Kennedy Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 619 N. Fairfax Ave, Los Angeles, California 90036
- CMS Provider Number
- 055977
- Inspections on file
- 47
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Kennedy Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a properly functioning and secure main entrance door, which allowed an unhoused individual to enter unnoticed and sleep in an unassigned bed in a resident’s room. The resident, who had DM, pancreatic cancer, muscle weakness, impaired mobility, and required moderate to total assistance with ADLs but had intact cognition, used the call light multiple times without staff response for a period of time. An LVN later discovered the intruder, who appeared homeless and was carrying a plastic bag and a mobile phone, and escorted him out but did not document or report the incident. The resident’s family subsequently found the resident’s mobile phone missing and reported the theft. Maintenance leadership acknowledged the front door’s mechanical problems and the lack of a maintenance log, despite policy requiring documentation of building inspections and maintenance schedules.
A resident with intact cognition, multiple serious medical conditions, and moderate to severe depressive symptoms shared a room where an unhoused individual entered through a malfunctioning front door and slept in an unassigned bed. The resident reportedly used the call light multiple times without timely staff response and later discovered a mobile phone missing. An LVN encountered the unauthorized person, who appeared homeless and claimed to have checked in while holding a phone, and escorted him out but did not assess the resident, notify management, or document the incident. The DON later confirmed there was no record of the event or any post-incident assessment in the chart, despite facility policies requiring thorough documentation of changes in condition and investigation of possible abuse, neglect, exploitation, or misappropriation of property.
A resident with intact cognition but significant medical issues and depressive symptoms was admitted without a documented inventory of personal belongings, despite facility policy requiring such documentation. An unhoused individual entered through a malfunctioning front door, stayed and slept in an unassigned bed in the resident’s room, and was later seen by an LVN holding a mobile phone and a plastic bag. The resident reportedly used the call light multiple times without staff response and later reported a missing mobile phone. The LVN escorted the intruder out but did not document the event, notify management, or assess the resident, and the DON later confirmed there was no record of the incident, no resident assessment, and no belongings inventory, in violation of the facility’s abuse/misappropriation and personal property policies.
A cognitively intact resident with multiple comorbidities and depressive symptoms had no documented personal inventory, and an unhoused individual entered the room, slept in an unassigned bed, and was later associated with the disappearance of the resident’s mobile phone. An LVN observed the intruder, escorted him out, but did not document the event, notify management, or assess the resident. The DON and Administrator acknowledged that an unknown person gained entry through a malfunctioning front door, that the resident’s phone went missing and was later returned broken, and that the matter was handled internally and reported to police, but not to the state agency. No incident or resident assessment was documented, and no follow-up investigation report was submitted as required by the facility’s abuse, neglect, exploitation, and misappropriation reporting policies.
A resident with tobacco use disorder did not receive a physician-ordered nicotine patch for smoking cessation because an LVN reported the medication was unavailable, despite the DON confirming it was in stock as a house supply. This failure to administer the medication as ordered was not in accordance with facility policy and professional standards.
Surveyors found that acetaminophen and docusate sodium liquid stored in a medication cart were not labeled with the date they were first opened. During interviews, an LVN and the DON confirmed that these medications should have been dated to comply with facility policy and ensure safe use.
A resident with chronic wounds and reduced mobility, who was on enhanced barrier precautions (EBP), was repositioned in bed by a CNA who wore gloves but failed to use a protective gown as required by facility policy. The CNA was unaware of the resident's EBP status, despite clear care plan instructions and room signage, resulting in a failure to follow infection control protocols during high-contact care.
A resident with an indwelling urinary catheter, cognitive impairment, and multiple medical conditions was observed with an uncovered catheter drainage bag in a shared room, despite physician orders and care plan interventions requiring a privacy cover. Staff and the DON confirmed the lack of a privacy bag, which was inconsistent with facility policy to promote resident dignity.
Staff members used personal cell phones to send and receive text messages containing residents' names, room numbers, and care details, including information about rehabilitation programs. These messages were shared among various staff, such as CNAs, a PT, and the director of rehabilitation, despite facility policy and HIPAA regulations prohibiting the transmission of protected health information (PHI) to personal devices. The DON confirmed that this practice was not allowed.
A resident with an indwelling urinary catheter and multiple diagnoses experienced pain and weakness, prompting a physician order for a urine sample to test for a UTI. The order was not carried out or documented by nursing staff, resulting in a two-day delay in care and treatment, contrary to facility policy requiring prompt response to changes in condition.
Staff did not consistently use required PPE while providing high-contact care to a resident on enhanced barrier precautions for multi-drug resistant organisms. A nurse was observed changing an incontinent brief without full PPE, and staff interviews revealed confusion about the correct type of precaution and lapses in following protocol, despite facility policy mandating gown and glove use during such activities.
Surveyors identified deficiencies in food storage, labeling, preparation, and kitchen sanitation, including improper storage of cooked meats and leftovers, failure to follow required cool down and thawing procedures, and unclean equipment. Staff confirmed that facility policies were not followed, affecting all residents receiving food from the kitchen.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required. The care provided was not consistent with the established plan or the resident's expressed wishes.
A deficiency was cited for not providing a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of residents.
Multiple residents reported that the food was unpalatable, repetitive, and lacked seasoning, leading to poor intake and reliance on outside food. Despite care plans and dietary interventions for residents with medical needs, complaints were not effectively addressed by dietary or nursing staff, and facility policy requiring palatable meals was not followed.
The facility did not ensure that several staff members completed and had documentation of required annual and upon-hire TB skin tests, annual physical exams, and abuse training, as identified during interviews and record reviews with the DSD and DON. Missing documentation included TB test results, background checks, and annual skills competencies for multiple staff, in violation of facility policy.
A resident with muscle weakness and paraplegia, who was cognitively intact, reported his cellphone and charger stolen and was unable to contact family for an extended period. Despite multiple reports to the SW, DON, and Administrator, the facility did not promptly replace the items, and documentation of the incident was lacking, contrary to facility policy requiring respect for residents' personal belongings.
A housekeeping employee was hired without a required background check, as confirmed by a review of the employee file and facility policy. The DSD acknowledged that background checks are necessary for all new hires to ensure resident safety, but this process was not completed for the staff member in question.
A resident with Alzheimer's disease, chronic kidney disease, and dementia did not have their Annual MDS assessment completed and submitted within the required CMS timeframe. The MDS assessment was still in progress and overdue, with staff confirming the delay and acknowledging late assessments. Facility policy requires timely completion and submission of MDS assessments, but this was not followed in this instance.
The facility did not submit required MDS assessments to CMS within the mandated timeframes for four residents with complex medical conditions, as confirmed by record review and staff interviews. The assessments remained incomplete and unsubmitted past the required deadlines, contrary to facility policy.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period following assessment, as identified through record review.
A resident with severe cognitive impairment and multiple comorbidities did not receive the prescribed amount of tube feeding due to staff failing to monitor and respond to an inactive enteral pump, resulting in significantly less nutrition being administered than ordered.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Several staff members, including an LVN, Housekeeping, Activities Assistant, and Occupational Therapist, did not complete required annual competencies, physicals, TB tests, or abuse training for multiple years. Facility leadership confirmed these requirements are necessary for maintaining staff competency and resident safety, and facility policy mandates annual evaluations and training.
A shared bedroom in the facility was found to be below the required 80 square feet per resident, with only 77.62 square feet provided for each of two residents. Observations showed that residents could move freely and had no complaints, but the room did not meet federal size standards.
A resident with multiple health conditions who required significant assistance with daily activities experienced repeated failures of the call light system, as observed during multiple attempts to summon staff. The call light did not consistently activate, and maintenance identified a cracked button and possible wiring issues. Facility policy requires the call system to be functional at all times, but this was not maintained.
Two shower rooms were found to be unclean and had a persistent urine odor due to improperly sealed soiled briefs and wet floors. A resident reported disliking the use of these rooms because of the foul smell and visible soiled items, and staff were aware of the issue but had not adequately addressed it. Facility policy required a clean and pleasant environment, but these standards were not met.
Several residents did not have their medications properly stored or documented, with one resident keeping unprescribed medications at bedside and mixing pills from different bottles. Medications for three residents were not administered within the required timeframe, with repeated delays observed. Staff interviews confirmed that these practices did not align with facility policy, which requires timely administration and proper documentation of all medications.
A resident with a history of diabetes and other health issues experienced severe complications due to inadequate foot care. The facility failed to conduct an MRI recommended by a Wound Physician Specialist to rule out osteomyelitis after the resident's foot wound reopened. Additionally, the facility did not document wound care services properly or develop an individualized care plan. These deficiencies resulted in the resident being transferred to a hospital with sepsis and undergoing multiple amputations.
A resident with multiple health issues, including a foot wound and chronic conditions, did not have a comprehensive care plan addressing their specific needs. The facility failed to develop individualized plans for wound care, pain management, and refusal of repositioning, and did not adequately address the resident's aggressive behavior towards staff. This lack of documentation and tailored interventions could negatively impact the resident's health and safety.
A resident with multiple health conditions and cognitive impairment required maximum assistance for ADLs and was at risk for immobility and skin breakdown. Despite the facility's policy for repositioning every two hours, staff reported the resident frequently refused repositioning due to pain, and no care plan was developed to address these refusals. The facility failed to document refusals consistently and did not notify the physician, leading to a deficiency.
A resident with multiple health issues and moderate cognitive impairment experienced unnecessary pain due to the facility's failure to adhere to its pain management protocol. Despite staff observations of pain-related behaviors, such as yelling and screaming during repositioning, the resident's pain was not adequately assessed or managed. The facility's policy required a comprehensive pain assessment, which was not consistently implemented, leading to the resident's suffering.
A resident with multiple health issues and moderate cognitive impairment exhibited aggressive behavior, but the facility failed to document and address these behavioral health needs. Staff interviews revealed that the resident was verbally aggressive during repositioning, and pain management was not provided despite expressions of pain. The facility did not follow its policy on behavioral assessment and monitoring, leading to a deficiency in care.
A resident at risk for pressure injuries did not receive proper preventive care due to the facility's failure to set the low air loss mattress according to the resident's actual weight and to monitor and record the resident's weight as per policy. The resident, with conditions like venous insufficiency and diabetes, reported discomfort with the mattress, which was set incorrectly at 400 lbs. The facility's oversight in weight monitoring and mattress setting placed the resident at risk for poor wound healing.
A facility failed to inform a resident's designated POA of healthcare decisions, leading to the resident being discharged against medical advice with an emergency contact instead. The resident had dementia, chronic kidney disease, and heart disease. The facility did not obtain the POA documentation timely, contrary to its policy on advance directives.
The facility failed to have a DON onsite for at least 8 consecutive hours daily from November 2024 to January 3, 2025. The DON was on sick leave, and no interim DON was appointed. Interviews revealed a lack of management of nursing services, and no notification was sent to the State Agency. The facility's job description for the DON includes overseeing resident care and managing the nursing department.
A facility failed to implement a comprehensive care plan for a resident with a nephrostomy tube dislodgment. Despite multiple incidents of tube dislodgment and related issues, no care plan was developed or revised to address the resident's changing condition. A registered nurse confirmed the absence of a care plan, which was against the facility's policy requiring updates for significant changes in condition.
A facility failed to label and document a resident's peripheral catheter dressing as per policy, risking infection. The resident, with severe cognitive impairment and a history of polymyositis, had an unlabeled IV line observed during a survey. The facility's policy requires labeling with date, time, and initials, and changing the dressing every 72 to 96 hours.
A resident with dementia and chronic kidney disease was not treated with dignity during meal assistance, as a CNA stood over him while feeding, contrary to facility policy. The CNA cited a lack of available chairs, although the facility had enough chairs, and the RN Supervisor confirmed the importance of sitting while assisting residents.
A facility failed to notify a resident's legal representative of a change in the resident's condition, violating the resident's rights. The resident, with a diagnosis of UTI and dementia, experienced a weight gain, but the facility did not inform the DPOA, as required by their policy.
A facility failed to provide a resident's Durable Power of Attorney (DPOA) with access to medical records, violating its own policies. The resident, with diagnoses including a UTI and dementia, had fluctuating decision-making capacity. The DPOA requested access but did not receive the necessary form, despite being informed of the process by staff. The Medical Record Director confirmed not sending the release form, resulting in the DPOA lacking access to important medical records.
A resident with a history of mental health disorders left a facility without authorization, and the incident was not reported as an elopement within 24 hours as required. The resident was observed by a housekeeper leaving with belongings, and a LVN unsuccessfully searched for the resident. The DON documented the incident as leaving against medical advice, contrary to the facility's policy on reporting unusual occurrences.
A resident with multiple mental health and physical conditions eloped from the facility without authorization. The resident was found by a housekeeper at the entrance with belongings, stating he was leaving. The LVN was informed after the resident had left, and a search was initiated but the resident was not found. The facility's policy on wandering and elopement was not effectively followed.
The facility failed to uphold resident dignity and communication standards. A resident was fed while staff stood over them, contrary to policy. Another resident was left to eat lying flat, risking aspiration. Two residents reported staff speaking in an unfamiliar language, breaching communication policies.
A resident with severely impaired cognition received the pneumococcal vaccine without documented informed consent. The facility's policy requires that residents or their legal representatives receive information and education about the vaccine's benefits and side effects, which was not documented in this case. Interviews with staff confirmed the oversight.
The facility failed to ensure call lights were within reach for three residents, hindering their ability to summon assistance. One resident with Alzheimer's and chronic kidney disease had a disconnected call light, another with rectal cancer had the call light on the floor, and a third with cerebral infarction had no call light within reach. An LVN and the DON confirmed these deficiencies, which violated the facility's policy.
The facility failed to provide a safe and comfortable environment for three residents. Two residents reported excessive noise levels, which disrupted their rest, while another resident faced issues with broken room equipment, including a window chain, bedside drawer, and electric wall plug. The facility's policies on maintaining a homelike environment and proper equipment maintenance were not adhered to.
The facility failed to provide adequate pressure ulcer prevention for three residents. A resident with paraplegia was found without required heel protectors, risking further injury. Another resident's low air loss mattress was set incorrectly, not matching their weight, which is against facility policy. A third resident, at risk for pressure ulcers, also had issues with mattress settings not being properly managed according to their weight.
The facility failed to manage psychotropic medication regimens for two residents. One resident's Risperdal was not discontinued despite a pharmacy recommendation and physician agreement, lacking necessary documentation. Another resident received escitalopram and Seroquel without timely informed consent, as required by facility policy. The DON acknowledged these oversights, which contravened established procedures.
The facility failed to implement proper infection control measures for residents on transmission-based precautions. A resident with ESBL was not placed in a private room despite available space, and staff did not wear appropriate PPE when caring for residents in contact isolation rooms. Additionally, a resident with E. coli was not placed in a contact precaution room as per policy and CDC guidelines.
Failure to Maintain Secure Main Entrance and Respond to Call Light Resulting in Unauthorized Entry and Theft
Penalty
Summary
The facility failed to maintain a safe and functional main entry door, allowing an unhoused individual to enter the building without staff awareness and remain inside. A door service company’s receipt documented that the main entry door closer no longer had latching force, was not closing properly, and the closing force was not responding correctly. The Maintenance Director reported that the front door magnet that should ensure automatic closure was not working properly, and also stated that although doors are checked frequently, there was no maintenance log documenting entrance door checks, despite facility policy requiring maintenance records such as inspection of the building and maintenance schedules. A resident with diabetes mellitus, malignant neoplasm of the endocrine pancreas, muscle weakness, and difficulty walking, who required moderate to total assistance with ADLs but had intact cognitive skills, was affected by this failure. The resident’s family member reported that an unhoused individual entered the facility, stayed and slept in an unassigned bed in the resident’s room, and that the resident pressed the call light multiple times without staff response for a while. The family member stated the resident felt terrified and later discovered her mobile phone was missing. An LVN stated she found the unhoused individual in the resident’s room, noted he appeared homeless and carried a plastic bag, and escorted him out after he claimed to have checked in while holding a mobile phone. The LVN acknowledged ongoing issues with the front door not fully closing and locking from the outside, and also stated she did not document the incident or report it to management or staff. The Administrator confirmed that an unhoused individual entered without staff knowledge and stole the resident’s mobile phone.
Failure to Assess and Document After Unauthorized Room Entry and Property Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an unauthorized individual entered a resident’s room and allegedly misappropriated the resident’s property. The resident involved had diagnoses including diabetes mellitus, malignant neoplasm of the endocrine pancreas, muscle weakness, and difficulty walking, and required moderate to total assistance with ADLs. An MDS assessment indicated the resident’s cognitive skills for daily decision-making were intact and that the resident had moderate to severe depressive symptoms, including little interest or pleasure in activities, feeling down or hopeless, and sleep disturbances. On the morning in question, an unhoused individual gained access to the facility through a front door that did not fully close and lock, entered the resident’s room, and slept in an unassigned bed in that room. The resident’s family member reported that the resident discovered the individual in the room, pressed the call light multiple times, and no staff responded for a while. The family member stated that the resident’s mobile phone was later found missing and that the resident felt terrified and unsafe following the incident. The family member reported the missing phone to facility staff. A LVN stated she observed the unauthorized individual in the resident’s room early that morning, noted that no resident was assigned to that bed, and escorted the individual out after determining he did not belong in the facility. The LVN reported that the individual appeared homeless, carried a plastic grocery-type bag, and showed a mobile phone while claiming he had checked in. The LVN did not assess the resident after the incident, did not document the event, and did not report it to management or other staff, and she did not know how long the individual had been in the room or what he had done there. The DON later confirmed there was no documentation in the resident’s medical record of the incident or any post-incident assessment, despite facility policies requiring complete, objective, and accurate documentation of changes in a resident’s condition and requiring identification, investigation, and protection of residents in situations involving possible abuse, neglect, exploitation, or misappropriation of property.
Failure to Secure Facility Access and Protect Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s personal property and to follow its own policies for documenting and investigating misappropriation of resident belongings. A resident admitted with diabetes mellitus, malignant neoplasm of the endocrine pancreas, muscle weakness, difficulty walking, and moderate to severe depressive symptoms had intact cognitive skills but required moderate to total assistance with ADLs. Review of the medical record as of 2/17/2026 showed no personal inventory list of the resident’s belongings, and the Medical Records Director confirmed that the resident’s personal belongings were not inventoried or documented upon admission, contrary to the facility’s Personal Property policy requiring such documentation. The report describes an incident in which an unhoused individual entered the facility without staff knowledge and stayed and slept in an unassigned bed in the same room as the resident. The resident’s family member reported that the resident pressed the call light multiple times after discovering the individual sleeping in the room and acting strangely, but no staff responded for a while. The family member stated that the resident felt terrified and unsafe, and that the resident’s mobile phone was discovered missing that morning and reported to staff. A LVN stated she noticed the unhoused individual in the resident’s room early in the morning, initially thought there was no resident assigned to that bed, and questioned the individual, who claimed to have checked in and was holding a mobile phone and a plastic grocery-type bag. The LVN escorted the individual out but did not document the incident, did not report it to management or staff, and did not assess the resident. She did not know how long the individual had been in the room or what he did while there, and reported that the CNA had also seen the individual and assumed he was a new resident. The DON stated she was informed that a person with no business in the facility had gained access and stayed in a bed in the resident’s room, that the front door was broken and not closing and locking properly, and that the resident’s mobile phone went missing after this access. The DON confirmed there was no documentation of the incident, no assessment of the resident after the incident, and no documentation of the resident’s personal belongings inventory, despite facility policies requiring inventory of belongings and complete documentation and investigation of any misappropriation of resident property.
Failure to Report and Document Alleged Theft and Intrusion per Abuse/Misappropriation Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies for reporting and investigating theft and misappropriation of resident property, including timely reporting to the state licensing/certification agency and completion of a follow-up investigation report. A resident admitted with DM, malignant neoplasm of the endocrine pancreas, muscle weakness, difficulty walking, and moderate to severe depressive symptoms had intact cognitive skills but no documented personal inventory list in the medical record. The Medical Records Director confirmed that the resident’s personal belongings were not inventoried or documented. On the morning in question, the resident’s family member reported that an unhoused individual entered the facility without staff knowledge, stayed and slept in an unassigned bed in the resident’s room, and behaved strangely. The family member stated the resident pressed the call light multiple times without staff response and later felt terrified and unsafe. The family member also reported that the resident’s mobile phone was discovered missing that morning and reported this to facility staff. An LVN stated she saw the unknown individual in the resident’s room early that morning, noted he appeared homeless, was carrying a plastic bag, and claimed he had “checked in” while holding a mobile phone. The LVN escorted him out but did not document the incident, did not report it to management, and did not assess or check on the resident afterward. The DON and Administrator later acknowledged that an unknown person had gained access through a malfunctioning front door, that the resident’s phone went missing and was later retrieved broken, and that the incident was investigated internally and reported to police. However, they stated it was not reported to the state licensing/certification agency, and there was no documentation of the incident or resident assessment in the medical record, contrary to facility policies requiring reporting all such allegations to local, state, and federal agencies as required, and documenting and reporting investigation findings, including a follow-up report within five business days.
Failure to Administer Physician-Ordered Nicotine Patch
Penalty
Summary
The facility failed to follow a physician's order for the administration of a nicotine patch for a resident admitted with diagnoses including tobacco use and generalized muscle weakness. The physician's order specified that a 14mg nicotine patch should be applied transdermally once daily for six weeks as part of a smoking cessation plan. During medication administration, the assigned LVN reported that the nicotine patch was not available and did not administer the medication as ordered. The LVN also acknowledged that the physician should be notified when a medication is unavailable and recognized the potential for withdrawal or side effects if the patch was not given. Further investigation revealed that the nicotine patch was actually available as a house supply in the medication room, and the DON confirmed it should have been administered. The facility's policy on administering medications requires that medications be given safely, timely, and in accordance with prescriber orders, including any required timeframe. The failure to administer the nicotine patch as ordered constituted a lapse in following professional standards of clinical practice and facility policy.
Failure to Date Opened OTC Medications on Medication Cart
Penalty
Summary
Surveyors observed that over-the-counter medications, specifically acetaminophen and docusate sodium liquid, were stored in a medication cart without being labeled with the date they were first opened. This observation was made during a medication cart review, where it was noted that the containers lacked any indication of when they were initially accessed. During interviews conducted at the time of observation, both the LVN and the DON confirmed that the medications should have been dated upon opening to ensure proper tracking of their use. A review of the facility's policy and procedure on medication labeling and storage indicated that medications and biologicals dispensed by the pharmacy must be labeled in accordance with federal and state requirements and accepted pharmaceutical practices. The policy specifically requires opened vials to be dated and discarded within a specified timeframe unless otherwise directed by the manufacturer. The failure to date the acetaminophen and docusate sodium liquid containers represents noncompliance with these established procedures.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection control policy for a resident who was on enhanced barrier precautions (EBP) due to multiple chronic wounds and a history of cerebrovascular accident with left side weakness and reduced mobility. According to the resident's care plan, EBP, including the use of gowns and gloves during high-contact care activities, was required to reduce the risk of transmission of multidrug-resistant organisms (MDROs). The resident was dependent on staff for most activities of daily living, including bed mobility and hygiene. On the observed date, a certified nurse assistant (CNA) entered the resident's room wearing gloves but did not don a protective gown while repositioning the resident in bed, an activity classified as high-contact care. The CNA stated during an interview that he was unaware the resident was on EBP. Facility policy, as reviewed, required both gloves and gowns to be used during such activities for residents on EBP. The Director of Staff Development confirmed that the resident was on EBP and that staff should have used the appropriate personal protective equipment during repositioning.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
The facility failed to protect a resident's privacy and dignity by not ensuring that the resident's indwelling urinary catheter drainage bag was covered, as required by physician orders and the resident's care plan. The resident, who had diagnoses including toxic encephalopathy, obstructive and reflux uropathy, and depression, was assessed as having moderately impaired cognitive skills and required maximal assistance with activities of daily living. Documentation indicated that the catheter was to be kept in a privacy bag at all times to promote dignity and prevent exposure. During an observation, the resident's catheter drainage bag was found uncovered and visible in a shared room with two other residents. Staff interviews confirmed that the privacy bag was not in use, and the DON acknowledged that the catheter should have been covered to maintain the resident's dignity. Facility policies also required that urinary catheter bags be kept covered to promote resident well-being and self-esteem, and to prevent demeaning practices.
Resident PHI Shared via Staff Personal Cell Phones
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of residents' personal and medical records by transmitting protected health information (PHI) through text messages sent to personal cell phones. Interviews revealed that a restorative nursing assistant (RNA), a certified nursing assistant (CNA), and a physical therapist (PT) all received or sent group text messages containing residents' names, room numbers, and specific care or rehabilitation program details. These messages were sent among various staff members, including the director of rehabilitation, occupational therapist, director of staff development, and others, using their personal devices. The director of nursing (DON) confirmed that transmitting resident information to personal phones is not permitted, as it includes identifiable information such as names and room numbers, which is protected under HIPAA regulations. Review of facility policies indicated that employee cell phones are only to be used for personal calls and texts during breaks, and that the facility is committed to complying with privacy and security laws regarding PHI. Despite these policies, staff continued to use personal devices to communicate resident information, leading to a breach in confidentiality.
Failure to Implement Physician Orders and Timely Care for Suspected UTI
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident who had multiple diagnoses, including toxic encephalopathy, obstructive and reflux uropathy, and depression. The resident, who had an indwelling urinary catheter and required maximal assistance with activities of daily living, complained of pain and weakness. Although staff notified the medical doctor, the order to collect a urine sample to test for a urinary tract infection (UTI) was not carried out by the registered nurse. The order was not entered into the resident's medical record, and there was no documentation of a change in condition at the time of the complaint. This lapse resulted in a two-day delay in obtaining the urine sample and, consequently, a delay in the resident's care and treatment for a suspected UTI. The facility's policies required prompt assessment, documentation, and implementation of physician orders upon changes in a resident's condition, which were not followed in this instance. The deficiency was identified through interviews and record reviews, confirming that the required interventions were not implemented as per the facility's protocols.
Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow physician orders and facility policy regarding the use of personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions. Specifically, a licensed vocational nurse was observed changing the resident's incontinent brief without wearing complete PPE, despite the resident being on enhanced barrier precautions due to diagnoses including sepsis, urinary tract infection, and chronic kidney disease. The resident required maximal assistance for activities of daily living and had moderately impaired cognitive skills, as documented in the Minimum Data Set. Interviews with staff revealed a lack of adherence to PPE protocols, with one nurse admitting to not wearing full PPE because she was in and out of the room and forgot to put it back on. There was also confusion among staff regarding the type of transmission-based precaution in place, with one nurse incorrectly identifying the precaution as droplet rather than enhanced barrier. Facility policy clearly stated that enhanced barrier precautions require the use of gowns and gloves during high-contact care activities, such as changing briefs, to prevent the spread of multi-drug resistant organisms.
Deficient Food Storage, Preparation, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, labeling, preparation, and sanitation practices affecting all residents. Improper storage and labeling of food items were noted, including cooked pork roast and prepared tuna stored in the refrigerator without adherence to the facility's policy of using refrigerated leftovers within 72 hours. The cool down method for prepared foods was not properly followed, and several food items were found with expiration dates. Dietary staff did not consistently follow the correct thawing process for large pork roasts, and there was a lack of proper labeling and dating of defrosting meat as required by facility policy. Additionally, the kitchen environment was found to be unsanitary, with dirty stove tops, floors, and large silver pans observed during the inspection. Dietary staff and supervisors acknowledged that these practices did not meet professional standards and could result in unsafe food for residents. The facility's own policies on thawing meats and handling leftovers were not followed, as confirmed by staff interviews and record reviews.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with the established plan, which may include not following prescribed treatments or disregarding the expressed wishes and objectives of the resident regarding their care. This lapse was observed during the survey process, but the report does not specify the number of residents affected, their medical histories, or their conditions at the time of the deficiency.
Failure to Meet Residents' Nutritional and Dietary Needs
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. The report notes that the required standards for resident nutrition and dietary accommodations were not met, resulting in a deficiency finding related to dietary services. No additional details about specific residents, their medical history, or the precise nature of the dietary shortcomings are provided in the report.
Failure to Provide Palatable and Appetizing Food to Residents
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food to residents, as evidenced by multiple complaints and observations involving seven residents. Several residents reported that the food was unappealing, lacked seasoning, and was repetitive, with chicken being served frequently. Some residents described the food as rubbery, unrecognizable, or inedible, leading them to consume very little of their meals or rely on family members to bring in outside food. Observations confirmed that residents often returned their trays untouched or ate only a small portion of the meals provided. Record reviews revealed that residents with significant medical conditions, such as diabetes, muscle weakness, anemia, and recent fractures, were affected by the poor food quality. Care plans for these residents included interventions to cater to food preferences and monitor intake, yet these interventions were not effectively implemented. For example, one resident with diabetes and at risk for malnutrition had poor oral intake and required increased nutritional supplements, but continued to express dissatisfaction with the food and reported significant weight loss. Interviews with dietary and nursing staff indicated a lack of awareness and follow-up regarding resident complaints about food palatability. The Dietary Supervisor and Dietary Manager acknowledged receiving complaints but did not maintain logs of uneaten food or consistently address the issues. The Registered Dietician was unaware of specific complaints and had not visited some newly admitted residents to discuss dietary needs. The Director of Nursing was also unaware of the extent of food-related complaints, despite policies requiring communication of such concerns. Facility policy stated that residents should receive nourishing, palatable, and well-balanced diets that consider their preferences, but this was not consistently achieved.
Failure to Complete and Document Required TB Screening and Annual Examinations for Staff
Penalty
Summary
The facility failed to ensure that staff completed required annual and upon-hire Tuberculin (TB) skin tests, maintained TB skin test results on file, and completed annual physical examinations for four out of seven employees reviewed. Specifically, one nurse did not have annual TB skin tests for two consecutive years, another nurse had no documented TB test result, a treatment nurse had neither a TB skin test nor result on file, and an occupational therapist lacked documentation of abuse training since hire. Additionally, there were missing background checks, annual skills competencies, and abuse training for some staff members. These findings were identified during interviews and concurrent record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who both acknowledged the requirements for annual TB testing and competencies. The DSD was uncertain about the required retention period for employee documents and confirmed that the facility's policy mandates TB screening for all new hires before duty assignment and annually thereafter. Record reviews confirmed the absence of required TB skin tests and other documentation in several employee files. The DON stated that annual TB testing and competencies are necessary to prevent staff from forgetting essential care skills. The facility's policy and procedures also require screening for latent TB infection and active TB prior to employment and annually, but these were not consistently followed for the staff reviewed.
Failure to Replace Stolen Personal Possessions for Resident
Penalty
Summary
The facility failed to allow a resident to retain his personal possessions, specifically his cellphone and cellphone charger, after they were reported stolen by his former roommate. The resident, who was cognitively intact and required moderate to maximum assistance with activities of daily living due to muscle weakness and paraplegia, reported the theft to the Social Worker, Director of Nursing, and Administrator on several occasions. Despite these reports, the facility did not replace the stolen items in a timely manner, resulting in the resident feeling angry because he was unable to contact his family members. Record reviews revealed that the resident's inventory list was incomplete and that the Social Service Director was aware of the missing items but did not document the incident in the medical record. The Social Service Assistant also acknowledged being informed of the theft but failed to follow up with the Administrator for approval to replace the items. The facility's policy states that residents are permitted to retain and use personal possessions, and staff are to treat residents' belongings with respect, but these procedures were not followed in this case.
Failure to Complete Background Check for New Hire
Penalty
Summary
The facility failed to conduct a required background search for one out of seven employees, specifically a housekeeping staff member, prior to their employment. During an interview and concurrent record review with the Director of Staff Development (DSD), it was found that the housekeeping employee was hired without a background check, as there was no background search report present in the employee's file. The DSD confirmed that background checks are completed to ensure staff do not have a criminal background and to maintain resident safety. Additionally, a review of the facility's Facility Assessment Tool indicated that new hires must undergo background checks, confirming that this process was not followed for the housekeeping employee.
Failure to Timely Complete and Submit Annual MDS Assessment
Penalty
Summary
The facility failed to complete and submit an Annual Minimum Data Set (MDS) assessment for a resident within the required timeframe established by the Centers for Medicare & Medicaid Services (CMS). The resident in question had a history of Alzheimer's disease, chronic kidney disease, and dementia, and was originally admitted in 2021 and re-admitted in 2023. During a review, it was found that the most recent annual MDS assessment for this resident was dated but had not yet been submitted to CMS, with the MDS Assistant confirming that the assessment was still in progress and overdue for submission. Interviews with facility staff revealed that the delay in MDS submission was known, and the Director of Nursing acknowledged the existence of late assessments. The facility's policy requires that MDS assessments be conducted and submitted according to federal and state timelines, with the assessment coordinator or designee responsible for timely submission. The failure to submit the MDS assessment as required constituted a deficiency in adhering to regulatory requirements for resident assessment and care planning.
Failure to Timely Submit MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for four out of thirteen sampled residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within the required timeframes. Record reviews revealed that the quarterly MDS assessments for these residents, who had complex medical conditions such as diabetes mellitus, dementia, kidney failure, major depressive disorder, atrial fibrillation, lymphedema, high blood pressure, congestive heart failure, and other chronic illnesses, were not submitted on time. The MDS Assistant confirmed during interviews and record reviews that the assessments for these residents were still in progress and had not been submitted to CMS by the required deadlines. The facility's policy and procedures require that resident assessments be conducted and submitted in accordance with federal and state timeframes, with the assessment coordinator or designee responsible for timely submission. Despite this, the Director of Nursing acknowledged that late MDS assessments were discovered and had not yet been completed or submitted for the affected residents. The failure to submit these assessments as required was directly observed and confirmed by both documentation and staff interviews.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. This deficiency was identified based on a review of facility records, which showed that required assessment data were not submitted to the State in the specified timeframe. The report does not provide additional details about specific residents or their medical conditions at the time of the deficiency.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to ensure that tube feeding was administered as ordered for a resident with multiple comorbidities, including protein calorie malnutrition, COPD, chronic kidney disease, stroke, and dysphagia. The resident was admitted with severe cognitive impairment and was totally dependent on staff for daily care, including eating. Physician orders and the care plan specified that the resident was to receive Jevity 1.5 at 60 cc per hour for 20 hours, totaling 1200 cc and 1800 kcal, to be administered via enteral pump starting at 2 pm until the total volume was delivered. During observation, the enteral pump was found to be inactive and alarming, with only 166 ml of tube feeding administered, far less than the ordered amount. Staff did not respond to the pump's alarm or address the discrepancy when it was observed. Further interviews confirmed that the resident had only received 400 cc since the previous afternoon, and staff acknowledged that the resident was not receiving the total amount of tube feeding as ordered. Facility policy required adequate nutritional support through enteral nutrition as ordered, but this was not followed in this instance.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Complete Annual Staff Competencies and Training
Penalty
Summary
The facility failed to ensure that three out of seven reviewed employees, including a Licensed Vocational Nurse, a Housekeeping staff member, an Activities Assistant, and an Occupational Therapist, completed required annual competencies and training. Record reviews revealed missing annual physical examinations, Tuberculin (TB) skin tests, background checks, skills competency assessments, and abuse prevention training for multiple years for these staff members. Specifically, the Licensed Vocational Nurse lacked annual physicals and TB tests for two consecutive years, as well as missing annual skills competency and abuse training. The Housekeeping staff and Occupational Therapist also had missing annual skills competencies and abuse training, while the Activities Assistant had no documented annual skills competencies for four years. Interviews with the Director of Staff Development and the Director of Nursing confirmed that annual competencies, physicals, and TB tests are required upon hire and yearly thereafter. Both directors acknowledged the importance of these requirements in maintaining staff competency and resident safety. Facility documentation and policies also indicated that competency evaluations are to be conducted upon hire and annually, and that all nursing staff must meet specific competency requirements as defined by state law.
Failure to Meet Minimum Room Size Requirements for Shared Bedroom
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in one of its multiple resident bedrooms, specifically room [ROOM NUMBER], which measured 154 square feet for two beds, resulting in only 77.62 square feet per resident. This does not meet the federal requirement of 160 square feet for a two-bed room. The deficiency was identified through observation, interview, and record review, including a facility-submitted request for a room size waiver and a client accommodations analysis. The waiver letter indicated that the room size did not adversely affect residents or their special needs, and that both ambulatory and non-ambulatory residents could move freely without harm or impediment. No grievances were reported by residents, family members, or staff regarding the room size. During general observations, residents were seen to have ample space to move freely within the room, and there was sufficient space for beds, side tables, and care equipment. One resident was observed ambulating in the room without difficulty, and another did not express concerns about the room size. Despite these observations, the room did not meet the minimum square footage required by federal regulation for a two-bed room.
Non-Functional Call Light System in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be intermittently non-functional. The resident, who had diagnoses including bilateral primary osteoarthritis of the hip, asthma, and a urinary tract infection, required moderate to maximal assistance with activities of daily living. During multiple observations, the resident pressed the call light, but the light outside the room did not activate, indicating the system was not consistently alerting staff. The resident reported that staff sometimes did not answer the call light, or responses were delayed, particularly when assistance was needed for toileting and changing incontinence briefs. Further investigation by the Maintenance Director revealed that the call button was not reliably working, with a visible crack in the red button and possible wiring issues. The Director of Nursing confirmed that if call lights are not functioning, staff may not be aware when residents need help. Review of facility policies indicated that call lights are required to be plugged in and functional at all times, and that maintenance is responsible for ensuring the system is in good working order. The deficiency was based on direct observation, resident interview, and review of facility records and policies.
Failure to Maintain Clean and Odor-Free Shower Rooms
Penalty
Summary
The facility failed to provide a homelike environment by not ensuring that two shower rooms were clean and free from urine odor. Observations revealed that both shower rooms had wet floors, soiled incontinent briefs in trash cans that were not properly sealed, and a persistent foul-smelling urine odor. These conditions were confirmed during multiple observations and interviews, including with a resident who reported disliking the use of the shower rooms due to the odor and visible soiled briefs. The resident stated that staff were aware of the issue but had not taken sufficient action to address it. A review of the resident's records indicated that she required assistance with activities of daily living and had intact cognitive skills. The facility's policy required a clean, sanitary, and pleasant environment, but the observed conditions did not meet these standards. The DON stated that showers were supposed to be deep cleaned twice daily and that staff were responsible for cleaning up after each use, including properly sealing soiled briefs, but these procedures were not followed as observed.
Failure to Properly Store, Document, and Timely Administer Medications
Penalty
Summary
The facility failed to ensure that medications for several residents were properly stored, documented, and administered according to physician orders and facility policy. One resident, who had a history of psoriatic arthritis mutilans, muscle weakness, and major depressive disorder, was found to be keeping all her medications at her bedside, including a lidocaine patch that was not ordered by a physician or documented in her records. This resident reported that her family supplied her medications, and she would mix pills from old and new bottles, leading to concerns about medication expiration and proper documentation. The nurse confirmed awareness of the resident's self-stored lidocaine patch but stated she had not administered it, and there was no physician order for its use. Additionally, the facility did not administer medications in a timely manner as ordered by physicians for three residents. Medication Administration Audit Reports showed that medications scheduled for administration at 9 a.m. were repeatedly given late, sometimes several hours past the scheduled time. Residents reported that their morning medications were often administered late, and one resident stated that requests to receive medications on time were not consistently honored by nursing staff. These delays were observed across multiple days and affected residents with various medical conditions, including diabetes, epilepsy, asthma, and anxiety disorder. Interviews with staff, including the Director of Nursing, revealed that all medications kept by residents should be documented and have corresponding physician orders. The DON acknowledged that undocumented use of medications, such as the lidocaine patch, could result in unassessed pain and that mixing medications from different bottles could obscure expiration dates. Facility policy required medications to be administered within one hour of the prescribed time and for all medications to be checked for expiration prior to administration, but these procedures were not followed in the cases reviewed.
Failure to Provide Adequate Foot Care Leads to Severe Complications
Penalty
Summary
The facility failed to provide adequate foot care for a resident, leading to severe complications. The resident, who had a history of type II diabetes mellitus, chronic kidney disease, and chronic congestive heart failure, was readmitted with a left lower leg wound. Despite recommendations from a Wound Physician Specialist (WPS) for an MRI to rule out osteomyelitis, the facility did not ensure the MRI was conducted. This oversight occurred after the resident's left plantar foot wound reopened, and the WPS expressed concerns about the potential for osteomyelitis and gangrene. The facility also failed to implement its wound care policy and procedures by not documenting the services provided on multiple dates and not conducting thorough assessments of the resident's condition. The resident's care plan did not include an individualized plan for the left foot wound, despite the wound's reclassification from a blister to an arterial ulcer. Interviews with nursing staff revealed a lack of awareness about the MRI recommendation and inadequate documentation of wound assessments, which contributed to the resident's deteriorating condition. As a result of these deficiencies, the resident was transferred to a general acute care hospital with a diagnosis of sepsis due to a necrotizing soft tissue infection. The resident underwent a left ankle disarticulation and later a below-the-knee amputation. The facility's failure to follow professional standards of practice and ensure proper documentation and communication among staff led to significant harm to the resident.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan tailored to the individual needs of a resident, identified as Resident 1, who was readmitted with multiple health issues including a left lower foot wound, epilepsy, chronic kidney disease, chronic congestive heart failure, and type II diabetes mellitus. Upon review, it was found that the care plan did not address the resident's specific needs for wound care, pain management, and refusal of repositioning, which are critical given the resident's medical history and current condition. The care plan also lacked strategies to manage the resident's episodes of aggressiveness towards staff. Interviews with staff, including registered nurses and certified nursing assistants, revealed that there was no individualized care plan developed for the resident's left foot wound upon readmission, nor was there a plan for managing the resident's pain and refusal to be repositioned. Staff reported that the resident frequently complained of pain and refused to have his legs touched, which made it difficult to provide necessary care. The resident's aggressive behavior towards staff was also not adequately addressed in the care plan, as there were no documented strategies for managing these episodes. The facility's policy and procedure for comprehensive, person-centered care plans require that they include measurable objectives and timeframes to meet the resident's needs. However, the care plan for Resident 1 did not meet these requirements, as it failed to incorporate the resident's refusal of treatment and the need for behavioral monitoring and assessment. The lack of documentation and individualized interventions in the care plan had the potential to negatively impact the resident's health and safety, as well as the quality of care and services received.
Failure to Maintain Resident's Range of Motion and Mobility
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion (ROM) and mobility for a resident, leading to a deficiency. The resident, a male with a history of epilepsy, chronic kidney disease, chronic congestive heart failure, and type II diabetes mellitus, was admitted and readmitted to the facility. His cognitive skills were moderately impaired, and he required maximum assistance for activities of daily living (ADLs). The care plan indicated a need to monitor and report any changes in his condition, but the facility did not adequately address his refusal to be repositioned, which was necessary to prevent further immobility and skin breakdown. Interviews with staff revealed that the resident frequently complained of pain and refused to have his legs touched, making it difficult for staff to reposition him as required. Certified Nursing Assistants (CNAs) reported that the resident would yell and scream when attempts were made to reposition him, and he often returned to a prone position. Despite these challenges, the facility did not develop a care plan to address the resident's refusals and behavior, nor did they document these refusals consistently. The facility's policy and procedure for repositioning required a consistent program for changing the resident's position every two hours, with documentation of any refusals. However, interviews with Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) indicated that this was not consistently followed. The DON acknowledged the need for a care plan to address the resident's refusal to be repositioned and the importance of notifying the physician, but these actions were not taken, leading to the deficiency.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to effectively manage the pain of a resident, leading to unnecessary suffering. The resident, a male with a history of epilepsy, chronic kidney disease, chronic congestive heart failure, and type II diabetes mellitus, was admitted and readmitted to the facility with a moderate cognitive impairment. Despite having physician orders to assess pain daily and use nonpharmacological interventions before administering medication, the facility did not consistently follow these protocols. The resident's care plan aimed for him to verbalize pain control to a tolerable level, but this goal was not met. Interviews with staff revealed that the resident frequently complained of pain, especially when repositioned, and exhibited behaviors such as yelling and screaming, which are indicative of pain. Certified Nursing Assistants reported that the resident resisted care and expressed pain when his legs were touched, yet these observations were not adequately addressed by the nursing staff. Licensed Vocational Nurses and a Registered Nurse acknowledged the resident's behaviors but did not administer pain medication, as the resident verbally denied pain when asked directly. The facility's policy required a comprehensive pain assessment using a standardized instrument appropriate to the resident's cognitive level, but this was not implemented. The Director of Nursing recognized that signs of pain include facial grimacing and behavioral issues, yet the staff did not perform a thorough assessment when these symptoms were present. The failure to adhere to the facility's pain management protocol resulted in the resident experiencing unnecessary pain.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, who was admitted with multiple diagnoses including epilepsy, chronic kidney disease, chronic congestive heart failure, and type II diabetes mellitus. The resident's cognitive skills were moderately impaired, requiring maximum assistance for activities of daily living. Despite having a care plan in place to address potential verbal aggression related to ineffective coping skills, the facility did not document behavioral monitoring or assessments for the resident's ineffective coping skills. Interviews with staff revealed that the resident exhibited aggressive behavior, such as yelling and screaming, particularly when staff attempted to reposition him. Certified Nursing Assistants reported that the resident would become verbally aggressive during these interactions, and Licensed Vocational Nurses noted that the resident expressed pain but did not receive pain management interventions. The staff's approach was to avoid disturbing the resident, which led to a lack of proper assessment and documentation of the resident's behavioral disturbances. The Director of Nursing indicated that staff should notify the physician and involve social services for psychosocial assessment and support when behavioral disturbances occur. However, the facility's policy on behavioral assessment, intervention, and monitoring was not followed, as there was no documentation of the onset, duration, intensity, and frequency of the resident's behavioral symptoms. This lack of adherence to the policy contributed to the deficiency in providing necessary behavioral health care and services to the resident.
Failure to Properly Set Mattress and Monitor Weight
Penalty
Summary
The facility failed to provide preventive care consistent with professional standards of practice for a resident at risk for pressure injuries. The resident, who was admitted with conditions including venous insufficiency, type II diabetes mellitus, and muscle weakness, required a low air loss mattress to prevent and treat pressure wounds. However, the mattress was improperly set at a weight of 400 lbs, which did not correspond to the resident's actual weight, as confirmed by a registered nurse. This improper setting was observed during an interview with the resident, who reported discomfort with the mattress. Additionally, the facility did not monitor and record the resident's weight according to its policy and procedure. The resident's care plan required weekly weight monitoring for four weeks upon admission and then monthly if stable, but there was no record of the resident's weight being documented since admission. The facility's policy on weight assessment and intervention emphasized the importance of monitoring resident weights to detect undesirable or unintended weight changes, yet this was not adhered to, placing the resident at risk for poor wound healing and potential development of new pressure injuries.
Failure to Notify Resident's POA of Healthcare Decisions
Penalty
Summary
The facility failed to ensure that a resident's court-delegated general power of attorney (POA) was informed of the resident's healthcare decisions. The resident, who had diagnoses including unspecified dementia, chronic kidney disease, and atherosclerotic heart disease, was admitted and readmitted to the facility. The resident's face sheet initially listed an emergency contact, but the POA documentation, which designated a different responsible party, was not obtained until several years after the initial admission. This oversight led to the resident being discharged against medical advice with the emergency contact, rather than the designated POA, being informed of the discharge and related medical information. The Social Services Director (SSD) acknowledged that the facility did not obtain the POA documentation in a timely manner and failed to update the resident's face sheet accordingly. The facility's policy and procedure on advance directives required that such documents be obtained and maintained in the resident's medical record, but this was not adhered to in this case. The failure to notify the correct POA placed the resident at risk for making uninformed decisions due to their medical condition.
Absence of Director of Nursing and Lack of Interim Appointment
Penalty
Summary
The facility failed to ensure that a Director of Nursing (DON) was present onsite for at least 8 consecutive hours a day from November 2024 to January 3, 2025. This deficiency was identified through observation, interviews, and record reviews. During an interview, a registered nurse (RN 1) stated that the DON had been on sick leave since November 2024, and there was no interim DON appointed in their absence. RN 1 also mentioned a lack of knowledge about any clinical consultant managing the nursing services. A review of the DON's timesheet records with the Medical Record Director (MRD) revealed no available timesheet records for the DON. The Administrator-in-Training confirmed the DON's absence since November 2024 and acknowledged that no interim DON was appointed, nor was any notification sent to the State Agency regarding the absence. The facility's job description for the DON, prepared in July 2018, outlines the essential duties of overseeing and supervising resident care, managing the nursing department, and ensuring compliance with policies and procedures.
Failure to Implement Comprehensive Care Plan for Nephrostomy Tube Dislodgment
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who experienced a change in condition due to the dislodgment of a nephrostomy tube. The resident, who was admitted with a diagnosis of nephrostomy catheter displacement and fibromyalgia, required total dependence on staff for activities of daily living. Despite multiple incidents of nephrostomy tube dislodgment and other related issues such as blood in the drainage bag and minimal urine output, the facility did not develop or revise a care plan to address these changes in the resident's condition. The absence of a care plan was confirmed during a record review and interview with a registered nurse, who acknowledged that a care plan should have been in place to ensure consistent interventions by the staff. The facility's policy on comprehensive, person-centered care plans mandates that such plans include measurable objectives and timetables to meet the resident's needs and be updated when there is a significant change in condition. However, this policy was not followed, leading to a deficiency in the care provided to the resident.
Failure to Label and Document IV Dressing
Penalty
Summary
The facility failed to ensure proper labeling and documentation of a peripheral catheter dressing for a resident, which is a requirement according to the facility's policy. During an observation, it was noted that the resident's peripheral intravenous (PIV) line had no date on the transparent dressing, which is a critical step to ensure timely changes and prevent infections. The facility's policy mandates that the dressing should be labeled with the date, time, and initials at the time of insertion and changed every 72 to 96 hours or sooner if the dressing's integrity is compromised. The resident involved had a history of polymyositis with myopathy, dysphagia, and cerebral atherosclerosis, and was readmitted to the facility with an order to establish an IV line. The Minimum Data Set indicated that the resident's cognitive skills for daily decisions were severely impaired. During an interview, a registered nurse confirmed that the PIV line and dressing should be labeled when inserted to track when it is due for a change, which was not done in this case, leading to a potential risk of infection at the IV site.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident during meal assistance. Resident 1, who was admitted with diagnoses including unspecified dementia and chronic kidney disease, required moderate to maximal assistance for activities of daily living due to moderately impaired cognitive skills. During a meal observation, a Certified Nursing Assistant (CNA) was seen standing over Resident 1 while feeding him lunch, which is against the facility's policy that emphasizes feeding residents with attention to safety, comfort, and dignity. The CNA admitted to standing over the resident because there was no chair available, despite the facility having enough chairs. The Registered Nurse Supervisor confirmed that staff should be seated while assisting residents with meals to uphold their dignity. The facility's policy on meal assistance, reviewed earlier in the year, clearly states that residents who cannot feed themselves should be fed with attention to their dignity, which includes not standing over them during meals.
Failure to Notify Legal Representative of Change in Resident's Condition
Penalty
Summary
The facility failed to implement its policy and procedures regarding resident rights by not informing a resident's legal representative of a change in the resident's condition. The resident, who had a diagnosis of urinary tract infection and unspecified dementia, was noted to have fluctuating capacity to understand and make decisions. Despite this, the facility did not notify the resident's Durable Power of Attorney (DPOA) about a significant change in condition, specifically a weight gain of three pounds in a week, as documented in the SBAR communication tool. The facility's policy, reviewed on 4/17/2024, mandates that residents and their legal representatives be informed of any changes in the resident's condition and participate in care planning. However, the registered nurse confirmed that no notification was sent to the legal representative following the change in condition on 8/6/2024. This oversight violated the resident's rights to be informed and involved in their care planning, as outlined in the facility's policies.
Failure to Provide Medical Records Access
Penalty
Summary
The facility failed to ensure that medical records were readily available and producible upon request for a resident, as per the facility's policy and procedures. The deficiency involved not keeping the resident's medical records up to date with the most recent Durable Power of Attorney (DPOA) for healthcare documentation. Additionally, the facility did not provide the resident's DPOA with a medical record release form when requested, resulting in the DPOA not having access to important medical records and history. The resident in question was admitted with diagnoses including a urinary tract infection and unspecified dementia, with fluctuating capacity to understand and make decisions. The resident's family member, who was appointed as the DPOA, requested access to the medical records but did not receive the necessary request form from the facility. Despite notifying the Medical Record Director (MRD) and being informed of the process, the MRD confirmed not sending the release form to the family member. This failure was in violation of the facility's policies, which guarantee residents' rights to access their personal and medical records.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an unusual occurrence involving a resident's elopement within 24 hours to the State Survey Agency. The resident, who had a history of schizoaffective disorder, PTSD, major depressive disorder, osteoarthritis, muscle weakness, and cardiomyopathy, was admitted to the facility with intact mental cognition and was independent in several activities of daily living. On the morning of the incident, a housekeeper observed the resident at the facility's entrance with belongings, indicating an intention to leave. The housekeeper later informed a Licensed Vocational Nurse (LVN) that the resident had left the facility without authorization. The LVN immediately began searching for the resident, both inside and outside the facility, but was unable to locate them. The Director of Nursing (DON) later stated that the resident was documented as leaving against medical advice rather than an elopement. The facility's policy requires reporting unusual occurrences affecting residents' health, safety, or welfare to appropriate agencies within 24 hours, which was not adhered to in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident, leading to the resident's elopement from the premises without the facility's knowledge. The resident, who had been admitted with multiple diagnoses including schizoaffective disorder, PTSD, major depressive disorder, osteoarthritis, muscle weakness, and cardiomyopathy, was found by a housekeeper at the facility's entrance with his belongings, stating he was leaving. Despite being alert and oriented, the resident did not have authorization to leave, and the staff was unaware of his departure until informed by the housekeeper. The incident occurred when the housekeeper, upon starting her shift, encountered the resident at the entrance and later informed a Licensed Vocational Nurse (LVN) that the resident had left. The LVN, realizing the resident did not have permission to leave, initiated a search but was unable to locate the resident. The facility's policy on wandering and elopement required staff to prevent residents from leaving and to inform the charge nurse or director of nursing services, but these procedures were not effectively followed in this case.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of several residents, as observed during a survey. For Resident 61, staff were observed standing over the resident while feeding, which is against the facility's policy that requires staff to be at eye level to ensure the resident's comfort and dignity. This practice was confirmed by both the CNA involved and the Registered Nurse Supervisor, who stated that squatting is not an acceptable alternative to sitting while feeding residents. Resident 27 was found lying flat in bed while attempting to eat, with the meal tray placed above his head, which posed a risk of aspiration. The resident's condition, including severe dementia and schizophrenia, required substantial assistance, yet the staff failed to provide the necessary support to ensure safe and dignified eating conditions. The Director of Nursing acknowledged that residents should be cleaned before and after meals and that their head should be elevated to prevent aspiration. Additionally, Residents 50 and 37 reported difficulties in communication due to staff speaking in a language they did not understand, contrary to the facility's policy that mandates English-only communication unless the resident speaks a different language. This lack of adherence to communication policies potentially hindered the residents' ability to communicate effectively with staff, impacting their overall care experience.
Failure to Obtain Informed Consent for Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was informed and consented in advance to the risks and benefits of pneumonia vaccines and immunizations. This deficiency was identified for one of the five sampled residents, who had severely impaired cognition and required maximal assistance with activities of daily living. The resident received the pneumococcal vaccine on two occasions, but there was no documented informed consent in the medical record prior to the administration of the vaccine. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that informed consent should have been obtained and documented before administering the vaccine. The facility's policy and procedures require that residents or their legal representatives receive information and education about the benefits and potential side effects of the pneumococcal vaccine, and that this education is documented in the resident's medical record. However, this process was not followed in the case of the resident in question.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, which is a critical tool for residents to summon assistance. Resident 66, who has chronic kidney disease, Alzheimer's disease, and dysphagia, was observed in bed with the call light not connected and out of reach. This was confirmed by an LVN who acknowledged that the call light was not accessible, preventing the resident from communicating needs. Resident 192, diagnosed with dysphagia, rectal cancer, and chronic kidney disease, was also found with the call light on the floor, out of reach. The resident's care plan specifically included an intervention to ensure the call light was within reach due to a high risk for falls. An LVN confirmed the call light was not accessible, which hindered the resident's ability to communicate needs. The facility's policy mandates that call lights should be within easy reach when residents are in bed. Resident 51, with a history of cerebral infarction, prostate cancer, and other conditions, was observed without a call light within reach. An LVN confirmed the absence of the call light, emphasizing the risk and communication barrier it posed. The DON reiterated that call lights must be accessible to all residents to prevent delays in care. The facility's policy supports this requirement, indicating a failure to adhere to established procedures.
Failure to Maintain a Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for three residents. Resident 59 reported that the facility was noisy, with staff contributing to the noise by slamming doors, which made it difficult for the resident to rest. The Director of Nursing acknowledged that noise levels should be controlled and comfortable for residents. The facility's policy on maintaining a homelike environment emphasized the importance of comfortable sound levels, which was not adhered to in this case. Resident 74 also experienced issues with noise, stating that the facility became noisy during after-hours, preventing the resident from sleeping or resting. The Director of Nursing confirmed that noise levels should be reduced, especially during the evening. This indicates a failure to provide a quiet environment conducive to rest, as required by the facility's policies. Resident 44 faced issues with the physical condition of their room, including a broken window chain, a malfunctioning bedside drawer, and a non-functional electric wall plug. The Maintenance Supervisor was aware of these issues but had not addressed them, despite knowing about them for two weeks. The Director of Nursing stated that equipment should be in proper working condition to accommodate residents' preferences and comfort. The facility's maintenance policy requires that buildings and equipment be maintained in a safe and operable manner, which was not fulfilled in this instance.
Failure to Provide Adequate Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide preventive care consistent with professional standards for three residents at risk of developing pressure injuries. Resident 292, who has paraplegia, muscle weakness, and other health issues, was observed without the required heel protectors, despite having an order to offload bilateral heels with heel protectors at all times. The resident's heels were resting directly on the mattress, and the resident reported not knowing where the heel protectors were placed after being moved. The treatment nurse confirmed the resident's need for heel protectors to promote wound healing and prevent worsening of the wounds. Resident 1, who has severely impaired cognition and requires maximal assistance for activities of daily living, was found with a low air loss mattress set incorrectly. The mattress was set between 80 lbs. to 160 lbs., while the resident's weight was 178 lbs., and the setting should have been between 160 lbs. to 240 lbs. according to the facility's policy and the Director of Nursing. The incorrect setting was confirmed during an interview with a licensed vocational nurse, who acknowledged the discrepancy. Resident 16, also with severely impaired cognition and at risk for pressure ulcers, was supposed to have a low air loss mattress set according to their weight. The facility's policy requires the mattress to be adjusted based on the resident's weight, as per the physician's order. However, the report does not specify if the mattress was set incorrectly, only that the facility failed to ensure proper settings for the low air loss mattress according to the physician's order and facility policy.
Failure to Manage Psychotropic Medication Regimens
Penalty
Summary
The facility failed to manage and monitor the psychotropic medication regimens for two residents, leading to deficiencies in their care. For Resident 26, the facility did not implement the pharmacy's recommendation to discontinue Risperdal, an antipsychotic medication. Despite the attending physician agreeing to a dose adjustment and discontinuation, there was no documentation or physician order to carry out this change. The Director of Nursing acknowledged that pharmacy recommendations should be verified and completed by the physician, and nursing staff should ensure the physician's response is executed. The facility's policy requires immediate reporting and documentation of medication irregularities, which was not adhered to in this case. For Resident 52, the facility failed to obtain timely informed consent for the administration of psychotropic medications, specifically escitalopram and Seroquel. The resident's medical record lacked the necessary informed consent documentation for these medications, as confirmed by the Medical Record Director. The Director of Nursing stated that informed consent should be obtained and documented for all psychotropic medications. The facility's policy mandates that the prescribing clinician must obtain and document informed consent before administering psychotropic medications, which was not followed in this instance.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for residents on transmission-based precautions. Resident 66, who was on contact isolation for ESBL in the urine, was not placed in a private room despite the availability of empty rooms. Instead, Resident 66 shared a room with Resident 192, who was not on any contact isolation. This oversight was confirmed by both the Infection Preventionist Nurse and the Director of Nursing, who acknowledged the availability of private rooms and the risk posed to other residents. Additionally, staff failed to wear appropriate Personal Protective Equipment (PPE) when providing care to residents in contact isolation rooms. Certified Nursing Assistant 4 was observed assisting Resident 192 without wearing full PPE, despite the room being designated as a contact isolation room due to Resident 66's condition. This lapse in protocol was acknowledged by Licensed Vocational Nurse 2 and the Infection Preventionist Nurse, who emphasized the importance of wearing full PPE to prevent the transmission of infections. Furthermore, Resident 292, who tested positive for E. coli in the urine, was not placed in a contact precaution room as per the facility's policy and CDC guidelines. Instead, Resident 292 was placed in a shared room without any signage for contact precaution isolation. The Infection Preventionist Nurse and the Director of Nursing stated that Resident 292 was on enhanced precaution rather than contact precaution, despite the CDC's recommendation for contact precautions for incontinent residents with E. coli infections.
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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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