be treated with respect, be free from abuse, be informed of and participate in treatment decisions, and that refusals of care must be assessed and addressed by the CN or DON without coercion or intimidation.
Failure to Investigate and Act on Abuse Allegations Against Contracted Phlebotomist
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and to report, investigate, and act on allegations of abusive conduct by a contracted phlebotomist. On the date in question, a cognitively intact resident with a left artificial knee joint following joint replacement surgery reported that a male phlebotomist entered her room around 4 a.m. without introducing himself, without a name badge or identification, and proceeded to draw blood despite her questions about who he was and why the blood draw was needed. She stated he did not use a tourniquet and inserted the needle in a forceful, stabbing manner that caused significant pain. According to nursing progress notes and her interview, she verbally told him to stop, yelled at him to stop the procedure, and felt her rights were violated when he continued to re‑insert the needle, causing her anguish and anxiety and contributing to her decision to leave the facility against medical advice. A second cognitively intact resident with spinal stenosis also reported rough, unprofessional conduct by the same phlebotomist on more than one occasion. She stated that during a prior blood draw, he did not identify himself, did not knock, pulled the curtain open, held her arm down despite her telling him she had small veins and that it hurt, and told her to “cool off.” She reported that his technique was poor, that he used a stabbing technique, and that her arm was bruised for a week after the first encounter. When he returned early in the morning on the same date as the first resident’s incident, again without acknowledging himself, she told him to get out and refused to allow him to draw her blood. She reported these concerns to nursing staff, including that she had been a certified phlebotomist for 25 years and believed his technique inflicted unnecessary pain. Multiple staff members were aware of the residents’ complaints but did not ensure that the allegations were treated and processed as potential abuse in accordance with the facility’s abuse and neglect policy. Nursing progress notes documented that staff were aware of the first resident’s complaints and told her the phlebotomist would be reported to the core lab company administrator, but there was no documented evidence of immediate action to ensure resident safety or to prevent the phlebotomist from continuing to provide services. The registered nurse supervisor, case manager, charge nurse, and director of staff development all acknowledged receiving complaints or hearing about the phlebotomist being rude, harsh, or having “heavy hands,” yet the charge nurse did not report or further investigate, and the case manager only provided limited information to the administrator. The registered nurse supervisor stated she attempted to call the core lab to identify the phlebotomist but did not document or follow up thoroughly. As of the survey date, there was no record that the facility had identified the phlebotomist, investigated the concerns of the two residents, or notified the contracted laboratory company, and no interventions had been implemented to prevent further incidents, despite the facility’s written policy requiring investigation of alleged abuse and neglect to clarify what happened and identify possible causes. The second resident’s refusal to allow further blood draws from the phlebotomist led to a delay in necessary lab work, treatment, and diagnosis. Staff interviews confirmed that the phlebotomist typically arrived before the start of the morning shift, that some staff were unfamiliar with his identity, and that communication with the vendor was acknowledged as an area needing improvement. The director of nursing stated he was unaware of any issues with the contracted phlebotomist and emphasized that residents can refuse blood draws and that poor service or delays in blood draws may risk delayed care. Despite these acknowledgments and the facility’s abuse and neglect policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and neglect as failure to provide necessary services to avoid physical harm, pain, mental anguish, or emotional distress, the facility did not initiate or document an abuse investigation into the phlebotomist’s conduct toward the two residents.
Failure to Notify Physician and Document Discharge Planning for Resident Requesting Return Home
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and to follow through on discharge planning as documented in an Interdisciplinary Team (IDT) meeting for one resident. The resident was admitted with chronic kidney disease and, per a recent MDS, had decision-making capacity and required varying levels of assistance with ADLs, including cleanup assistance for eating and oral hygiene, maximal assistance for toileting, showering, lower body dressing, and footwear, and partial or supervisory assistance for transfers and upper body care. The resident’s care plan, initiated months earlier, included interventions to evaluate and discuss prognosis for independent or assisted living, identify and address limitations and risks, establish and revise a pre-discharge plan, arrange community resources, and monitor for anxiety, fear, and distress. Record review showed that an IDT meeting was held to discuss the resident’s ongoing desire to discharge home, which the resident had been expressing since the prior year. The IDT documented that the resident would remain in the facility until full recovery and that discharge home would occur once deemed safe by the MD, and the IDT notes stated that the physician would be notified regarding the resident’s request and the team’s determination that discharge was not safe. However, as of the survey date, there was no documentation that the physician had been notified, no physician progress note addressing discharge appropriateness, no physician orders related to discharge planning or safety concerns, and no follow-up documentation indicating that any consultation occurred. Interviews confirmed these documentation gaps and failures in communication. The resident reported not having seen a doctor since arrival at the facility and described emotional distress, frustration, and feeling uninformed about discharge goals, discharge planning, and the steps needed to return home. The resident stated that a meeting about going home had occurred but that nothing further was done. The social services staff, who participated in the IDT, stated that the resident was not deemed safe to discharge but could not provide documentation of the specific clinical, functional, or safety factors supporting that conclusion, acknowledged that the resident had decision-making capacity, and admitted she had not updated the resident on discharge goals or notified the physician as indicated in the IDT summary. The DON stated that the resident remained without documented discharge goals or a documented rationale for why discharge home was not feasible and that someone from the team should have notified the MD to evaluate the resident for discharge goals, consistent with the facility’s policy requiring communication of marked physical or psychological changes to the physician for proper management.
Failure to Develop and Document Resident-Centered Discharge Goals and Rationale
Penalty
Summary
The deficiency involves the facility’s failure to develop and document discharge goals and to provide a documented rationale for determining that discharge was not feasible for a resident who wished to return home. The resident was admitted with chronic kidney disease and, per the MDS, had decision-making capacity and required varying levels of assistance with ADLs, including maximal assistance for toileting, showering, and lower body dressing, and partial assistance for transfers. Progress notes documented that an IDT meeting was held to discuss the resident’s desire to discharge home, and the IDT concluded the resident would remain in the facility until deemed safe for discharge by the MD. However, despite the resident expressing a desire to go home since a prior date, there was no documentation of specific discharge goals or a clear explanation in the record as to why discharge home was not feasible. The resident’s care plan contained general statements about evaluating and discussing prognosis for independent or assisted living, identifying limitations and needs for maximum independence, establishing a pre-discharge plan, arranging community resources, and monitoring for anxiety, fear, and distress. However, the record lacked evidence that these care plan elements were implemented in a resident-specific, measurable way. There was no documented assessment of the resident’s discharge needs, no documented exploration of community supports or alternative discharge options, and no measurable discharge planning interventions or objectives. The record also did not reflect ongoing communication with the resident about next steps in the discharge process. Interviews further supported the lack of documented discharge planning. The resident reported feeling emotionally distressed, uninformed about the discharge process, and believed the facility was not allowing discharge, stating he felt captured and had not seen a doctor since arrival. The SS, who was part of the IDT, stated the resident was not deemed safe to discharge and had decision-making capacity, but could not provide documentation outlining the specific clinical, functional, or safety factors that made discharge not feasible and acknowledged not updating the resident on discharge goals after the IDT meeting. The DON confirmed that the resident remained in the facility without documented discharge goals or a documented rationale for why discharge home was not feasible, despite facility policies requiring weekly IDT reevaluation of discharge potential, documentation of changes in the medical record, updating the care plan with the discharge plan, and documenting when returning to the community is not feasible and why.
Failure to Develop and Implement Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an appropriate discharge plan and readmission process for a resident who had been transferred to a general acute care hospital (GACH) for psychiatric evaluation and was not permitted to return. The resident was initially admitted with encephalopathy, epilepsy, dysphagia following a CVA, and severe cognitive impairment, and was largely dependent on staff for ADLs. The admission record did not show a psychiatric diagnosis, but the resident had an order for PRN quetiapine for agitation and was documented as lacking capacity to understand and make decisions. The care plan and an IDT conference shortly after admission identified a discharge goal of returning home with family when able, with the facility offering to assist with home health and DME arrangements or alternative placement options once the MD cleared discharge. After admission, the resident became physically combative with staff, including kicking, punching, and disrobing, and was placed on 1:1 observation. This escalation led to a physician order to transfer the resident to GACH on a 5150 hold. The facility considered this transfer a proper discharge due to the change in condition. The facility’s policies on readmission and transfers/bedholds stated that residents discharged to the hospital would be given priority for readmission and that the facility would develop discharge planning procedures focusing on discharge goals and preparation for transition to post-discharge care. However, following the transfer, the facility did not complete or revise a discharge plan addressing the resident’s post-hospital needs or potential return, despite the previously documented goal of discharge home with family and the facility’s stated role in coordinating services and placement. GACH case management notes documented that the resident had been decannulated and was ready for discharge for at least three months, and that multiple referral packets and updated clinical information were faxed to the facility and other SNFs over several months. On at least one follow-up call, the facility’s admissions coordinator confirmed receipt of the referral and stated the resident was not appropriate for readmission because of the prior 5150 transfer, even after being informed by the GACH case manager that the resident was calm, not on restraints, and did not require a sitter. The DON acknowledged awareness of a referral in mid-December, stated that the information indicated the resident was still restrained, and confirmed he did not contact GACH to verify the resident’s current status. The DON maintained that the facility would not readmit the resident and did not address whether hospitalization was an appropriate long-term disposition, despite facility policies requiring priority readmission and comprehensive discharge planning. These actions and inactions resulted in the resident remaining in the hospital for months after being cleared for discharge. The facility’s own policies titled “Readmission to the Facility” and “TRANSFERS / BEDHOLDS AND DISCHARGES – OUT OF FACILITY” required that residents discharged to the hospital be given priority for readmission upon bed availability and that discharge planning procedures focus on the resident’s discharge goals and preparation for transition to post-discharge care. Despite these policies, the facility did not reassess or update the resident’s discharge plan after the psychiatric transfer, did not engage in documented IDT discharge planning with the hospital’s input, and did not coordinate or facilitate the resident’s return or alternative placement once the resident was clinically ready for discharge. Instead, the facility relied on the fact of the prior 5150 transfer as the basis for refusing readmission, without documented individualized assessment of the resident’s current condition or needs, and without documented communication with GACH to clarify the resident’s status. This lack of effective discharge planning and refusal to readmit contrary to policy formed the basis of the cited deficiency.
Failure to Document and Address Resident Grievances About Care and Assistance
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and document a cognitively intact resident’s repeated grievances about inadequate assistance and nursing care. The resident was admitted with esophagitis, duodenal ulcer, and generalized muscle weakness, and assessments showed he used a walker and wheelchair, was independent with several ADLs, and required assistance with toileting hygiene and bathing. A later history and physical documented that the resident had capacity to make medical decisions and had expressed dissatisfaction with staff and the facility, specifically reporting inadequate assistance and communication issues. During an interview conducted with a translation hotline, the resident reported ongoing diarrhea, stated he did not understand why his medications were not working, and complained that CNAs, housekeeping, and licensed nurses were not providing the assistance he needed. Staff interviews confirmed that the resident voiced many complaints about charge nurses, housekeeping, and CNAs, and that he repeated these complaints. The ADON reported that the last IDT meeting with the resident, used to discuss the plan of care and any concerns, occurred on 11/11/25, despite the resident’s ongoing complaints. The social worker stated that no grievance had been filed for this resident and that his multiple complaints were addressed immediately, but the facility could not provide any documentation to support that the complaints were recorded or resolved. This was inconsistent with the facility’s written grievance policy, which requires staff to record the nature and specifics of grievances on a designated form, for the grievance official to log and document actions taken, and to keep the resident informed of progress toward resolution.
Topical Medication Applied Without Physician Order
Penalty
Summary
The facility failed to obtain a physician's order prior to the application of a topical medication for a resident with severe cognitive impairment and high risk for pressure ulcers. During an observation, a Certified Nurse Assistant and a Restorative Nurse Assistant identified bloody drainage, redness, and small skin tears in the resident's buttock skin folds and notified the Licensed Vocational Nurse (LVN). The LVN assessed the area, identified new Moisture Associated Skin Damage (MASD) with bloody discharge, cleansed the area with normal saline solution, and applied zinc oxide ointment without a physician's order. The LVN stated it was common practice to follow the skin treatment protocol by cleansing and applying zinc oxide ointment before reporting the condition to the physician. Review of facility policies and procedures confirmed that the application of zinc oxide ointment requires a physician's order and that medications should only be administered upon a clear, complete, and signed order from an authorized prescriber. The Director of Nursing and Director of Staff Development both confirmed that the facility's protocols do not allow for the application of topical agents such as zinc oxide without a physician's order. This practice was not in accordance with professional standards or the facility's own policies.
Failure to Document Nurse-to-Nurse Reports at Discharge
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurate for two residents who were discharged to other facilities. For both residents, physician orders required that a nurse-to-nurse report be given to the receiving facility at the time of discharge. However, there was no documentation in either resident's medical record indicating that this report was provided, despite staff interviews confirming that the reports were given verbally. The absence of this documentation resulted in incomplete and inaccurate medical records for both residents. One resident, admitted with diagnoses including cerebral infarction, diabetes mellitus, and generalized muscle weakness, was discharged to another facility with a physician order specifying a nurse-to-nurse report. Another resident, with spinal stenosis, diabetes mellitus, and a history of falls, was also discharged under similar orders. In both cases, staff acknowledged during interviews that the nurse-to-nurse reports were not documented in the residents' records. Facility policy required that all services provided, including communication with other staff or facilities, be documented in the medical record to ensure completeness and accuracy.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) wrapped a linen sheet around a resident's legs and tied it to the bedframe, restricting the resident's movement. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was found with his legs immobilized by the sheet. Multiple staff members, including registered nurses and other CNAs, observed the resident in this state and confirmed that the sheet was tied tightly enough to prevent movement. The CNA responsible stated that the action was intended to prevent the resident from sliding out of bed, but acknowledged that this was not an approved or trained method for addressing such issues. The resident involved had a complex medical history, including type 2 diabetes, Alzheimer's disease, dementia, dysphagia, benign prostatic hyperplasia, and hyperlipidemia. The Minimum Data Set assessment indicated severe cognitive impairment and total dependence on staff for care. Nursing notes and interviews documented that the resident was typically active in bed, moving his legs frequently, and that the restraint was not authorized by a physician or included in the resident's care plan. The facility's investigation substantiated that the CNA used an unauthorized method to restrict the resident's movement, in violation of facility policy and without a physician's order. Facility policy explicitly prohibits the use of physical restraints, including tucking sheets so tightly that a resident cannot move, unless ordered by a physician and with proper consent. Staff interviews, including those with the Director of Nursing and Director of Staff Development, confirmed that the use of a sheet as a restraint was not standard practice and was considered a violation of resident rights and dignity. The incident was identified as a suspicion of involuntary restraint, and the CNA involved was suspended and subsequently resigned.
Failure to Timely Report Alleged Abuse Involving Unauthorized Restraint
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the California Department of Public Health (CDPH) and the ombudsman within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, dementia, and type 2 diabetes, who was found with a linen sheet wrapped around his legs and tied to the bedframe. Multiple staff members, including CNAs and RNs, observed the resident with his legs restrained by a sheet, which was not authorized by a physician and was not in accordance with facility policy. The staff immediately notified supervising nurses, and the sheet was removed upon discovery. Interviews and documentation revealed that the CNA responsible for applying the sheet did so in an attempt to prevent the resident from sliding off the bed, but acknowledged that this was not the proper method and was not how he was trained. The facility's investigation substantiated that the CNA used an unauthorized restraint, and the action was identified as a suspicion of involuntary restraint. Staff members who witnessed the incident described the restraint as tight, preventing the resident from moving his legs, and recognized it as a form of abuse. The CNA involved was suspended pending investigation and later resigned. Despite the immediate internal response, the facility administrator, who served as the abuse coordinator, did not report the incident to CDPH and the ombudsman within two hours of becoming aware of the situation. Both the administrator and the director of nursing stated that the delay was due to the absence of serious bodily injury. However, facility policy and regulatory requirements mandate that all allegations of abuse be reported immediately, but not later than two hours if the alleged violation involves abuse, regardless of injury. The delay in reporting constituted a failure to comply with mandated reporting requirements.
Failure to Implement Infection Control Policies During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its infection control policies and procedures during a COVID-19 outbreak, as evidenced by multiple observed lapses. Staff did not consistently wear N95 masks as required, with some personnel, including staffing coordinators, not wearing N95 masks despite the presence of COVID-19 positive staff and residents. One LVN was observed wearing an N95 mask over a surgical mask, which the infection preventionist confirmed defeats the purpose of the N95 by preventing a proper seal. Additionally, a CNA was seen leaving a resident's room while still wearing gloves, retrieving clean linen from a cart, and re-entering the room without removing or changing gloves, contrary to the facility's standard precautions policy. Further, the facility did not comply with local health department guidelines intended to contain the spread of COVID-19. These lapses included failure to maintain social distancing, not staggering communal activities, not separating laundry of exposed and non-exposed residents, and not keeping doors closed for residents exposed to COVID-19. Interviews with the infection preventionist and director of nursing confirmed that these guidelines were not followed, and that adherence to these protocols is essential for infection mitigation. Review of facility policies indicated that staff are to be educated and adhere to proper infection control techniques, including prompt glove removal and compliance with local masking requirements.
Failure to Notify Responsible Party of Discharge Delay and Inadequate Voicemail Monitoring
Penalty
Summary
The facility failed to notify and update a resident's responsible party (RP) regarding a significant delay in the resident's transportation for discharge. The resident, who was cognitively intact and dependent on staff for several activities of daily living, was scheduled for discharge home with transportation initially set for the morning but delayed multiple times throughout the day. Although the resident was informed of the new transportation time, the RP was not notified of the changes, resulting in the RP waiting and becoming worried when the resident did not arrive home as expected. The RP made several attempts to contact the facility, leaving voicemails that were not reviewed or responded to by staff. Interviews with facility staff revealed that no one was assigned to check the facility's voicemail system, and several staff members, including the receptionist, RN supervisor, and DON, stated they did not know how to retrieve voicemail messages. Facility policy required prompt notification of changes in a resident's condition or status to the resident and their representative, but this was not followed. The lack of communication led to the resident feeling anxious about going home and the RP experiencing distress due to the lack of information.
Failure to Update Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to revise and update the care plan for a resident after the discontinuation of Alprazolam, a medication used to treat anxiety disorder. The resident, who had diagnoses including anxiety disorder, mood disorder, and generalized muscle weakness, was admitted and later re-admitted to the facility. The resident's Minimum Data Set assessment indicated moderately impaired cognitive skills and significant dependence on staff for daily activities. A physician's order was given to administer Alprazolam as needed for anxiety, and the care plan was developed to reflect this intervention, including monitoring for side effects and effectiveness. However, when the physician discontinued the Alprazolam order, the care plan was not updated to reflect this change. Both the assistant director of nursing and the acting director of nursing confirmed during interviews that the care plan should have been discontinued when the medication was stopped. The facility's policy required ongoing assessment and revision of care plans as resident conditions changed, but this was not followed, resulting in the care plan inaccurately reflecting the actual care provided to the resident.
Failure to Sanitize and Properly Store Used Oxygen Concentrators
Penalty
Summary
The facility failed to adhere to its infection control policy regarding the cleaning and disinfection of reusable medical devices, specifically oxygen concentrators. During an observation in the supply room, five oxygen concentrators that had been used by residents were found not sanitized and not covered with plastic, as required by facility policy. These devices were stored in the same area as clean supplies, and staff interviews confirmed that the concentrators were awaiting pickup by a hospice company and had not been disinfected or separated from clean items. Staff, including an LVN, the infection preventionist, and the assistant director of nursing, acknowledged that the used concentrators were not sanitized and that there was no separate storage area for them. The facility's policy, reviewed on 4/30/25, requires that reusable items such as oxygen concentrators be cleaned and disinfected between residents, then covered and stored in a designated location. The failure to follow these procedures resulted in unsanitized equipment being stored with clean supplies, contrary to established infection control protocols.
Medications Left Unattended at Bedside
Penalty
Summary
A medication cup containing pills was observed left unattended on the bedside table of a resident who had been admitted with diagnoses including hypertension, seizure disorder, and generalized muscle weakness. The resident's care plan required medications to be administered as ordered and for staff to monitor for effectiveness and side effects. The Minimum Data Set indicated the resident was cognitively intact but required moderate assistance with several activities of daily living, including set up with eating. On the morning of the incident, the resident confirmed that a licensed vocational nurse (LVN) had given her the medication but she had not yet taken it. Interviews with facility staff, including the restorative nursing assistant and the LVN involved, confirmed that the medication cup was left at the bedside and that the LVN did not remain with the resident to ensure the medication was taken. The director of nursing also confirmed that facility policy requires staff to remain with residents until all medications have been taken. Review of the facility's policy on administering oral medications reiterated this requirement.
Failure to Implement Care Plan for Intake and Output Monitoring
Penalty
Summary
The facility failed to implement the care plan for a resident with chronic kidney disease, heart failure, and dementia. The care plan, initiated due to impaired renal function, required monitoring of the resident's intake and output to prevent renal complications. Despite this intervention being documented in the care plan, there was no evidence that intake and output were actually monitored or recorded for the resident. Both a licensed vocational nurse and a registered nurse supervisor confirmed the absence of documentation regarding intake and output monitoring during interviews and record reviews. The resident in question was totally dependent on activities of daily living, had severe cognitive impairment, was incontinent of urine and bowel, and received nutrition via a gastrostomy tube. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to be developed and implemented for each resident. However, the lack of documentation and monitoring of intake and output as specified in the care plan constituted a failure to meet the resident's hydration and nutritional needs as outlined in the plan.
Inaccurate Transcription and Documentation of GT Feeding Orders
Penalty
Summary
The facility failed to accurately transcribe and document a physician's order for gastrostomy tube (GT) feeding and water administration for one resident. The physician's order specified that the resident should receive Nutren tube feeding at 50 ml/hr and water at 40 ml/hr for 16 hours, but the order and the Medication Administration Record (MAR) both indicated a start time of 6 p.m. and a stop time of 6 a.m., which only covers 12 hours instead of the prescribed 16 hours. This discrepancy was present in the resident's medical record and persisted from the date of the order through the end of the month, with the MAR signed as if the order had been correctly carried out. The resident involved had significant medical conditions, including heart failure, chronic kidney disease, and dementia, and was totally dependent on activities of daily living with severe cognitive impairment. Both the registered dietitian and a licensed vocational nurse confirmed during interviews and record reviews that the GT feeding and water flush should have been administered over 16 hours, from 6 p.m. to 10 a.m., and agreed that the documentation was incorrect. The facility's policy required that medical records be complete and accurate, but this was not followed in this instance.
Call Light System Malfunction Due to Improper Resetting of Bathroom Switch
Penalty
Summary
The facility failed to ensure that the resident call light system remained functional for all residents on the second floor on 5/3/2025 and 5/4/2025. The deficiency occurred when a bathroom call light switch in one of the resident rooms was not properly reset by staff after being triggered. Instead of returning the switch fully to the 'up' position, it was left halfway, which caused the entire call light system on the second floor to malfunction and enter safety mode. As a result, all call lights for the second floor were activated on the nurse’s station panel, and residents were unable to use the call system to request assistance during this period. During this time, 71 residents on the second floor were affected, including a resident with a history of autonomic nervous system disorder, falls, contractures, muscle weakness, mild cognitive impairment, and a history of TIA. This resident was dependent on staff for all activities of daily living and reported that the call light system was not working throughout the night, requiring the use of a hand bell to summon staff. The resident emphasized the importance of the call light system for requesting help with personal care and in situations of feeling unwell. Interviews with facility staff, including the Maintenance Director and DON, confirmed that the malfunction was due to improper resetting of the bathroom call light switch. The facility’s policy required that each resident have a functional means to call staff from their bed and bathroom at all times, but this was not maintained due to the failure to properly reset the switch, resulting in a system-wide outage for the second floor.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who was at high risk for falls. The resident, admitted with diagnoses including dementia and a history of falling, had a care plan intervention that required a floor mat to be placed on the right side of their bed to minimize the risk of injury from falls. However, during an observation, it was noted that the floor mat was not present as required by the care plan. Interviews with facility staff, including a registered nurse supervisor and a licensed vocational nurse, confirmed the absence of the floor mat and acknowledged its necessity to prevent injury in case of a fall. The facility's policy and procedures emphasize the development and implementation of a comprehensive, person-centered care plan to meet the resident's needs, which was not adhered to in this instance.
Failure to Maintain BLS Certification for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) maintained current Basic Life Support (BLS) certification, which is a set of emergency procedures designed to sustain life in victims experiencing cardiac arrest. During an interview and record review, it was found that CNA 1's BLS certificate had expired. The Director of Staff Development (DSD) stated that the facility required BLS certification only for licensed staff, which needed to be renewed every two years, and that CNAs were not required to have BLS certification. However, the facility's policy and procedures indicated that personnel should have completed training on the initiation of cardiopulmonary resuscitation (CPR) and BLS, including defibrillation, for victims of sudden cardiac arrest, and that key clinical staff members should obtain and/or maintain certification in BLS. This deficiency had the potential for CNA 1 not to recognize residents who may need immediate emergency intervention.
Failure to Monitor and Respond to Sensor Pad Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was at high risk for falls. The resident, diagnosed with dementia and a history of falling, was admitted with a care plan that included the use of a sensor pad alarm to alert staff when the resident attempted to get out of bed unassisted. However, the facility did not ensure the sensor pad alarm was consistently monitored and functioning, nor did they ensure staff responded immediately when the alarm was triggered. The resident experienced unwitnessed falls on three separate occasions. On each occasion, there was no documentation indicating whether the sensor pad alarm was in place or if it had been triggered. Interviews with staff revealed that the resident sometimes removed the sensor pad alarm, and there was no evidence that staff consistently checked the placement and functionality of the alarm. The facility's policy indicated that alarms should not be the sole intervention to prevent falls, yet there was a lack of documentation and response to the alarm system. The facility's policies on safety and supervision, as well as fall risk management, emphasized the importance of implementing and documenting interventions to reduce accident risks. Despite these policies, the facility did not effectively communicate or implement the necessary interventions to prevent the resident's falls. The lack of immediate response to the alarm and failure to ensure the alarm's functionality contributed to the resident's repeated falls, highlighting a deficiency in the facility's supervision and accident prevention measures.
Failure to Conduct Weekly Blood Tests for Resident with Chronic Kidney Disease
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident diagnosed with osteomyelitis of the vertebra and chronic kidney disease stage five. The physician had ordered weekly blood tests, including a complete blood count (CBC) and a comprehensive metabolic panel (CMP), to be conducted every Friday. However, the facility did not perform the required blood tests on the specified date, 7/5/24, following the initial test on 6/28/24. This oversight was identified during a review of the resident's records and confirmed by the registered nurse supervisor, who could not find documentation explaining why the test was not conducted. The director of nursing also confirmed the absence of documentation regarding the missed blood test and noted that the resident had a history of refusals, although there was no record of refusal for this specific test. The facility's policy and procedures require staff to process test requisitions and ensure tests are conducted as ordered by the physician. The failure to perform the blood test as ordered could potentially hinder the monitoring of the resident's kidney function, which is critical given the resident's condition.
Failure to Prevent Falls for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision and care for a resident with a history of falls, cognitive impairment, and poor safety awareness. The resident, who required assistance with transferring and toileting, experienced multiple falls over a period of two months. Despite a physician's order for visual checks every 30 minutes after an initial unwitnessed fall, the facility did not consistently implement this intervention. Additionally, the resident's care plan was not updated after a second fall, and no new interventions were developed to prevent further incidents. The resident was readmitted to the facility with multiple diagnoses, including dementia, end-stage renal disease, and hemiplegia following a stroke. The resident's condition required partial to moderate assistance with daily activities and supervision for safety. After the first fall, the facility's interdisciplinary team recommended interventions such as visual checks and physical therapy screening, but these were not effectively implemented or updated after subsequent falls. On the third fall, the resident was found in the bathroom with injuries, including a hematoma and a shoulder fracture, requiring hospitalization. Interviews with staff revealed lapses in supervision, as the assigned CNA was on break without proper coverage, leading to a failure in conducting the required visual checks. The facility's policies on fall risk assessment and care planning were not adequately followed, contributing to the resident's repeated falls and injuries.
Failure to Obtain Proper Discharge Order
Penalty
Summary
The facility failed to obtain a discharge order from the primary physician for a resident before discharging them. The resident was admitted with diagnoses including aftercare following surgery, unsteadiness on feet, and generalized muscle weakness. Despite being cognitively intact, the resident required assistance with various activities of daily living. On 1/22/25, a telephone order was entered by a licensed vocational nurse indicating the primary physician gave an order to discharge the resident on 1/23/25. However, the primary physician's progress note dated 1/24/25 indicated that neither the primary physician nor their team gave such an order. The case manager and registered nurse supervisor were unable to confirm who gave the discharge order, and the director of nursing stated that the physiatrist wrote an order for discharge on 1/23/25. The facility's policy requires nursing services to obtain discharge orders and ensure accurate documentation. The failure to obtain a proper discharge order and the resulting inaccurate documentation led to a deficiency in the facility's adherence to professional standards of practice.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for one resident, identified as Resident 1, before administering Trazadone, Wellbutrin XL, Duloxetine, and Brexpiprazole. The resident was admitted with diagnoses including morbid obesity, cerebral infarction with left-sided weakness, and major depressive disorder. Despite being cognitively intact, the resident did not sign the informed consent forms, nor did a responsible party. The forms were only signed by the physician, and the facility's policy required either the resident or a responsible party to sign, with two nurses witnessing the consent if the resident was unable to sign. The Medication Administration Record (MAR) showed that the resident received these medications over several weeks without the required consent. Interviews with the registered nurse supervisor and the director of nursing confirmed the oversight, acknowledging that the consent forms lacked the necessary signatures. The facility's policy emphasized the importance of obtaining informed consent for psychotropic drugs, involving the resident in care decisions, and verifying consent with the attending physician. However, these procedures were not followed, leading to the deficiency.
Failure to Provide Adequate Hygiene Care for Incontinent Resident
Penalty
Summary
The facility failed to provide adequate toileting and personal hygiene care for a resident who was frequently incontinent of bowel and bladder. The resident, who was cognitively intact but dependent on assistance for activities of daily living, consistently refused personal and toileting hygiene after episodes of incontinence. Despite the resident's refusal, the facility did not involve the resident's responsible party in discussions about the care plan or notify the physician about the resident's refusal of hygiene care. The resident's care plans indicated potential limitations in activities of daily living due to depressive symptoms and nonadherence to hygiene needs. However, the facility did not follow through with the interventions outlined in the care plans, such as reporting non-compliant behavior to the physician and responsible party. Interviews with nursing staff revealed that the resident was often smelly and refused hygiene care, even after being administered pain medication to alleviate discomfort during care. The facility's policy and procedures required that residents unable to perform activities of daily living independently receive necessary services to maintain hygiene. However, the facility did not adhere to these policies, as evidenced by the lack of follow-up interdisciplinary team meetings to address the resident's refusal of care and the absence of physician notification. This deficiency resulted in the resident experiencing poor hygiene and an unpleasant smell, with the potential for developing infections and pressure ulcers.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for five sampled residents, resulting in their inability to call for assistance when needed. This deficiency was observed during a survey where the call lights for Residents 60, 73, 201, 213, and 225 were found to be out of reach. Each of these residents had specific care plans that included interventions to keep the call light within reach, yet these interventions were not followed. Resident 201, who was admitted with diagnoses including dysphagia and severe cognitive impairment, was observed in a wheelchair with the call light out of reach. Similarly, Resident 213, with hemiplegia and cognitive impairment, and Resident 225, who was cognitively intact but dependent on assistance for personal care, also had their call lights out of reach. These observations were confirmed by LVN 2, who acknowledged the importance of having the call lights accessible to residents. Further observations revealed that Resident 60, with dementia and other health issues, and Resident 73, with hemiplegia and cognitive communication deficits, also had their call lights placed out of reach. Interviews with staff, including CNAs and nurses, confirmed the oversight and highlighted the potential risks of residents being unable to call for help. The facility's policy required call lights to be within reach, but this was not adhered to, leading to the deficiency.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to assess and directly notify the primary physician of a significant change in condition for a resident with limited range of motion and mobility. This deficiency involved a resident who was unable to walk with the Restorative Nursing Aide (RNA) using hand-held assistance or a front-wheeled walker. The failure to communicate this change in condition to the physician resulted in the discontinuation of RNA services without direct discussion with the physician, potentially contributing to the development of a sacro-coccyx wound. The resident, admitted with diagnoses including Alzheimer's disease, dementia, and a history of falling, was initially evaluated by physical therapy to require minimal assistance for bed mobility, transfers, and walking. Despite being admitted to hospice care, the resident's RNA services for ambulation were discontinued based on orders from the hospice company, without direct communication with the resident's physician. The facility's documentation did not reflect any change of condition documentation for the resident's inability to participate in RNA, and the hospice physician did not recall any reports regarding the RNA services. Interviews with facility staff revealed that the RNA had reported the resident's inability to participate in RNA to the Registered Nurse Supervisor, but the change of condition was not documented or communicated to the physician. The Director of Nursing confirmed that the nurse should have assessed the resident, completed SBAR documentation, and directly communicated with the physician. The facility's policy required prompt notification of the physician and detailed observations by the nurse, which were not followed in this case.
Inaccurate Assessment Leads to Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, leading to the administration of psychotropic medications without proper documentation of diagnoses. The resident, who was admitted with a history of dementia, alcohol dependency, and opioid dependency, was prescribed several psychotropic medications, including Depakote, Quetiapine, and Venlafaxine, without corresponding diagnoses documented in the medical record. The Minimum Data Set (MDS) indicated depression as a diagnosis, but no other psychiatric or mood disorder diagnoses were listed to justify the use of these medications. Interviews with facility staff, including the MDS Nurse, Social Services Director, and Director of Nursing, revealed that the resident had not seen a psychiatrist since readmission, and the necessary psych consult was not conducted. The facility's policy required that psychotropic medication orders include a diagnosis, which was not adhered to in this case. This oversight resulted in an increased risk of the resident receiving unnecessary medications, as confirmed by the staff during the interviews.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, which resulted in a deficiency. Resident 197, who was admitted with conditions including hemiplegia, hemiparesis, dementia, and muscle weakness, had a care plan that did not incorporate their preferred activities such as reading magazines and books. Despite the resident's mild cognitive impairment and moderate dependency, the care plan only mentioned social and recreational involvement without specific adaptations for their interests. During an observation, the resident was found lying in bed with the TV on, and a CNA noted the resident liked to sit up and engage in activities, indicating a disconnect between the care plan and the resident's preferences. Resident 530, admitted with depression and muscle wasting, had no cognitive impairment but was moderately dependent on assistance. The resident expressed a preference for group activities but was unable to participate due to mobility issues, leading them to watch TV or listen to music. However, the care plan did not reflect the resident's request to listen to music, which was communicated to the staff but not updated in the care plan. This oversight was confirmed during an interview with the Activities Director, who acknowledged the importance of updating care plans to reflect current interests. Resident 44, with diagnoses of schizophrenia and major depressive disorder, had severe cognitive impairment and was dependent on assistance. The resident's preferences included participating in religious services and playing bingo, but the care plan did not exist, leaving the resident isolated and without structured activities. The Activities Director and the Director of Nursing both confirmed the absence of an activity care plan for Resident 44, emphasizing the necessity of such plans to prevent resident isolation and ensure staff are aware of individual preferences.
Inconsistent Activity Provision for Residents
Penalty
Summary
The facility failed to provide consistent activities for three residents, which had the potential to negatively impact their physical, cognitive, and emotional health. Resident 197, who was admitted with diagnoses including hemiplegia, hemiparesis, dementia, and muscle weakness, was observed in bed with the TV on and no activity materials or staff present. The resident's care plan indicated a need for social and recreational involvement, but observations showed a lack of engagement in activities. Resident 530, admitted with depression and muscle wasting, was also observed in bed with the TV on and no activity materials or staff present. The resident expressed that activity staff visits were inconsistent, despite the care plan emphasizing the importance of group activities. The Activities Director confirmed that the resident was not seen by an activity aide on several days in December, which could affect the resident's psychosocial well-being. Resident 44, with diagnoses of schizophrenia and major depressive disorder, expressed a preference for activities such as bingo and religious services. However, the resident's activity records showed limited engagement in these preferred activities. The Activities Director and Director of Nursing acknowledged that the resident's preferences were not consistently followed, which could impact the resident's psychosocial well-being. The facility's policy indicated that activity programs should be staffed to meet residents' needs, but this was not observed in practice.
Failure to Provide Prescribed ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for five residents, as per physician orders. Resident 37 did not receive active range of motion (AROM) exercises for both arms and sit-to-stand transfers using a front-wheeled walker (FWW) as prescribed. The documentation for these tasks was incomplete, and the resident reported not receiving these exercises for over a week. The Director of Staff Development (DSD) acknowledged the lack of documentation and stated that the resident could experience a decline in ROM and mobility if the restorative nursing aide (RNA) services were not provided. Resident 127 did not receive passive range of motion (PROM) exercises for both legs and arms, nor the application of prescribed splints and a pressure relief ankle foot orthosis (PRAFO) as ordered. The documentation was incomplete for several dates, and the resident reported not receiving the exercises or splints on certain days. The DSD confirmed the lack of RNA services in accordance with physician orders, which could lead to a decline in ROM and mobility. Similarly, Resident 44 did not receive PROM exercises for both arms and legs as ordered, with documentation missing for several dates. The resident reported receiving exercises only every couple of weeks, and the DSD confirmed the deficiency in RNA services. Resident 36 did not have the left-hand splint applied as ordered, and the documentation did not include this task for several months. The DSD acknowledged the oversight and the potential for a decline in ROM and mobility. Resident 128 was not properly assessed for the application of knee splints, and the physical therapist noted that the splints should not have been applied due to the resident's refusal and potential for pain and skin breakdown. The facility's policy indicated that residents with limited ROM and mobility should receive treatment to prevent further decline, but this was not adhered to for the residents involved.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility failed to provide necessary occupational therapy (OT) and physical therapy (PT) services to a resident, identified as Resident 96, who had range of motion (ROM) and mobility concerns. Despite having physician-signed care plans for OT and PT, the resident did not receive the prescribed therapy interventions from October 9, 2024, to October 29, 2024. This lapse potentially contributed to further ROM limitations in the resident's knees. Resident 96 was admitted to the facility with a history of falling and adult failure to thrive, and was readmitted after a hospitalization. The PT evaluation on October 9, 2024, indicated the resident had impaired mobility and was referred for PT due to these concerns. The PT plan included therapeutic exercises and gait training, to be conducted three times per week for four weeks. Similarly, the OT evaluation on October 10, 2024, noted decreased strength and mobility, with a plan for therapeutic activities five times per week for 60 days. However, there was a significant gap in therapy sessions, with the resident receiving PT and OT only on October 9 and 10, and then not again until October 29, 2024. The delay in therapy services was attributed to the facility waiting for insurance authorization, despite having physician orders in place. The Director of Rehabilitation and the Director of Nursing acknowledged that the facility's policies did not require waiting for insurance authorization before providing treatment. Observations and interviews revealed that the resident's condition had deteriorated, with bent hips and knees and complaints of pain during repositioning. The facility's failure to provide timely therapy services as per the care plan resulted in a deficiency in the quality of care provided to Resident 96.
Incomplete Therapy Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that the clinical records for four residents with limited range of motion and mobility were complete, specifically lacking discharge summaries from physical and occupational therapy. Resident 96's records were missing PT and OT discharge summaries for two separate treatment periods, which were supposed to be completed on the last day of treatment. The absence of these summaries was confirmed during interviews with the occupational and physical therapists, as well as the Director of Rehabilitation, who emphasized the importance of these documents in ensuring proper follow-up care. Resident 130's clinical records also lacked PT and OT discharge summaries following their last treatment sessions. The evaluations indicated that Resident 130 required assistance with mobility and daily activities, and the treatment plans included therapeutic exercises and neuromuscular reeducation. The Director of Rehabilitation reiterated the necessity of completing discharge summaries to ensure that the recommended care was continued after therapy ended. Similarly, Resident 44 and Resident 37's records were incomplete without PT discharge summaries. Resident 44 had conditions such as schizophrenia and functional quadriplegia, while Resident 37 had B-cell lymphoma and diabetes, both requiring extensive therapy plans. The Director of Nursing confirmed that clinical records should accurately reflect the care provided, and the facility's policy stated that discharge summaries are crucial for justifying the treatment period and outlining follow-up care.
Failure to Utilize Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to respect the resident's right to dignity and respect by not utilizing its translation services to communicate with a non-English speaking resident. Resident 82, who was admitted with diagnoses including congestive heart failure, toxic encephalopathy, and depression, had severe cognitive impairment and required moderate assistance with activities of daily living. The resident's preferred language was Mandarin, as indicated in the Social Services Assessment and Language Barrier care plan, which included interventions such as obtaining an interpreter and providing activities in the resident's native language. Despite these documented needs, the facility did not provide adequate translation services. Licensed Vocational Nurse 5, who was responsible for Resident 82, used a personal phone to translate instead of the facility's translation services. The Social Services Director confirmed that residents with language barriers should be provided with tools like translators or communication boards, and the Director of Nursing stated that staff should use the facility's translation service if no staff spoke the resident's language. The facility's policy required providing an interpreter for non-English speaking residents, but this was not followed, potentially affecting the resident's psychosocial wellbeing.
Failure to Update Resident Care Plan Quarterly
Penalty
Summary
The facility failed to update the care plan for Resident 173, who was admitted with diagnoses including diabetes, dysphagia, gastrostomy, and spinal stenosis. The care plan titled 'Alteration in Comfort' was last revised on 5/18/2024, and it was not updated quarterly as required. This oversight was identified during a review of the resident's records and interviews with facility staff, who acknowledged that the care plan should have been reviewed and revised to assess its effectiveness and the resident's progress. Interviews with facility staff, including a Restorative Nursing Aide, a Licensed Vocational Nurse, a Registered Nursing Supervisor, and the Director of Nursing, revealed that the care plan was not updated despite the facility's policy requiring quarterly reviews and updates for any change in the resident's condition. The staff admitted that without regular updates, it was challenging to determine if Resident 173 was making progress toward the care plan goals. The facility's policy and procedure documents also indicated that care plans should be revised according to the Resident Assessment Instrument schedule and as dictated by changes in the resident's condition.
Failure to Provide Ordered Padded Side Rails for Seizure-Prone Resident
Penalty
Summary
The facility failed to ensure that a resident identified as at risk for seizures was free from accidents by not providing the physician-ordered bilateral padded side rails on the resident's bed. The resident, who was admitted with diagnoses including epilepsy, hemiplegia, hemiparesis, and aphasia, was severely impaired in cognitive skills and dependent on staff for activities of daily living. The physician's order dated 9/20/2024, and the care plan revised on 10/26/2024, both indicated the need for bilateral padded side rails to prevent injury during seizures. During an observation and interview, it was confirmed that the resident only had one padded side rail instead of the required two. The Licensed Vocational Nurse and the Director of Nursing acknowledged the importance of having both side rails padded to prevent injury during a seizure. However, the facility did not have a specific policy for seizure precautions that included padded side rails, despite the care plan indicating their necessity. This oversight placed the resident at increased risk for falls and injuries during a seizure.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 96, had physician orders to receive oxygen therapy via nasal cannula as needed for shortness of breath. Resident 96 was admitted with diagnoses including emphysema, cachexia, and chronic kidney disease, and required extensive assistance from staff for daily activities. During an observation, the resident was found receiving oxygen at 5 liters per minute without a physician's order, as confirmed by LVN 6. The LVN admitted that placing residents on oxygen without a physician's order was a common practice among facility staff. The Director of Nursing (DON) acknowledged that an order should have been placed before administering oxygen therapy, emphasizing the potential dangers of administering oxygen without proper orders. A review of the resident's care plan indicated a goal of preventing shortness of breath, with interventions including administering oxygen at two liters per minute as ordered. The facility's policy on oxygen administration required verification of a physician's order before proceeding, which was not followed in this instance.
Deficiencies in Staff Evaluations and Certification
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 6) and one Registered Nurse (RN 3) had completed annual performance evaluations, and one Registered Nurse (RN 4) had a completed annual competency evaluation. Additionally, a Certified Nursing Assistant (CNA 7) was found to have an expired certification. These deficiencies were identified through interviews and record reviews conducted by the Director of Staff Developer (DSD) and the Director of Nursing (DON). The DSD confirmed the absence of required evaluations and the expired certification, emphasizing the importance of these evaluations and certifications for maintaining staff performance and ensuring resident safety. The DSD and DON highlighted the significance of annual performance and competency evaluations in assessing staff performance, addressing issues such as attendance, and ensuring adherence to proper procedures in resident care. The expired certification of CNA 7 was particularly concerning, as it directly impacted the quality of care provided to residents. The facility's policies required annual evaluations and up-to-date certifications, but these were not adhered to, potentially affecting the care of all 294 residents in the facility.
Failure to Conduct Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure that one of six Certified Nursing Assistants (CNA 5) had a completed annual performance evaluation as required by the facility's policy and procedures. CNA 5 was hired on 7/26/2022, but a review of their employee file revealed no performance evaluation had been conducted. During an interview and record review with the Director of Staff Developer (DSD), it was confirmed that CNA 5's annual performance evaluation was missing. The DSD emphasized the importance of these evaluations for addressing issues such as attendance and call-offs. The Director of Nursing (DON) also confirmed that annual performance evaluations are necessary to provide coaching to employees who may not be meeting job requirements. The facility's policy, revised in June 2010, mandates that employee job performance be reviewed and evaluated at least annually.
Medication Administration Errors and Lack of Clarification in Orders
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents, leading to potential adverse effects. For one resident, the facility did not remove and apply new Lidocaine patches as scheduled, resulting in prolonged exposure to the medication. Additionally, the resident's psyllium husk powder was not administered with the prescribed amount of water, increasing the risk of side effects. The Licensed Vocational Nurse (LVN) involved acknowledged the errors and the potential for increased risk of irregular heartbeat and hospitalization due to excessive Lidocaine. Another resident's medication administration was also mishandled. The LVN held the resident's aspirin due to a reported nosebleed, despite no physician order to do so. The LVN failed to assess the resident for signs of bleeding and documented the aspirin as administered, which was inaccurate. The facility's Director of Nursing (DON) confirmed that the resident was at risk for stroke and other complications due to the improper handling of medications. Furthermore, the facility did not clarify the frequency of administration for certain medications, including a Lidocaine patch and nasal spray, for the second resident. This lack of clarity in medication orders posed a risk of side effects from improper dosing. The facility's policies and procedures require that medication orders include all necessary details, but these were not followed, leading to the deficiencies observed.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 6.06% error rate. This deficiency was observed in the cases of two residents. For Resident 256, the error involved the administration of psyllium husk, a fiber laxative, which was not given in accordance with the physician's orders. The Licensed Vocational Nurse (LVN) used an incorrect amount of water to dissolve the psyllium husk, providing only four ounces instead of the prescribed eight ounces. This error was due to the lack of graduated cups for accurate measurement, as acknowledged by the Director of Nursing (DON). In the case of Resident 205, the error involved the administration of aspirin, which was not given as per the physician's orders. The LVN withheld the aspirin due to the resident's complaint of nosebleeds, despite there being no physician order to hold aspirin for this reason. The LVN failed to visually check for signs of nosebleed and incorrectly documented that the aspirin was administered. The facility's policy required that medications be administered according to orders and that any concerns be discussed with the physician, which was not followed in this instance. Both cases highlight the facility's failure to adhere to physician orders and proper medication administration procedures. The errors in medication administration for Residents 256 and 205 were directly linked to the lack of proper equipment for measuring medication and the failure to follow established protocols for assessing and documenting medication administration. These deficiencies were identified through observation, interviews, and record reviews conducted by the surveyors.
Failure to Administer Lidocaine Patch as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering the resident's lidocaine patch according to physician orders. The resident, who was admitted with a diagnosis including generalized muscle weakness, had intact cognition and required varying levels of assistance for daily activities. The physician's orders specified that a lidocaine patch should be applied to each knee daily and removed per schedule. However, during an observation, it was found that the patches dated from two days prior had not been removed, and new patches were applied without the required drug-free period. The Licensed Vocational Nurse (LVN) involved admitted to forgetting to apply the new patches on the scheduled day due to being distracted by other tasks. This resulted in the resident receiving additional lidocaine, as the old patches were not removed on time. The Director of Nursing confirmed that the prolonged application of the patches could lead to adverse effects. The facility's policy on medication administration requires adherence to physician orders and documentation of medication administration, which was not followed in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and removal of expired, undated, and discontinued medications, affecting several residents. During inspections, it was found that medications such as insulin, Calcitonin nasal spray, Zytiga, and Stiolto Respimat were either expired, not labeled with an open date, or stored contrary to manufacturer requirements. For instance, an opened Insulin Lispro Kwikpen for a resident was found expired, and a Licensed Vocational Nurse (LVN) acknowledged that the expired insulin should have been removed and discarded as it could compromise safety and effectiveness. Additionally, the facility did not remove expired Vitamin D3 from the medication room and failed to store refrigerated medications and vaccines at the required temperature range. The refrigerator in the medication room was found to be at 30°F, which is below the manufacturer's recommended range of 36°F to 46°F. This improper storage affected medications such as Ozempic, Mounjaro, Prevnar 20, Tubersol, and omega-3 fish oil, potentially compromising their safety and effectiveness for residents. The Director of Nursing (DON) confirmed that the medications stored in the refrigerator were not at the required temperature range and acknowledged that expired and improperly stored medications could lead to adverse health consequences for residents. The facility's policies and procedures for medication storage and disposal were not followed, leading to the potential for medication errors and compromised resident safety.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, leading to several deficiencies. Expired food items, including a container of cottage cheese and single-serve cartons of milk, were found stored in the reach-in refrigerator. The dietary supervisor acknowledged that these items were expired and should have been discarded, as consuming expired milk could cause gastrointestinal problems. Additionally, the facility's policy indicated that commercially processed foods must be dated when opened and are good for seven days or until the expiration date, which was not adhered to in this case. The facility also failed to label food items taken from the freezer with thaw dates, which is crucial for monitoring their shelf life. Nutritional supplements and juice cartons were stored in the refrigerator without thaw dates, contrary to the manufacturer's instructions that specified a limited shelf life once thawed. The dietary supervisor confirmed that the facility did not label these items with thaw dates, which could lead to the consumption of expired products, potentially causing gastrointestinal issues in residents. Furthermore, the facility did not follow proper sanitation practices in the kitchen. Kitchen staff were observed using disposable towels stored in a bucket of water without detergent or sanitizer to clean food contact surfaces. This practice could lead to cross-contamination and foodborne illness. Additionally, an open tube feeding bag was found in the resident refrigerator without a label or date, which could also cause cross-contamination. The licensed vocational nurse confirmed that tube feeding formula should not be stored in the resident refrigerator and that food items must be dated to ensure they are discarded before expiration.
Improper Waste Management in Dumpster Area
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas in a sanitary manner. During an observation and interview, it was noted that one of the five garbage dumpsters was overfilled with trash bags and uncovered. The floor area around the dumpsters was littered with disposable gloves, paper, and food, including melted ice cream. This situation was observed outside the food storage area, indicating a lack of adherence to proper waste management protocols. Interviews with the Dietary Staff (DS) and the Facility Maintenance Manager (FMM) revealed that the dumpster lids should be covered, and the area should be kept clean to prevent attracting pests. The facility's policy on trash collection and removal, dated November 2023, requires that trash bags be tightly closed, transported in covered carts, and deposited into covered trash bins. Additionally, the FDA Food Code 2022 mandates that outdoor receptacles be covered with tight-fitting lids to prevent access by insects and rodents. The failure to comply with these standards poses a risk of pest infestation in the facility.
Inadequate Infection Control Practices for COVID-19 Observed Residents
Penalty
Summary
The facility failed to implement proper infection control practices for three residents who were under observation for COVID-19 exposure. Staff members, including Certified Nursing Assistants, Physical Therapists, Occupational Therapists, and Restorative Nursing Aides, were observed not wearing required eye protection such as face shields or goggles while providing care to these residents. This was in direct violation of the facility's posted COVID-19 precautionary signage and federal guidelines, which mandated the use of eye protection in addition to gowns, gloves, and N-95 masks. Resident 96, who was admitted with a history of falling and adult failure to thrive, was under COVID-19 observation due to an exposure. Despite the posted yellow COVID-19 sign indicating the need for eye protection, staff members were observed entering the resident's room without wearing face shields or goggles. Similarly, Resident 228, admitted with a displaced fracture and a history of falling, was also under COVID-19 observation. Staff assisting this resident with ambulation were noted to be non-compliant with eye protection requirements. Resident 74, who had a history of acute respiratory failure and dementia, was also under COVID-19 observation. A family member visiting Resident 74 was observed not wearing eye protection while in close contact with the resident, despite the facility's policy and posted signage requiring such precautions. Interviews with staff, including a Licensed Vocational Nurse and the Infection Prevention Nurse, confirmed the lack of adherence to the facility's infection control protocols, which were aligned with CDC guidelines.
Unsafe Toilet Seat Side Rails Lead to Resident Fall
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for Resident 38 by not ensuring a stable toilet seat with side rails. On the morning of January 6th, Resident 38 reported falling in the bathroom due to the instability of the toilet seat side rails, which were loose and wobbly. During an observation, it was noted that the side rails were attached with grey screws and moved freely, failing to provide adequate support for the resident. Resident 38 expressed that she could not grab onto the side rails because they were unstable, contributing to her fall. Further observations and interviews with the Maintenance Staff and Maintenance Manager confirmed that the side rails were not securely attached and would not prevent falls. The Maintenance Staff indicated that the side rails were designed to move up and down but acknowledged they were not 100% safe. The Maintenance Manager confirmed the instability of the side rails when weight was applied. The Director of Nursing also observed the issue and recognized the risk of falls and physical injury to residents. A review of the facility's policies revealed no specific guidelines regarding the stability of toilet seats with side rails to prevent falls.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner for two residents, leading to potential delays in care planning and submission of information to the Federal database. Resident 130, who was admitted to hospice care, experienced a significant change in status on 10/15/2024. However, the MDS assessment was not completed until 11/24/2024, 40 days after the change in status, which exceeded the 14-day requirement. This delay was acknowledged by the MDS Coordinator and MDS RN during an interview, where they confirmed the late completion and submission of the MDS to the Federal database. Similarly, Resident 37 was admitted to the facility on 9/18/2024, but the Admission MDS was not completed until 10/22/2024, 35 days post-admission, also exceeding the 14-day requirement. The delay was attributed to the MDS staff performing additional duties due to the absence of a Director of Nursing (DON). The MDS Coordinator confirmed the late completion and submission of Resident 37's Admission MDS during an interview. These failures in timely assessment completion had the potential to delay the development of the residents' care plans.
Delayed MDS Completion for Two Residents
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments in a timely manner for two residents, leading to delayed submission of information to the Federal database. Resident 96, who was admitted with a history of falling and adult failure to thrive, had their Quarterly MDS assessment completed 28 days after the Assessment Reference Date (ARD), exceeding the required 14-day completion period. The delay was attributed to the MDS staff performing additional duties due to the absence of a Director of Nursing (DON). Similarly, Resident 127, admitted with hemiplegia following a cerebral infarction, had their Quarterly MDS assessment completed 21 days after the ARD, also surpassing the 14-day requirement. The MDS Coordinator acknowledged that the late completion of Resident 127's MDS was due to the same staffing issues. Both instances of late MDS completion resulted in delayed submission to the Federal database, as confirmed during interviews with the MDS Coordinator and MDS RN.
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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