Kern River Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 5151 Knudsen Drive, Bakersfield, California 93308
- CMS Provider Number
- 555912
- Inspections on file
- 72
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Kern River Transitional Care during CMS and state inspections, most recent first.
A resident whose primary language was Spanish did not receive vital admission documents in their preferred language. The facility lacked a Spanish version of the Admissions Agreement and did not provide written or oral translation, despite policy requirements and staff acknowledgment that such translation was necessary.
The facility did not ensure that care and services provided met professional standards of quality, as evidenced by practices that did not align with established guidelines.
A resident who did not have a bowel movement for six days was not provided with the required bowel management protocol, as the DON confirmed that no medications were administered and the facility's policy for assessment and intervention was not followed.
Three LVNs lacked documented competency training for CPAP and BIPAP care, resulting in inconsistent application of respiratory devices for residents. A resident reported variable effectiveness of her BIPAP mask depending on which LVN applied it, and the DON confirmed that several residents required these therapies without staff having received proper training.
A resident at high risk for falls was not wearing non-skid socks as required by their care plan and facility policy, and after an unwitnessed fall, an LVN and CNA transferred the resident without waiting for an RN assessment as mandated by the facility's fall protocol. The resident complained of hip pain and was later sent to the hospital for further evaluation.
A resident's responsible party was not given the opportunity to participate in the selection of a hospice provider, nor was there documentation that the hospice process or available providers were explained. The DON confirmed the lack of documentation, and facility policy requires residents and their representatives to be informed and involved in care decisions.
A resident's transition to hospice care was not properly coordinated, as no initial IDT conference was held and the first conference lacked a facility nurse. Only two care plans were updated to reflect hospice involvement, contrary to facility policy requiring comprehensive, interdisciplinary care planning.
The facility did not consistently obtain or document informed consent for psychoactive medications and bed alarms, as required by its own policies. In multiple cases, consent forms were missing physician or nurse signatures, or were not signed by the resident or responsible party, even though medications or interventions were administered. This included residents with varying levels of cognitive impairment and involved both medication and restraint interventions.
Nursing staff failed to demonstrate and document competency in providing specialized care, including dialysis site assessment, suprapubic catheter care, and management of midline and PICC lines for several residents. Required skills were not validated or documented as per facility policy, and assessments were not consistently performed or recorded.
Staff failed to adhere to infection control protocols, including not wearing required PPE during close contact with a resident on Enhanced Barrier Precautions, exiting a resident's room with contaminated PPE, improper disposal of wound dressings, lack of hand hygiene between glove changes, use of non-sterile instruments for wound care, and accessing disinfectant wipes from an open container. These deficiencies were observed during care of residents with wounds and confirmed through staff interviews and policy review.
The facility did not ensure that all CNAs completed the required annual dementia-specific in-service training, as attendance records showed that only a portion of the CNA staff participated in each session, and none met the full five-hour requirement. This was confirmed through record reviews and interviews with the DSD.
Two residents and their responsible parties did not receive completed Baseline Care Plan (BCP) summaries within 48 hours of admission, as required by facility policy. Documentation and signatures confirming receipt of the BCP summaries were missing, and staff interviews confirmed that the summaries were not provided in a timely manner.
Multiple residents were found with unlabeled and unsecured medications at their bedsides without proper assessment for self-administration, and a controlled substance destruction record lacked the required second nurse signature, in violation of facility policy.
The facility did not ensure its Social Services Director was qualified or fulfilled essential duties, resulting in missed Advance Directive information for several residents, lack of timely dental and podiatry referrals, incomplete social history assessments, and failure to notify the Ombudsman of a resident's transfer. The SSD also did not conduct in-room visits or timely documentation, and some residents were not properly assessed or referred for PASRR, as confirmed by the DON.
The QAPI committee did not identify or address ongoing deficiencies in infection prevention, control practices, and social services. Meeting minutes showed a focus on new resident assessments, with no discussion of the specific issues found by surveyors. The Social Services Director was replaced due to incompetence, and the DON took over those duties, but only weekly reviews of admission records were conducted. These failures left all residents at risk for infectious diseases and unmet medically necessary services.
The facility did not ensure that the Infection Preventionist attended two out of three required QAPI committee meetings, as verified by sign-in sheets and administrator review. The IP's attendance was only confirmed for one meeting, while the other two meetings lacked documentation of the IP's presence.
A resident's personal belongings were lost after staff failed to complete the required inventory of personal effects upon admission, contrary to facility policy. The resident reported the missing items to nursing staff, but they were not returned or replaced, and the Social Services Director was not aware of the loss.
The facility did not accurately complete PASARR screenings for three residents, resulting in missed Level II evaluations for individuals with documented mental health diagnoses and psychotropic medication use. The DON acknowledged that the screenings were not done correctly, and the required referral process was not followed according to facility policy.
Surveyors found that the facility did not develop or implement individualized care plans for four residents with specific needs, including foot care, respiratory failure, and IV site management. Staff interviews and record reviews confirmed the absence of required care plans, despite clear evidence of medical conditions and facility policy requiring comprehensive, person-centered planning.
Two residents had IV catheters that were not managed according to facility policy, including failure to flush, change, or remove the IVs as ordered. One resident's IV remained in place and unchanged for over the recommended period, while another resident's IV site was not cared for or discontinued as directed, with no documentation or staff awareness of the IV. These actions did not meet professional standards for IV catheter care.
Two residents dependent on staff assistance did not receive necessary personal and oral hygiene care. One resident had untreated dry, flaky feet with overgrown, discolored toenails and debris between the toes, while another had poor oral hygiene with dental caries and missing teeth, and did not receive consistent mouth care. Staff interviews and record reviews confirmed lapses in care and documentation, contrary to facility policies.
A resident with significant visual impairment was not provided with individualized activities that matched their abilities and preferences. The care plan included activities the resident could not perform due to blindness, and staff did not offer alternatives or assistance, resulting in the resident having nothing to do except remain in bed.
A resident with visibly dry, flaky skin, swollen toes, and overgrown, discolored toenails did not receive appropriate foot care or a podiatry referral, despite a physician's order and clear signs of foot disorders. Nursing staff acknowledged the need for intervention but did not act, and documentation in nursing and social services records failed to address the resident's foot condition or the need for specialist care.
A resident with a suprapubic catheter did not have documented catheter changes for several months, and staff could not provide evidence of competency or proper documentation for catheter care. The facility's policy lacked clear guidelines on which clinical personnel were qualified to change suprapubic catheters and did not meet current professional standards.
A resident requiring dialysis did not have documented assessments of their dialysis access site on several occasions, as the post-dialysis treatment sections of the communication forms were left blank. An LVN stated that the facility would call the dialysis center if information was missing, but the required documentation was not present as per facility policy.
A resident with multiple missing and discolored teeth, as well as reported cavities, was not assisted by staff in obtaining a dental appointment despite a physician's order and the resident's request. The Social Services Director did not make or document a dental referral, and the social history assessment was incomplete, lacking necessary information about the resident's dental needs.
Two residents had incomplete and inaccurate medical records, including one whose weekly nursing summaries did not match observed skin and toenail conditions, and whose hemodialysis communication assessments were left incomplete on several occasions. Another resident's initial social history assessment was started but not finished, with both the DON and SSD confirming the documentation lapses.
The facility did not ensure that two residents fully understood the Binding Arbitration Agreements they signed. One resident with moderate cognitive impairment and a dementia diagnosis was asked to sign without adequate assessment of their understanding, while another resident, whose responsible party should have signed and who required language assistance, signed without a translator or responsible party involvement. Facility policy requires clear explanation and language access, which was not provided in these cases.
A resident in an LTC facility did not have a care plan developed for their refusal of showers and baths over 13 days, nor for their significant respiratory conditions, including asthma and COPD. The DON confirmed these omissions during a review, which violated the facility's policy requiring comprehensive, person-centered care plans.
A facility failed to obtain a physician's order and document the removal of a midline IV catheter for a resident receiving Meropenem for a bacterial infection. The catheter was removed without proper documentation or a physician's order, contrary to facility policy, leading to incomplete medical records and potential risks for the resident.
A facility failed to implement a fall prevention care plan for a resident at risk for falls. The care plan included the red star program, requiring a red star on the resident's nameplate after multiple falls. However, the resident was observed attempting to get out of bed unassisted without the red star in place, as confirmed by the DON. The facility's policy emphasizes resident-centered fall prevention, which was not followed.
A facility failed to follow its Fall Management policy for a resident with a history of falls, resulting in an incomplete post-fall assessment. The resident experienced multiple falls, and the Post Fall Review (PFR) assessment did not include a review of medications, as required by the facility's policy. The DON and Administrator confirmed the assessment's incompleteness, acknowledging the omission of the medication review.
A facility failed to report a suspicion of financial abuse to a resident's attending physician, as required by their policy. The incident involved a resident discovering missing money from their bank account during a bank visit with the Administrator. Despite the policy's requirement for immediate reporting to the attending physician, the Director of Nursing and the Administrator confirmed that this notification did not occur.
A resident reported being raped by two men multiple times, but the facility failed to report the allegation to the CDPH within 24 hours and did not complete an investigation within five business days. The DON was informed of the allegations and instructed staff to call 911, but did not report to CDPH, citing a change in the resident's story. The facility's policy requires immediate reporting and thorough investigation of abuse allegations.
A resident experienced two unwitnessed falls, and the facility failed to notify the attending physician and responsible party as required by their policy. The first fall was documented with notifications, but the second fall lacked documentation of any notifications. This deficiency was confirmed through interviews and record reviews.
A resident identified as high risk for falls experienced two separate falls, but the facility failed to revise the fall risk care plan after each incident. The Director of Nursing confirmed that the care plan should have been updated according to the facility's policy, which was not adhered to, resulting in a deficiency.
A resident experienced two unwitnessed falls, and the facility failed to conduct the required neurological checks. An LVN stated that such checks should be initiated and last for 72 hours, but the resident's medical records showed no documentation of these assessments. The DON confirmed the oversight, despite the facility's protocol for monitoring vital signs and neurological status after falls.
A facility failed to follow its policy on documentation accuracy, resulting in an inaccurate medical record for a resident. The Director of Nursing confirmed that the resident's discharge summary incorrectly listed another resident as the responsible party, despite the admission record indicating the correct emergency contact. This discrepancy highlights a deficiency in maintaining accurate clinical records.
A resident's grievance about being left in the bathroom for an extended period was not addressed or resolved by the facility, violating the resident's rights. The grievance involved a CNA's inappropriate response during a shift change and was documented but not acted upon according to the facility's grievance policy.
A resident experienced a change in cognitive status, becoming confused and severely impaired, but the facility failed to notify the primary care physician as required by policy. Staff interviews indicated a lack of awareness of the resident's baseline status, and the resident was eventually sent to the hospital after family concerns.
A facility failed to notify a physician of a resident's elevated blood pressure, recorded at 184/82, which exceeded the facility's threshold for reporting. The Director of Nursing confirmed there was no documentation of reassessment or physician notification. The facility's policy requires prompt notification of changes in a resident's condition, but this was not adhered to, potentially impacting the resident's care needs.
A facility failed to implement a care plan for a resident with moderate cognitive impairment who was non-compliant with using the call light, often yelling for assistance instead. Despite reminders from staff, the resident continued this behavior, and the ADON acknowledged the absence of a care plan addressing this issue, contrary to the facility's policy requiring comprehensive, person-centered care plans.
A facility failed to ensure complete communication and coordination with a dialysis center for a resident requiring dialysis. The Pre and Post-Dialysis Communication Form was incomplete, with post-dialysis assessments left blank on several occasions. The Director of Nursing confirmed the oversight, which contradicted the facility's policy requiring detailed documentation of dialysis-related care and observations.
A resident experienced an unwitnessed fall and was identified as high risk for falls, but the facility failed to update the care plan as required by their policy. The Assistant Director of Nurses confirmed the oversight during a review, noting that the care plan should have been revised following the incident.
A resident's call light was found on the floor and not within reach, contrary to the facility's policy. The resident, who had severe cognitive impairment and required assistance for daily activities, was unable to access the call light. Both a CNA and an LVN acknowledged that the call light should have been accessible.
A facility failed to monitor and document behavioral episodes for a resident with bipolar disorder, risking untreated worsening behavior. The care plan required documentation of behavioral symptoms, but this was not done, as confirmed by the DON.
The facility failed to document medication administration immediately for two residents, leading to inaccurate medical records. Despite timely administration, staff did not adhere to the policy requiring immediate documentation, as confirmed by the ADON and LVNs.
The facility failed to ensure medication carts and the medication room were free from expired medications and did not follow their policy on medication labeling. Expired medications and improperly labeled medications were found during observations, and an insulin was not dated as required.
The facility failed to maintain dignity for two residents. One resident had to wear donated clothing due to delayed laundry services, causing discomfort and dissatisfaction. Another resident, dependent on staff for oral hygiene due to ALS, had visibly poor oral hygiene and reported feeling neglected. Staff confirmed these issues, highlighting a lapse in maintaining residents' dignity.
The facility failed to ensure a PO and SAMA were completed for a resident self-administering multivitamins. The ADON confirmed the absence of required documentation, contrary to the facility's policy.
Failure to Provide Vital Documents in Resident's Primary Language
Penalty
Summary
The facility failed to provide vital documents in the primary language of a resident whose preferred and primary language was Spanish. Review of the resident's admission record and social history assessment confirmed Spanish as the resident's primary language. However, the Admissions Agreement provided to the resident was in English, and the facility did not have a Spanish version available. The Admissions Coordinator confirmed that the facility does not have an Admissions Agreement in Spanish. Additionally, the resident's hospital record indicated a need for an interpreter, and the Director of Nursing acknowledged that vital documents should have been provided in Spanish. The facility's policy on translation and interpretation services requires that individuals with limited English proficiency (LEP) have meaningful access to information and services, including written translation of vital information such as admission agreements. The policy also specifies that when written translation is unavailable, oral translation should be provided, and that family members should not be relied upon for interpretation unless explicitly requested by the resident. In this case, the facility did not provide the required written or oral translation of vital documents to the resident in their primary language.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff actions, or detailed events leading to the deficiency.
Failure to Initiate Bowel Management Protocol for Resident with Constipation
Penalty
Summary
A deficiency occurred when the facility failed to follow its Bowel Management Protocol for one resident who did not have a bowel movement for six consecutive days. The resident's Task: Bowel Continence record showed no bowel movement from 6/24/25 to 6/30/25. During an interview and record review, the DON confirmed that the bowel protocol, which includes administering medications to treat and prevent constipation, was not initiated for this resident. No medications were given, and the necessary steps outlined in the facility's policy were not followed. The facility's policy requires daily review of residents' bowel movement records, identification of those who have not had a bowel movement in three days, and administration of appropriate medications as ordered by a physician. In this case, the required assessment, tracking, and treatment were not performed, resulting in the resident not receiving needed medication to address constipation.
Lack of Staff Competency for CPAP and BIPAP Care
Penalty
Summary
The facility failed to ensure that three sampled Licensed Vocational Nurses (LVNs) possessed the necessary competencies to provide care for residents requiring continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP) therapy. During interviews and record reviews, it was found that there was no documented skills training for CPAP or BIPAP for these LVNs. A resident reported that the effectiveness of her BIPAP mask application varied depending on which LVN applied it, indicating inconsistency in staff competency. The Staffing Coordinator confirmed the absence of skills training records for the involved LVNs. The Director of Nursing acknowledged that there were seven residents with physician orders for CPAP and BIPAP and stated that training should be provided for these therapies to ensure proper application and resident comfort. Review of the facility's policy indicated that nursing staff are required to demonstrate skills and competencies based on the needs of the resident population, but this requirement was not met for CPAP and BIPAP care. The lack of appropriate training and competency assessment for these devices led to the deficiency.
Failure to Ensure Use of Non-Skid Socks and Proper Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls was wearing non-skid socks as required by the care plan. The resident, who had a documented high fall risk score and a care plan intervention specifying the use of non-skid socks, was found not wearing them at the time of an unwitnessed fall. Staff interviews confirmed that the non-skid socks had been removed prior to the incident, and the resident was not wearing them when found on the floor. The facility's policy required the use of proper footwear to prevent falls, but this was not followed in the resident's case. Additionally, the facility did not follow its in-service protocol on falls, which required an RN to assess any resident found on the floor before moving them. After the resident was found on the floor complaining of left hip pain, an LVN and a CNA transferred the resident to a wheelchair and then to bed without waiting for the RN's assessment. The RN supervisor arrived shortly after and, upon assessment, suspected a hip fracture and sent the resident to the hospital. Staff interviews confirmed awareness of the protocol but acknowledged it was not followed in this instance.
Failure to Involve Responsible Party in Hospice Provider Selection
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for one resident was able to participate in treatment decisions, specifically regarding the initiation of hospice care. The resident's family member, who was identified as the RP in the admission record, reported that while she agreed to start hospice care for the resident, she was not given a choice of hospice providers and did not consent to the specific hospice company assigned. Review of the resident's medical record with the DON confirmed there was no documentation that the RP was educated about the hospice process or informed of the available hospice companies. The facility's policy states that residents have the right to be informed and to participate in decisions and care planning, including choosing a physician and treatment.
Failure to Coordinate Hospice Care in Resident's Plan of Care
Penalty
Summary
The facility failed to ensure that a resident's plan of care was properly coordinated with hospice services. Upon review of the resident's medical record and interviews with the DON, it was found that when the resident began hospice care, no interdisciplinary team (IDT) conference was held at the start of hospice, as required. The first IDT conference that did occur included dietary, activities, social services, a hospice nurse, and the resident's representative, but did not include a facility nurse. Additionally, only two of the resident's care plans were updated to reflect the initiation of hospice care, rather than a comprehensive update as expected. Facility policies require that a coordinated plan of care be developed and maintained between the facility, hospice agency, and the resident or their family, with updates as necessary to reflect the resident's current status. The care planning process is intended to be interdisciplinary, involving multiple disciplines including the resident's physician and a facility nurse. The failure to hold a timely and fully staffed IDT conference and to comprehensively update the care plans resulted in a lack of proper coordination for the resident's hospice care needs.
Failure to Obtain and Document Informed Consent for Psychoactive Medications and Bed Alarms
Penalty
Summary
The facility failed to follow its own policies and procedures regarding informed consent for psychoactive/psychotropic medication use and the use of bed alarms for multiple residents. In several cases, consent forms for psychoactive medications such as escitalopram, amitriptyline, alprazolam, venlafaxine, bupropion, sertraline, Seroquel, lorazepam, and clonazepam were either missing required physician signatures, lacked verification by a licensed nurse, or were not signed by the resident or their responsible party. In some instances, documentation of informed consent was entirely absent, despite the medications being administered. The facility's policy required that the prescribing clinician obtain and document informed consent, and that a licensed nurse verify and sign the consent form prior to medication administration, but these steps were not consistently followed. The report details that for several residents, including those with varying levels of cognitive impairment as measured by the Brief Interview for Mental Status (BIMS), informed consent forms were incomplete or missing. For example, one resident with a BIMS of 12 had consent forms for two psychoactive medications that were not signed by a physician. Another resident with a BIMS of 3 had an incomplete consent for alprazolam, and a resident with a BIMS of 7 had no documentation of consent for lorazepam, despite receiving the medication on multiple occasions. In other cases, the responsible party's signature was present, but there was no verification by a nurse or physician, as required by policy. Additionally, the facility failed to obtain and document informed consent for the use of bed alarms for two residents. The consent forms for these interventions were incomplete, lacking signatures from a nurse or physician, and in one case, the responsible party's signature was not clearly documented. The facility's policy required that the physician provide education to the resident or responsible party about the risks, benefits, and alternatives of such interventions, and that informed consent be properly documented, but this was not done consistently.
Failure to Validate Nursing Staff Competency for Specialized Resident Care
Penalty
Summary
Nursing staff at the facility failed to demonstrate and document appropriate competencies for specialized care required by several residents. Specifically, three licensed vocational nurses (LVN 2, LVN 3, and TN 2) did not have documented competency in providing care for a resident undergoing dialysis, including assessment of the arterio-venous fistula site for bruit and thrill before and after dialysis treatments. The Director of Nursing (DON) and Director of Staff Development (DSD) confirmed that the competency forms for these nurses did not include dialysis care, and the required assessments were not performed as indicated in the residents' records. Additionally, the same three nurses lacked documented competency in the care and replacement of suprapubic catheters for another resident who returned from the hospital with this device. Although the nurses indicated prior experience or education in suprapubic catheter care, there was no evidence of return demonstration or validation of their skills by the facility. The DSD was unable to provide documentation of competencies in all areas related to suprapubic catheter care, assessment, and replacement for these nurses. Furthermore, two registered nurses (RN 1 and RN 3) did not have documented competencies for the care and management of midline catheters and peripherally inserted central catheters (PICC) for several residents receiving intravenous antibiotics. The competency forms reviewed did not include specific skills related to midline or PICC line care, and the DSD could not provide evidence of validated skills or knowledge for these procedures. The facility's policy required that nurses be competent in skills related to their assigned duties, with competencies validated prior to independent performance and annually thereafter, but this was not followed for the specialized care in question.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Multiple failures to follow infection prevention and control protocols were observed among staff members during resident care activities. One nurse provided care to a resident on Enhanced Barrier Precautions (EBP) for a right ankle wound without wearing the required isolation gown, despite signage and physician orders indicating the need for EBP. The nurse acknowledged awareness of the requirement but did not comply during close contact with the resident. An X-ray technician, while performing imaging for a resident on EBP, exited the resident's room into the hallway wearing contaminated gloves and an isolation gown to answer a phone call. The technician then returned to the room, removed the PPE, and failed to perform hand hygiene before touching equipment and leaving the room. Facility policy required removal of PPE inside the room and hand hygiene after glove removal, which was not followed. During wound care for another resident, a treatment nurse disposed of contaminated dressings in a regular trash bin instead of a biohazard container, did not perform hand hygiene between glove changes, and used non-sterile scissors to cut a sterile gauze strip for wound packing. The same gloves were used throughout the procedure, and the nurse stated the scissors were disinfected after use. Additionally, a central supply staff member accessed disinfectant wipes from a container without a lid, contrary to facility expectations. These actions were directly observed and confirmed through staff interviews and policy review.
Failure to Ensure Annual Dementia Training for All CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received at least five hours of dementia-specific in-service training annually, as required. Record reviews and interviews with the Director of Staff Development (DSD) revealed that out of 108 sampled CNAs, attendance at various one-hour dementia training sessions ranged from 33 to 68 CNAs per session, with no evidence that all CNAs completed the required training hours. The DSD confirmed during multiple interviews that only a portion of the CNAs attended each session, and none of the sessions individually or collectively ensured that every CNA met the five-hour annual requirement. Additionally, the facility's policy and procedure on in-service training, which mandates annual training in dementia management and resident abuse prevention for all staff, was not followed. The deficiency was identified through a review of attendance sheets for multiple training sessions, all indicating incomplete participation by the CNA staff. There were no specific residents mentioned as being directly affected in the report, but the lack of comprehensive training for all CNAs was established through documentation and staff interviews.
Failure to Provide Baseline Care Plan Summaries Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide completed Baseline Care Plan (BCP) summaries to two of six sampled residents or their responsible parties within 48 hours of admission. During interviews and record reviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), it was found that there was no documentation indicating that the BCP summaries were given to the residents or their representatives. Specifically, for one resident, the DON could not locate a signed document or any evidence that the BCP summary was provided within the required timeframe. Similarly, for another resident, the ADON confirmed that although the BCP summary indicated participation in the review, there was no documentation or signature showing that a copy was provided to the resident or their representative within 48 hours. The facility's policy and procedure require that a baseline plan of care be developed and a summary provided to the resident and their representative within 48 hours of admission. This summary should include initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information based on the comprehensive care plan. The lack of documentation and signatures for the two residents demonstrates that the facility did not meet its own policy requirements for timely communication of the baseline care plan upon admission.
Failure to Securely Store and Properly Dispose of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly labeled and securely stored, as required by professional standards and facility policy. During observations, multiple residents were found with medications, such as micronazole nitrate, eye drops, antifungal cream, and nystatin powder, left unsecured on their bedside tables. None of these residents had been assessed for self-administration of medications, and there were no orders or documentation supporting their ability to self-administer. Additionally, some of the medications were not labeled with the resident's name, and at least one resident denied ownership of the medication found at their bedside. Further review revealed that the facility did not follow its own policy for the destruction of controlled substances. A controlled substance destruction record was missing the required second nurse signature, as mandated by facility policy, which states that two licensed nurses must be present and sign off during the disposal of controlled substances. The DON acknowledged that the process was not followed as the ADON forgot to sign the record.
Unqualified Social Services Director and Failure to Provide Required Social Services
Penalty
Summary
The facility failed to ensure that the Social Services Director (SSD) met the required qualifications to manage and coordinate social services for its 126 residents. The SSD held a Bachelor of Science in Psychology and was working toward a master's in social work, but this was her first experience in a skilled nursing facility. During interviews and record reviews, it was found that the SSD had not facilitated several required social services, including providing Advance Directive information to six sampled residents or their representatives, making dental and podiatry referrals as ordered, and completing initial social history assessments. The SSD also reported not conducting resident visits in their rooms, instead waiting for care conferences, and delayed documentation for up to two days. Further review revealed that the SSD did not notify the Ombudsman regarding a resident's transfer and discharge, believing it was not her responsibility, and failed to appropriately assess and refer three residents for Pre-admission Screening and Resident Review (PASRR). The facility's policies and job descriptions outlined responsibilities for the SSD that were not being met, such as maintaining adequate records, making necessary referrals, and providing supportive visits. The Director of Nursing confirmed awareness of these occurrences during the survey.
QAPI Committee Failed to Identify and Address Infection Control and Social Services Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify ongoing issues and did not develop or implement corrective action plans for deficiencies in Infection Prevention and Control practices and Social Services. Review of QAPI meeting minutes revealed that meetings were focused on reviewing new resident assessments, but did not address or identify the specific deficiencies related to resident assessment and care planning. The Administrator confirmed that these issues were not discussed in recent QAPI meetings, and that the facility had not recognized the assessment deficiencies identified by the survey team. Additionally, the Social Services Director was found to be incompetent in job duties and was terminated, with the Director of Nursing assuming those responsibilities. Despite this change, the facility's admission records were only reviewed weekly, and the Administrator asserted full compliance. The facility's policy required an ongoing, data-driven QAPI program focused on care outcomes and quality of life, but the observed practices did not align with these requirements, resulting in unaddressed deficiencies that placed all residents at risk.
Infection Preventionist Absent from Required QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) attended two out of three Quality Assessment and Performance Improvement (QAPI) committee meetings during 2024 and 2025, as required. During a review of QAPI committee sign-in sheets for meetings held in September 2024, January 2025, and April 2025, it was found that the IP's attendance could only be verified for the January 2025 meeting. The sign-in sheets for the September 2024 and April 2025 meetings did not include the IP's signature, and the Administrator was unable to confirm the IP's presence at those meetings. The QAPI committee meetings were attended by various staff members, but the absence of the IP was specifically noted in two of the three meetings reviewed.
Failure to Document and Safeguard Resident Personal Property
Penalty
Summary
The facility failed to follow its policy and procedure regarding the documentation of personal property for a resident upon admission. Specifically, staff did not complete the inventory of personal belongings for the resident when she was readmitted, as confirmed by the Director of Nursing during a record review. The resident reported the loss of two sets of pajamas and a pair of pants, stating she informed nurses and nursing assistants, but the items were not returned or replaced. The Social Services Director was unaware of the lost belongings and had not been informed or spoken with the resident about the issue. The facility's policy requires that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary.
Failure to Accurately Complete PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately review and complete the annual Pre-Admission Screening Assessment and Resident Review (PASARR) for three of sixteen sampled residents. For one resident, the Level I PASRR screening was positive for serious mental illness, intellectual disability, developmental disability, or related condition, but no Level II PASRR was completed as required. The Director of Nursing (DON) confirmed that the Level I screening was positive and acknowledged that it was their responsibility to ensure the PASRR process was completed, but this did not occur. For two other residents, the PASRR Level I screenings were marked negative despite both residents having documented mental health diagnoses and being prescribed psychotropic medications. The admission records and order summaries indicated diagnoses such as unspecified psychosis, depression, and anxiety disorder, along with medications like Risperidone, Valium, and Lexapro. The DON acknowledged that the PASRR Level I screenings were not completed accurately, which resulted in the screenings not triggering the required Level II PASRR evaluations. The facility's policy stated that positive Level I screens should be referred for Level II evaluation, but this process was not followed.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents with specific and documented care needs. For one resident, observations revealed significant foot issues, including dry, flaky skin, red and swollen toes, thick and discolored toenails, and wounds, yet there was no care plan addressing foot care. Another resident with a history of respiratory disorders and acute respiratory failure with hypoxia did not have an individualized care plan for managing their respiratory condition. In both cases, staff interviews and record reviews confirmed the absence of appropriate care plans. Additionally, two residents with peripheral intravenous (IV) lines did not have individualized care plans for IV site care and management. One resident had an IV inserted with orders to change the site every 96 hours, but the site was never changed, and no care plan was in place. The other resident was observed with an IV and a gauze dressing, but again, no documented care plan was found. Review of the facility's own policy confirmed the requirement for comprehensive, person-centered care plans with measurable objectives and timetables, which was not met for these residents.
Failure to Follow IV Catheter Care and Removal Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for preventing intravenous (IV) catheter-related infections for two residents. For one resident, an IV was observed in place despite the last dose of IV medication being administered three days prior, and the resident reported that the IV had not been flushed since then. Review of the medical record showed the IV was inserted eleven days earlier and had not been changed or removed as ordered, contrary to the facility's policy requiring peripheral IV sites to be changed every 96 hours. The registered nurse confirmed that the IV should have been removed and that the site had not been changed as required. For another resident, an IV site was present in the left upper arm, and the resident stated that no treatment or dressing change had occurred since admission. The resident also reported providing a physician's order to discontinue the IV to a nurse, but there was no documented evidence of a physician order for care or removal of the IV in the medical record. Nursing staff were unaware of the presence of the IV, and the facility was unable to provide documentation of appropriate orders or care for the IV site. The facility's policy requires prompt removal of IV catheters that are no longer essential and mandates that peripheral catheters be changed every 96 hours.
Failure to Provide Adequate Personal and Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary personal and oral hygiene care for two residents who were dependent on staff assistance. One resident was observed with dry, flaky skin on both feet, overgrown and discolored toenails, and blackish debris between the toes. Interviews with nursing staff confirmed the presence of thick, discolored nails and possible fungal infection, as well as dry, red, and swollen toes. Although a CNA reported attempting to clean the resident's feet, the care was not completed due to the resident's pain, and the CNA did not return to finish the task. Facility policy required routine foot care in accordance with professional standards, but this was not followed. Another resident was found to have yellowish, gray teeth, multiple dental caries, and missing teeth, and reported not receiving mouth care on two consecutive days. Review of the resident's ADL documentation showed inconsistent oral care, with gaps in care and documentation. The ADON acknowledged that oral care was not consistently provided and that documentation did not always reflect when care was rendered. Nursing weekly summaries lacked adequate assessment of the resident's oral condition, contrary to facility policy, which required thorough documentation and assessment of oral care.
Failure to Provide Individualized Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to provide individualized activities to a resident with significant visual impairment, as required by their policy and procedure for activity programs. During observation and interviews, it was noted that the resident, who was blind in one eye and losing vision in the other, reported having nothing to do except sit in bed. The resident's care plan listed activities such as reading materials, TV, radio, and arts and crafts, but did not account for his inability to participate in these due to his blindness. Staff acknowledged that the resident could not engage in the listed activities without assistance, such as having someone read to him, but this support was not provided. Record reviews and staff interviews further revealed that the resident's preferences included listening to music, keeping up with the news, and spending time outdoors, but these interests were not addressed in the activity plan. The Social Services Director confirmed that the activities were not individualized to maximize the resident's participation. The facility's own policies require activity programs to be tailored to each resident's needs and to encourage maximum participation, but these were not followed in this case.
Failure to Provide Appropriate Foot Care and Podiatry Referral
Penalty
Summary
The facility failed to provide appropriate foot care and follow its own policies and procedures for a resident who exhibited significant foot and toenail issues. Observations revealed that the resident had dry, flaky skin on both feet, red and swollen toes, long, thick, discolored, and brittle toenails, as well as wounds and blackish debris between the toes. Despite these visible issues, there was no evidence that foot care was provided or that a referral to a podiatrist was completed, even though a physician's order for a podiatry consult was present upon admission. Interviews with nursing staff confirmed that the resident's toenails were overgrown, thick, and discolored, with possible fungal involvement, and that the resident had wounds and very dry skin. Staff acknowledged the need for a podiatry referral but admitted that no action was taken to initiate the referral or provide necessary foot care. Additionally, a CNA reported that while attempting to clean the resident's feet, the resident complained of pain, and the cleaning was not completed. No further attempts were made to address the resident's foot hygiene. Record reviews showed that nursing assessments and weekly summaries did not document the condition of the resident's skin, toes, or toenails, and there was no follow-up or progress notes from social services regarding the need for podiatry or foot care. The facility's policies required referral to qualified professionals for foot disorders and regular documentation and follow-up by social services, but these procedures were not followed, resulting in the resident's ongoing foot issues.
Deficient Suprapubic Catheter Care and Documentation
Penalty
Summary
Licensed nurses at the facility failed to demonstrate competency in assessing and changing a suprapubic catheter for a resident with a neuromuscular bladder dysfunction. The resident was admitted with a suprapubic catheter, and physician orders specified that the catheter should be changed as needed for dislodgement, malfunction, or leakage. However, there was no written documentation of any catheter changes over a four-month period, despite a nurse recalling a change due to leakage two months prior. The Director of Nursing was unable to provide evidence of the procedure or documentation, and the Director of Staff Development could not produce records of nurse competencies related to suprapubic catheter care and changes. Additionally, the facility's policy and procedure for suprapubic catheter care did not specify which clinical personnel were qualified to change the catheter, nor did it outline the required qualifications or competencies for performing this task. The policy also failed to align with current standards set by the Society of Urologic Nurses and Associates, which require clear protocols regarding personnel qualifications and training for suprapubic catheter changes. These deficiencies were identified through interviews, record reviews, and policy examination.
Incomplete Documentation of Dialysis Site Assessment
Penalty
Summary
The facility failed to ensure complete communication and coordination with the dialysis center regarding the assessment of a resident's dialysis access site. During review of the resident's Hemodialysis Communication Observation/Assessment forms for multiple dates, it was found that the post-dialysis treatment sections were left blank. An LVN confirmed that if the dialysis center does not complete the form, the facility typically calls the center to obtain the necessary post-dialysis information. The facility's policy requires staff to be trained in the care of residents with end-stage renal disease and to gather specific assessment data about the resident's condition on a daily or per shift basis. However, there was no documented assessment of the dialysis site for the resident on the reviewed dates.
Failure to Assist Resident with Dental Appointment and Referral
Penalty
Summary
The facility failed to assist a resident with obtaining a dental appointment, despite clear indications of dental issues and a physician's order for a dental consult and treatment. Upon admission, the resident had multiple missing teeth, yellowish/gray teeth, and reported cavities, specifically noting a cavity in a molar and expressing an urgent need to see a dentist. The resident's Admission Record and Order Summary Report documented the need for dental care, and the Interdisciplinary Team Conference Summary noted the resident's request for a referral to a dentist. However, interviews and record reviews revealed that the Social Services Director (SSD) did not make the necessary dental referral or document any notification to dental services to ensure the resident would be seen. The SSD also had not met with the resident to discuss dental needs. Additionally, the social history assessment was incomplete, with no documentation under the dental section regarding the resident's dental condition or the need for a referral. The facility's policy required social services to make appropriate referrals and maintain documentation, but these steps were not followed in this case.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Nursing Weekly Summary (NWS) did not accurately reflect the actual condition of the resident's skin, toes, and toenails. Observations revealed significant issues such as dry and flaky skin, red and swollen toes, long and discolored toenails, wounds, and black debris between the toes. However, the NWS entries for several weeks either indicated no new skin issues, marked the skin section as not applicable, or stated the skin was clear and intact, which did not match the resident's observed condition. The Director of Nursing (DON) confirmed that the documentation was not accurate and did not reflect the true condition of the resident's skin and nails. Additionally, the same resident's Nursing Hemodialysis Communication Observation/Assessments (NHCOA) were not completed on multiple dates. The forms were missing critical information such as assessments of the dialysis access site, documentation of medications administered, pain levels, and post-dialysis assessments. In several instances, both pre- and post-dialysis sections were left blank, and the Dialysis Center documentation was incomplete. The DON stated that licensed nurses should complete these assessments before and after dialysis and that the Dialysis Center staff should also document following treatment, but this was not done. For another resident, the Initial Social History Assessment was started but not completed. The Social Services Director (SSD) acknowledged that the assessment was initiated but left unfinished. Facility policy requires the social services department to obtain pertinent social data related to the resident's illness and care, and documentation policies require clinical records to accurately reflect care provided to ensure continuity and coordination of services. These failures resulted in incomplete records for both residents.
Failure to Ensure Understanding of Binding Arbitration Agreements
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the explanation and execution of Binding Arbitration Agreements (BAA) for two residents. In the first instance, the Admission Coordinator (AC) had a resident with a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment sign a BAA. The AC relied on basic questions and a review of nursing notes and diagnoses to determine the resident's understanding but did not identify documented episodes of confusion or the dementia diagnosis. The resident was considered their own responsible party, but the documentation showed cognitive impairment and confusion, raising concerns about the resident's ability to fully comprehend the legal implications of the BAA they signed. In the second instance, the AC had another resident sign a BAA even though the resident's admission record indicated that their son was the responsible party and that the resident's spoken language was not English. The AC did not document the use of a translator, and the responsible party did not sign the BAA. The facility's policies require that residents or their representatives be informed of the nature and implications of binding arbitration agreements in a manner they can understand, and that language access services be provided for individuals with limited English proficiency. These requirements were not met in either case, resulting in the residents not fully understanding the legal documents they signed.
Failure to Develop Care Plans for Refusal of Care and Respiratory Needs
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who consistently refused showers and baths over a 13-day period. During an interview and record review, the Director of Nursing (DON) confirmed that the resident's refusal of care was documented on several dates, yet no care plan was created to address these refusals. This oversight was contrary to the facility's policy and procedure, which mandates the development of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet each resident's needs. Additionally, the facility did not develop a respiratory care plan for the same resident, who had multiple respiratory diagnoses, including asthma, interstitial pulmonary disease, chronic obstructive pulmonary disease, respiratory disorders, and atelectasis. The DON confirmed that despite the resident's significant respiratory conditions, no care plan was in place to monitor and manage these issues. This lack of a respiratory care plan was also in violation of the facility's policy, which requires care plans to be derived from a thorough analysis of the resident's comprehensive assessment.
Failure to Document and Obtain Order for IV Catheter Removal
Penalty
Summary
The facility failed to obtain a physician's order and document the removal of a midline intravenous catheter for one of the residents. The resident was receiving Meropenem intravenously every six hours for a bacterial infection, with the last dose administered on February 11, 2025. However, by February 13, 2025, the resident's medication administration note indicated that there was no IV line access, suggesting the catheter had been removed without proper documentation or a physician's order. During an interview and record review, the Director of Nursing confirmed that there was no physician's order for the removal of the midline IV catheter and no documentation of its removal in the resident's progress notes. The facility's policy requires a physician's order for the removal of any IV catheter and documentation of the removal process, including measuring the catheter, ensuring the tip is intact, assessing for bleeding, and recording the intervention in the medical record. These steps were not followed, leading to incomplete medical records and potential risks for the resident.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to consistently implement care plans for a resident at risk for falls. The care plan for the resident, revised on December 2, 2024, included the red star program, an intervention for residents who have experienced two or more falls within 30 days. This program requires a red star to be placed on the nameplate outside the resident's room. However, during an observation on December 31, 2024, the Director of Nursing (DON) confirmed that the resident was attempting to get out of bed unassisted and did not have a red star on their nameplate, despite being care planned for the red star program. The facility's policy on managing falls and fall risk, revised in March 2018, emphasizes the need for staff to implement resident-centered fall prevention plans based on specific risk factors, which was not adhered to in this case.
Incomplete Post-Fall Assessment for High-Risk Resident
Penalty
Summary
The facility failed to implement its Fall Management policy and procedure for a resident with a history of falling, resulting in an incomplete post-fall assessment. The Director of Nurses (DON) confirmed that the resident experienced a fall in the bathroom and an unwitnessed fall, indicating a high risk for falls. During a review of the resident's Post Fall Review (PFR) assessment, it was found to be incomplete, lacking an evaluation of the resident's medications. The facility's policy requires a comprehensive PFR assessment after each fall, including a review of medications, cognition, behavior, and incontinence to determine the cause of the fall. Both the DON and Administrator acknowledged the incompleteness of the PFR assessment, confirming that the resident's medications were not assessed as required by the facility's policy.
Failure to Report Financial Abuse to Attending Physician
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of suspected abuse, neglect, exploitation, or misappropriation. Specifically, the facility did not report a suspicion of financial abuse to the attending physician of a resident. This incident involved a resident who discovered missing money from their bank account during a visit to the bank with the Administrator. Despite the facility's policy requiring immediate reporting of such suspicions to the resident's attending physician, the Director of Nursing and the Administrator confirmed that this notification did not occur. The facility's policy, revised in September 2022, explicitly states that the administrator or the individual making the allegation must report suspicions to the resident's attending physician, among other persons or agencies.
Failure to Report and Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the California Department of Public Health (CDPH) within the required 24-hour timeframe and did not complete an investigation within five business days. The incident involved a resident who reported being raped by two men on multiple occasions. The resident's progress notes indicated that the charge nurse was informed of the allegation, but there was no documentation of a completed investigation in the resident's clinical record. During an interview, the Director of Nursing (DON) acknowledged that staff had reported the resident's allegations to her, and she instructed them to call 911 and follow the abuse protocol. However, the DON did not report the allegation to the CDPH, citing that the resident had changed her story. The facility's policy and procedure require all allegations of abuse to be reported to local, state, and federal agencies and thoroughly investigated, with findings documented and reported. The failure to adhere to these procedures resulted in a deficiency.
Failure to Notify Physician and Family of Resident's Falls
Penalty
Summary
The facility failed to notify the attending physician (AP) and responsible party (RP) of a change of condition (COC) for a resident who experienced two unwitnessed falls. The first incident occurred when the resident was found sitting on the floor between his wheelchair and toilet, with no obvious injuries noted, and the nurse documented notifying the medical doctor (MD) and family. However, during the second incident, the resident was found on the floor again, and there was no documentation of notification to the MD or family. This lack of communication was confirmed during a review of the resident's medical records and interviews with the Director of Nursing (DON). The facility's policy and procedure for notifying changes in a resident's condition or status, revised in February 2021, requires prompt notification of the resident's AP and RP in the event of an accident or incident. The policy also mandates detailed observations and information gathering before notifying the physician, using tools like the Interact SBAR Communication Form. Despite these guidelines, the facility did not document the required notifications for the resident's falls, leading to a deficiency in communication and potential unmet care needs.
Failure to Revise Fall Risk Care Plan
Penalty
Summary
The facility failed to revise the fall risk care plan for a resident who was identified as high risk for falls, scoring an 18 on the Fall Risk Observation/Assessment. The resident experienced two separate falls, one while attempting to transfer from the toilet to a wheelchair and another incident where the resident was found on the floor. Despite these incidents, the care plan was not updated to reflect the increased risk or to implement new interventions to prevent further falls. The Director of Nursing confirmed that the care plan should have been revised following each fall incident, as per the facility's policy and procedure on falls. The policy requires staff to evaluate and document falls, categorize them, and identify interventions to prevent future occurrences. However, this process was not followed, leading to a deficiency in the care provided to the resident.
Failure to Conduct Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to conduct neurological checks for a resident who experienced two unwitnessed falls. During an interview, a Licensed Vocational Nurse (LVN) stated that neurological checks should be initiated if a fall is unwitnessed and should last for 72 hours. However, upon reviewing the resident's medical records, it was found that no neurological checks were completed for the incidents on the specified dates. The Director of Nursing (DON) confirmed that the resident had two separate unwitnessed falls and that the required neurological checks were not performed. The facility's Neurological Flow Sheet outlines the procedure for conducting these checks, which includes monitoring vital signs and neurological status at specified intervals for 72 hours. Despite this protocol, the necessary assessments were not documented for the resident following the falls.
Inaccurate Documentation in Resident's Medical Record
Penalty
Summary
The facility failed to adhere to its own policy and procedure titled 'Documentation Accuracy In The Health Record' for one of the sampled residents. During an interview and record review with the Director of Nursing (DON), it was found that the Admission Record (AR) for a resident indicated the emergency contact as the resident's wife, with no other responsible party listed. However, the Discharge Summary (DS) for the same resident incorrectly included the name of another resident, who was not affiliated with the first resident, as the responsible party. The facility's policy emphasizes the importance of accurate clinical records for ensuring continuity of care, assisting staff in coordinating services, and serving as a legal document. The discrepancy in the resident's records, confirmed by the DON, highlights a failure to maintain accurate documentation, which is crucial for the facility's operations and legal responsibilities. This inaccuracy in the medical record was identified as a deficiency during the survey.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address and resolve a grievance raised by a resident, which resulted in a violation of the resident's rights. The grievance involved an incident where a Certified Nursing Assistant (CNA) told the resident that they should not call for help during a shift change. Subsequently, the resident was left in the bathroom with the call light on for one and a half hours. This grievance was documented in the Grievances Interview Record (GIR) dated August 25, 2023. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that the grievance regarding the call light was not addressed or resolved. The facility's policy and procedure for the Resident Concern/Grievance Program, updated in December 2006, outlines that grievances should be communicated to the Administrator within one business day and resolved within five business days. However, in this case, the grievance was not resolved as per the facility's policy, leading to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to communicate a change in condition to the primary care physician for a resident, which had the potential to delay care and worsen the resident's condition. The resident was initially assessed as alert and oriented, but subsequent evaluations noted confusion and severe cognitive impairment. Despite these changes, there was no documentation indicating that the primary care physician was notified of the resident's new onset of confusion. Interviews with staff revealed a lack of awareness regarding the resident's baseline cognitive status, and the facility's policy required prompt notification of changes in a resident's condition to the physician. The resident was eventually sent to the hospital for altered mental status after a family member expressed concern about the resident's behavior. The failure to notify the physician was a deviation from the facility's policy and procedure.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for one of the sampled residents, identified as Resident 1. During an interview and record review with the Director of Nursing (DON), it was found that on 5/25/2024, Resident 1 had a recorded blood pressure of 184/82, which is significantly higher than the normal range. The facility's policy requires that any blood pressure reading over 160 should be reported to a physician. However, there was no documentation indicating that Resident 1 was reassessed or that the physician was notified of the high blood pressure. The facility's policy, titled 'Change in a Resident's Condition or Status,' mandates prompt notification of the resident, their attending physician, and the resident representative of any changes in the resident's medical or mental condition. Notifications are to be made within 24 hours, except in medical emergencies. The failure to notify the physician of Resident 1's elevated blood pressure had the potential to result in unmet care needs for the resident.
Failure to Implement Care Plan for Call Light Non-Compliance
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for a resident who was non-compliant with using the call light. The resident, identified as having moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12, was noted to frequently yell for assistance instead of using the call light. Despite staff reminding the resident to use the call light, the resident continued to be non-compliant, which was documented in the nurse's notes. The Assisted Director of Nursing (ADON) acknowledged during a review that there should have been a care plan addressing the resident's non-compliance with the call light. The facility's policy and procedure on comprehensive person-centered care plans, dated 2022, requires the interdisciplinary team to develop a care plan with input from the resident and their family or legal representative. The policy also mandates that the care plan be reviewed and updated when there is a significant change in the resident's condition. However, the facility did not have a care plan in place for the resident's non-compliance with the call light, which placed the resident at risk of not having their care needs met.
Incomplete Dialysis Communication and Assessment
Penalty
Summary
The facility failed to ensure proper communication and coordination between the facility and the dialysis center for a resident requiring dialysis services. Specifically, the Pre and Post-Dialysis Communication Form (PDCF) for a resident was found incomplete, with the post-dialysis assessment sections left blank on multiple occasions. During an interview and record review, the Director of Nursing acknowledged that the post-dialysis assessments were not completed as required. The facility's policy and procedure for hemodialysis catheters, dated February 2023, mandates documentation of the catheter location, dressing condition, dialysis occurrence, post-dialysis report from the dialysis nurse, and post-dialysis observations in the resident's medical record every shift. The lack of documentation had the potential to result in complications due to the absence of an assessment of the dialysis site.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following an unwitnessed fall, as required by their policy. The incident occurred on 6/8/24 when the resident was found lying supine on the floor by the right side of the bed after sliding off. The resident was identified as high risk for falls, but the fall care plan was not updated post-incident. During a review on 7/16/24, the Assistant Director of Nurses confirmed the absence of an updated care plan, acknowledging that it should have been revised following the fall. The facility's policy mandates that the interdisciplinary team reviews and updates care plans when there is a significant change in a resident's condition.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within easy reach, which could potentially impact the resident's ability to have their activities of daily living needs met. During an observation and interview, it was noted that the call light button was on the floor and not accessible to the resident. Both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) confirmed that the call light should have been within the resident's reach, either clipped to the sheet or the resident's clothes. The resident in question had a care plan indicating a decline in activities of daily living and mobility, requiring assistance due to behavioral symptoms, cognitive impairment, non-ambulatory status, pain, recent hospitalization, and weakness. The resident's Minimum Data Set (MDS) showed severe cognitive impairment and complete dependence on helpers for various tasks, including putting on footwear, toileting hygiene, bathing, and transfers. The facility's policy on answering call lights stated that the call light should be within easy reach of residents confined to bed or a chair, which was not adhered to in this instance.
Failure to Monitor and Document Behavioral Episodes
Penalty
Summary
The facility failed to monitor and document behavioral episodes for a resident diagnosed with a mental disorder, specifically bipolar disorder, which led to a potential risk of untreated worsening behavior. During an observation, the resident was noted to be agitated and upset while sitting in a wheelchair outside a conference room. The resident's care plan, dated 6/20/2024, indicated a risk for behavioral symptoms such as striking out, grabbing others, and being verbally or physically abusive. The care plan included interventions to document and record behavioral episodes, which were not followed. During a review of the care plan and an interview with the Director of Nursing (DON), it was confirmed that there was no documentation of behavioral monitoring for the resident. The facility's policy and procedure for comprehensive, person-centered care plans emphasized the need to describe services to assist residents in maintaining their physical, mental, and psychosocial well-being. However, the required documentation and monitoring of the resident's behavior were not conducted, leading to a deficiency in care.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the immediate documentation of medication administration for two residents. For Resident 1, the Medication Administration Audit Report (MAAR) showed discrepancies in the timing of medication administration and documentation. Medications such as Atorvastatin Calcium and Doxycycline Hyclate were scheduled for administration at 9:00 p.m. but were documented as administered at 10:58 p.m. Additionally, Humalog was scheduled for 9:00 p.m. but was documented as administered at 2:10 a.m. the following day. Similarly, for Resident 2, the MAAR indicated that medications like Empagliflozin and Losartan Potassium were administered later than scheduled, with documentation times not aligning with the scheduled administration times. Interviews with the Assistant Director of Nursing (ADON) and Licensed Vocational Nurses (LVN) revealed that while medications were administered on time, the staff failed to document the administration immediately, as required by the facility's policy. The ADON confirmed that the investigation into the late administration times showed that the medications were given timely but not documented promptly. Both LVN 1 and LVN 2 acknowledged that medications should be documented immediately after administration, aligning with the facility's policy titled 'Documentation of Medication Administration' dated November 2022.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that medication carts and the medication room were free from expired medications, which had the potential for residents to receive expired medications. During an observation and interview with the Director of Nursing (DON), an expired emergency drug supply box was found in the medication room refrigerator. Additionally, an insulin labeled with a discard date of 5/14/24 was found in a medication cart, and the Licensed Vocational Nurse (LVN) confirmed it was expired. The facility's policy and procedure (P&P) on medication storage indicated that outdated medications should be immediately removed from stock and disposed of according to procedures, which was not followed in these instances. The facility also failed to follow their P&P on medication labeling, which had the potential to result in medication errors. During observations and interviews with LVNs, several medications were found without proper labeling, including the resident's name, medication name, specific directions for use, strength of medication, prescriber's name, date filled, and quantity of medication filled. Additionally, an insulin in a medication cart was not dated, and the LVN did not know when it was placed in the cart. The facility's P&P indicated that insulin bottles/pens should be dated when opened and discarded as per manufacturer recommendations, which was not adhered to in this case.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain dignity for two residents, Resident 389 and Resident 84. Resident 389 was observed wearing donated clothing due to a delay in washing her personal clothing. The resident expressed discomfort and dissatisfaction with the oversized donated clothes, which negatively impacted her sense of dignity. The family member confirmed that the resident's personal clothes had not been returned from the laundry for an extended period. Interviews with staff revealed issues with the turnaround time for laundry services, which led to the resident having to wear someone else's clothes temporarily. Resident 84, diagnosed with Amyotrophic Lateral Sclerosis (ALS), was dependent on staff for oral hygiene. Observations and interviews indicated that the resident's oral hygiene was not maintained, as evidenced by yellowish-white debris along the gum line and a film coating the lower teeth. The resident and her family member reported that oral care was not being performed regularly, and the resident felt neglected. The facility's policy on dignity emphasized the importance of promoting residents' well-being and self-esteem, which was not upheld in this case. Interviews with staff, including a Licensed Vocational Nurse, confirmed that the lack of oral care for Resident 84 was a dignity issue. The facility's policy and procedure on dignity indicated that each resident should be cared for in a manner that enhances their sense of well-being and self-worth. The failure to provide timely laundry services for Resident 389 and adequate oral care for Resident 84 demonstrated a lapse in maintaining the residents' dignity and overall care quality.
Failure to Obtain Physician Order and Assessment for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a physician order (PO) was obtained and a Self-Administration of Medication Assessment (SAMA) was completed for one resident. During an observation and interview, a bottle of multivitamins was found on the resident's bedside table, and the resident stated he takes the multivitamins twice daily. The Assistant Director of Nursing (ADON) confirmed that there was no PO or SAMA for the multivitamin use. The facility's policy requires an interdisciplinary team to assess and determine if self-administration of medications is safe and appropriate, and any unauthorized medications found at the bedside should be turned over to the nurse in charge.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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