Lakewood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Downey, California.
- Location
- 12023 Lakewood Blvd., Downey, California 90242
- CMS Provider Number
- 555099
- Inspections on file
- 65
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 53
Citation history
Health deficiencies cited at Lakewood Healthcare Center during CMS and state inspections, most recent first.
A resident with osteoarthritis, prior bilateral knee surgeries, and impaired cognition experienced a fall and subsequently reported new onset left knee pain, limited range of motion, and a popping noise in the knee. Despite care plan directives to monitor and report joint pain and related symptoms to the physician, nursing staff did not ensure that the MD was promptly notified or that follow-up occurred when the pain and mechanical symptoms were reported. The resident stated that her pain was not effectively managed for months, and the DOR later noted crepitus on examination while the resident reported she had repeatedly informed nursing and rehab staff of the ongoing pain and popping.
A resident with chronic pain and impaired cognition experienced ongoing unaddressed pain when therapy staff failed to report pain-related refusals of PT and OT sessions to nursing, and nursing staff did not consistently reassess and document pain after administering medications. Therapy notes showed the resident refused ambulation and reported joint pain, yet no pain medications were given on those days and nursing was not notified. The resident later reported severe, widespread 10/10 pain, was prescribed PRN Tramadol for severe pain, but the MAR showed no administration of Tramadol or other pain medication following that report. Medication administration records also lacked numerical pain reassessments on multiple dates, and there was no IDT evaluation or modification of pain interventions after the onset of severe pain, contrary to the facility’s pain management policy.
A resident with osteoarthritis, schizophrenia, anxiety, gait abnormalities, and moderately impaired cognition had an At Risk for Fall care plan that required ensuring appropriate footwear when ambulating. Despite a documented fall risk and the need for assistance with ADLs and supervision for walking, progress notes contained no evidence that staff monitored the resident’s footwear. The resident later experienced a fall while returning from the restroom and was found barefoot, and an RN confirmed that the lack of documented footwear monitoring meant the fall-prevention intervention could not be verified as implemented.
A resident with schizophrenia, hyperlipidemia, and severe cognitive impairment, who required assistance with ADLs and supervision for bed mobility, was tied to the bed with linen by a CNA to prevent falls while the CNA attended another resident. The CNA reported securing linen across the resident’s chest and ankles to the bed, effectively restricting movement. Other staff, including another CNA, an LVN, and a PT, stated that using linen in this way constituted a restraint, removed the resident’s ability to move, stand, and walk, and required a physician’s order. The DON, referencing the facility’s Restraints and Resident Rights policies, confirmed that this action violated the resident’s right to be free from restraints imposed for non-medical reasons and to move freely with dignity and respect.
A resident with a history of falls, impaired mobility, and moderate cognitive impairment was being assisted to the restroom by a CNA who failed to follow the facility's ambulation policy. Instead of walking next to or slightly behind the resident as required, the CNA walked in front, resulting in the resident losing balance and falling. The resident sustained a laceration above the eyebrow that required hospital treatment and sutures.
A resident with severe cognitive impairment and a history of aggressive behavior struck another resident in his room, leaving the victim feeling violated and unsafe. Staff witnessed the incident and intervened, but failed to properly document, report, or implement protective interventions as required by facility policy. Key personnel, including the DON and social services, were unaware of the event, and no updates were made to care plans or records following the altercation.
Staff failed to report a witnessed altercation between two residents, one with severe cognitive impairment and another with moderate impairment, to the appropriate authorities as required. Although CNAs observed and reported the incident to an LVN, no documentation or further reporting occurred, and the event was not communicated to administration or CDPH. This lack of action delayed investigation and did not comply with facility policy for abuse reporting.
Two residents with significant cognitive and mental health impairments were involved in an altercation that was witnessed and reported by CNAs, but not documented or investigated by nursing staff as required by facility policy. The incident was not reported to administration or CDPH, and no clinical records reflected the event, resulting in a delay in investigation and a failure to follow abuse reporting procedures.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with COPD, schizoaffective disorder, and interstitial lung disease was admitted with physician orders for oxygen therapy, but no care plan was developed or implemented to address this need. Staff interviews and policy review confirmed that a care plan should have been in place to guide monitoring and interventions for oxygen administration.
A resident with COPD and cognitive impairment received oxygen at higher flow rates than prescribed, and the nasal cannula in use was not labeled with an open date as required by facility policy. Nursing staff confirmed the oxygen was not set according to the physician's order and that infection control protocols for labeling and changing the nasal cannula were not followed.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
A resident with severe cognitive impairment and behavioral disturbances was not provided with required 1:1 monitoring as ordered by the physician following a resident-to-resident altercation. Staff did not assign personnel for 1:1 monitoring on multiple days, and there was no documentation of behavioral reassessment or physician notification to clarify the ongoing need for monitoring.
A resident with cognitive impairment and multiple medical conditions was identified as an elopement risk, but staff did not follow the care plan intervention to monitor and document wandering behavior. Despite the care plan's directive, no episodes were recorded, and the resident ultimately left the facility unnoticed. Staff interviews confirmed the intervention was not implemented as required.
A resident with cognitive impairment and a history of fluctuating decision-making capacity eloped from the facility after staff failed to regularly inspect the exterior gate and did not document wandering behavior as required by the care plan. The gate's old padlock and chain were not routinely checked, and staff did not monitor or record episodes of wandering, despite facility policies mandating these actions.
A resident with impaired cognition and inability to make medical decisions was involved in an abuse allegation but the responsible party was not notified due to incorrect documentation on the face sheet. Staff interviews confirmed that the nurse did not contact the responsible party, relying on inaccurate records, despite facility policy requiring such notification.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with cognitive impairment and multiple medical conditions was treated roughly and spoken to disrespectfully by a CNA during personal care, leading the resident to feel unvalued and uncomfortable. The CNA admitted to being abrupt and did not report the resident's complaint of head pain to nursing staff, contrary to facility policy requiring respectful, person-centered care and prompt reporting of resident discomfort.
A resident with multiple medical and mental health diagnoses continued to smoke after a neurologist issued an order to avoid smoking due to health risks. The facility did not update the care plan or implement new interventions such as smoking cessation education or behavioral support, and the Interdisciplinary Team did not meet to address the new order. Staff acknowledged the care plan was not revised to reflect the smoking restriction.
A resident with multiple medical and mental health diagnoses did not receive ordered dental and podiatry services, nor was a neurologist's order for weekly drug testing clarified or implemented. The resident was observed with long, untrimmed toenails and reported dental discomfort, while staff confirmed that no appointments or drug testing had been arranged as required by physician orders and facility policy.
A resident with severe cognitive impairment and multiple medical conditions was able to exit the facility through an unsecured window due to the absence of a required screw, incomplete elopement risk assessment that did not include input from the responsible party, and lack of monitoring for known elopement triggers. Staff were unaware of the window's vulnerability and did not actively monitor the resident's behaviors related to elopement risk.
A resident with cognitive impairment and skin conditions did not receive prescribed hydrocortisone cream for dermatitis, and a dermatology consult order was not implemented. Nursing staff confirmed the orders were not transcribed or carried out, contrary to facility policy and expectations.
Two cognitively impaired residents, both at risk for falls, were left in their room during deep cleaning with a wet floor and an unattended bottle of Clorox spray. The housekeeping staff left the room to perform another task, leaving the residents exposed to potential hazards, despite facility policies and care plans indicating the need for supervision and removal of hazards during such procedures.
A resident with a history of psychosis, epilepsy, and anxiety disorder, who requested and had a physician order for care to be provided only by female CNAs after alleging inappropriate touching by a male CNA, was repeatedly assigned male CNAs for personal care. Facility records and staff interviews confirmed the assignments were made despite the care plan and order, resulting in the resident experiencing fear and anxiety.
A resident with significant mobility and cognitive impairments experienced two falls resulting in injuries, but the care plan was not updated to include safety interventions to prevent further incidents. Nursing staff confirmed the omission, and facility policy required care plan revisions after such events.
A resident with cognitive impairment and requiring substantial assistance was found with facial bruises and swelling, which were not reported to CDPH as required. Despite internal reporting, the facility failed to notify external agencies, delaying investigation and potentially risking further harm.
A resident with dementia and dermatitis did not receive appropriate skin care and monitoring as per their care plan. The facility failed to document and assess the effectiveness of prescribed treatment, leading to a delayed, non-healing skin condition. Staff interviews revealed that the resident's rash had worsened over time, and the facility's policy for weekly documentation of treatment effectiveness was not followed.
A facility failed to consult a psychiatrist before allowing a resident with schizoaffective disorder and anxiety to go out on pass, as required by policy. The resident went OOP multiple times without the necessary psychiatric consultation, posing potential risks to their well-being and safety.
A facility failed to provide a resident's medications to their Responsible Party (RP) during Out on Pass (OOP) instances, leading to inaccurate documentation of medication administration. The resident, with schizoaffective disorder, was prescribed Divalproex Sodium and Gabapentin, which were not given to the RP for administration while OOP. The facility's policies for medication administration and OOP were not followed, resulting in potential medication errors.
A resident with end-stage renal disease refused dialysis treatment on multiple occasions, and the facility failed to notify the doctor as required by policy. The resident, who had moderate cognitive impairment, missed scheduled dialysis sessions, leading to a ten-day gap without treatment. This lack of communication placed the resident at risk for medical complications, and the issue was confirmed through interviews with nursing staff.
A facility failed to send a pre-dialysis evaluation to the dialysis center for a resident with end-stage renal disease, leading to a lack of communication between the facility and the dialysis provider. The resident required dialysis twice a week and had moderate cognitive impairment. The facility's policy required a licensed nurse to complete the evaluation, but this was not done, as confirmed by staff interviews.
A resident with cognitive impairment and multiple diagnoses complained of an itchy scalp. An LVN assessed the resident's scalp, finding dryness and dandruff, and contacted the doctor, who prescribed a Selenium Sulfide shampoo. However, the LVN failed to document the assessment and doctor notification in the resident's clinical record, as confirmed by the DON. This lack of documentation was against the facility's policy on alert charting for changes in medical condition.
A resident with a history of schizophrenia and dementia experienced a change in condition, including aggression, and was prescribed hydroxyzine without informed consent from their responsible party. The facility failed to notify both emergency contacts of the condition change and subsequent hospital transfer, violating their policy for prompt family notification.
A resident with severe cognitive impairment and multiple diagnoses was found to be sleeping without a pillowcase, despite informing staff of the need. This deficiency was confirmed by a CNA and violated the facility's policy on providing a clean and comfortable environment.
The facility failed to ensure that call lights were within reach for five residents, impacting their ability to request assistance. Observations revealed call lights on the floor or out of reach, despite care plans requiring accessibility due to residents' cognitive and mobility impairments. Staff interviews confirmed the importance of accessible call lights to prevent delays in care and potential safety risks.
Two residents were observed without bedside tables, leading to discomfort during meals and activities. One resident had to eat off a walker, while another used a nightstand, both expressing dissatisfaction. Staff interviews confirmed the inadequacy of this setup, which contradicted the facility's policy to meet residents' needs.
The facility failed to create comprehensive care plans for three residents, leading to deficiencies in their care. A resident with multiple diagnoses lacked care plans for oxygen and respiratory therapy, while another with respiratory failure had no care plan for oxygen administration. Additionally, a resident with new hand tremors did not have a care plan addressing this change. Staff acknowledged the importance of care plans for guiding interventions, but these were not developed as required by facility policy.
The facility failed to properly inflate low-air-loss mattresses for several residents, setting them based on incorrect weights, which could lead to inadequate pressure relief and increased risk of pressure ulcers. Observations and interviews confirmed that the mattresses were not adjusted according to the residents' actual weights, despite facility policies requiring routine checks and adjustments by licensed nurses.
The facility failed to provide adequate RNA services for three residents due to insufficient CNA staffing and documentation issues. A resident with severe cognitive impairment did not receive PROM exercises for the upper extremities as ordered, while another resident with contractures did not have a knee extension splint applied for three months. Additionally, a third resident did not receive RNA services on multiple days. The lack of access to RNA orders in the EMR and the assignment of RNA tasks to the CNA task list contributed to these deficiencies.
The facility failed to monitor and record urine output for two residents with indwelling catheters, leading to a deficiency in catheter care. One resident, with multiple diagnoses including dementia and Alzheimer's, had an empty urine collection bag observed multiple times, and the CNA was unaware of the requirement to record output. Another resident, with chronic kidney disease and other conditions, had missing documentation for catheter care on several shifts. The facility's policy required monitoring and recording for 30 days, but this was not followed.
Two residents did not receive respiratory care according to professional standards. One resident received oxygen at a higher rate than ordered, with undated equipment and no signage indicating oxygen use. Another resident's respiratory equipment was not changed weekly as required, and there was no signage outside the room. Staff interviews confirmed these deficiencies, which were against the facility's policy for safe and sanitary oxygen administration.
A resident with diabetes and other conditions did not receive medications as per physician orders, with Metformin and Naproxen administered late and without food. The facility staff failed to verify food intake and did not report medication errors, leading to potential adverse effects.
A resident experienced a 14.81% medication error rate due to improper administration of metformin and naproxen without food, and late administration of lactulose and a lidocaine patch. The resident, with a history of diabetes and other conditions, expressed discomfort, which was not addressed. Interviews revealed non-compliance with medication administration policies, increasing the risk of adverse reactions.
A resident was administered carvedilol outside the physician-ordered parameters, with systolic blood pressure readings below 110 mmHg on three occasions. The resident had a history of hypertension and other disorders, and the error was acknowledged by an LVN, who noted the risk of further lowering blood pressure. The facility's policy required adherence to physician orders, which was not followed.
A facility failed to monitor and maintain proper medication storage temperatures in the AC Unit, leading to potential medication efficacy issues. The refrigerator lacked a thermometer, and room temperatures were not monitored. Inaccurate temperature logs and a faulty refrigerator thermometer resulted in temperatures outside the acceptable range, compromising medication integrity.
The facility failed to ensure kitchen staff were trained and evaluated for competency in preparing puree diets and testing Quat sanitizer concentration. A cook did not follow puree diet recipes, leading to inconsistent food textures, while dietary aides demonstrated incorrect procedures for testing sanitizer concentration. The facility's policies required standardized recipes and proper sanitation, but training records showed gaps in staff education.
The facility failed to follow standardized recipes for puree diets, resulting in runny seasoned brown rice and watery fruit cups, which did not meet the required consistency. This affected 23 residents, putting them at risk of difficulty in eating and potential weight loss. The cook was unaware of the recipes and had not received training, and the issue was confirmed by the RD and FSD.
The facility failed to prepare food by methods that conserved flavor and appearance, resulting in sticky rice and bland broccoli lacking sesame flavor. These deficiencies were confirmed by the RD and FSD during a tray line inspection and a regular diet test tray evaluation. The facility's policies and standardized recipes were not followed correctly, placing 260 residents at risk of unplanned weight loss due to poor food intake.
The facility failed to maintain safe and sanitary food storage and preparation practices, with issues such as cracked and rusted racks, ice buildup, and improper dish machine temperatures. These deficiencies could lead to harmful bacteria growth and cross-contamination, posing a risk of foodborne illness to residents.
The facility failed to properly dispose of garbage, with observations showing an uncovered dumpster and trash on the floor. Staff interviews confirmed the issue, acknowledging the risk of contamination and pest attraction. The facility's policies and the Food Code require covered receptacles, which were not maintained.
Failure to Promptly Notify Physician of New Onset Knee Pain After Fall
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician and ensure appropriate follow-up when a resident reported new onset left knee pain and functional changes following a fall. The resident, who had a history of osteoarthritis, prior bilateral knee surgeries, schizophrenia, anxiety, chondrocostal junction syndrome, and gait and mobility abnormalities, was initially admitted on an unspecified date. Her MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for assistance with ADLs including toileting, showering, dressing, and supervision or touching assistance for walking. Her care plan for arthritis, initiated 4/1/2025, directed staff to monitor, document, and report to the physician signs and symptoms such as joint pain, stiffness, swelling, decline in mobility or self-care, contracture formation, joint shape changes, crepitus, and pain after exercise or weight bearing. On 10/9/2025, a change of condition note documented that the resident was found sitting on the floor by her bed after losing her balance while returning from the restroom, indicating a fall event. On 10/12/2025, three days after the fall, licensed nursing staff were made aware of the resident’s report of new onset left knee pain and limited range of motion, but the facility did not ensure confirmation of physician notification. On 1/24/2026, the resident again complained of left knee pain accompanied by a popping noise, yet there was no confirmation that the physician had been notified at that time. During interviews, the resident reported that she had undergone two prior knee surgeries, felt that metal hardware was moving in her knee, and stated that her pain had not been effectively managed for three months. During an observation and interview on 1/27/2026, the Director of Rehabilitation examined the resident’s knee, noted a clicking consistent with crepitus, and the resident reported that the popping noise had worsened since the fall and that she had consistently reported the popping and pain to nursing and rehabilitation staff. These documented inactions and lack of confirmed physician notification and follow-up constituted the cited deficiency.
Failure to Assess, Communicate, and Manage a Resident’s Pain
Penalty
Summary
The deficiency involves the facility’s failure to effectively assess, reassess, and manage pain for a resident with chronic conditions including osteoarthritis, schizophrenia, anxiety, chondrocostal junction syndrome, and gait abnormalities. The resident’s MDS showed moderately impaired cognition and a need for assistance with ADLs. The care plan for arthritis directed staff to monitor, document, and report joint pain and related symptoms, and the chronic pain care plan instructed staff to anticipate pain needs and respond immediately to any complaint of pain. After a fall on 10/9/2025 that led to hospital evaluation, the resident reported worsening popping sensations and pain in the knee, which she stated she had repeatedly reported to nursing and rehabilitation staff, and she reported going 11 days without pain medication despite numerous complaints. On multiple occasions, therapy staff did not communicate the resident’s pain complaints and therapy refusals to nursing for assessment and intervention. On 10/15/2025, a physical therapy note documented a refusal to ambulate without a reason, and the MAR showed no pain medication given that day; the PTA later stated the resident had complained of pain and that he did not notify nursing. On 10/22/2025, the physical therapy note documented joint pain and refusal to ambulate, with no corresponding pain medication on the MAR, and the PTA acknowledged the resident continued to complain of left knee pain and that he should have notified the charge nurse. On 1/27/2026, the resident told an occupational therapist she was in pain and declined an OT session, but the OT did not notify the assigned LVN, who reported she had not been informed of any pain complaints. During interviews and observation on 1/27/2026, the resident was seen holding her knee, appearing uncomfortable, and reporting 10/10 pain and that staff were not addressing her pain. Nursing staff also failed to document numerical pain reassessments after administering pain medication and did not implement ordered pharmacologic interventions for new-onset severe pain. Review of Medication Administration Progress Notes for 12/2025 through 1/2026 showed that numerical pain ratings were not documented to evaluate the effectiveness of pain medication on several dates, which RN 1 confirmed meant the facility did not accurately assess and track the medication’s effectiveness. A change of condition note on 10/28/2025 documented new-onset 10/10 pain in both arms, both legs, and the coccyx; the resident refused Tylenol and ibuprofen and was prescribed Tramadol 50 mg PO every eight hours PRN for severe pain. The MAR contained no documentation that Tramadol or any other pain medication was administered following this report of 10/10 pain, and the DON stated the resident’s pain was not treated as ordered. Review of 2025 IDT notes showed no interdisciplinary evaluation or modification of pain management interventions after the new-onset 10/10 pain was reported, which the DON stated was a missed opportunity to address the resident’s pain management needs. The facility’s pain management policy required IDT review of pain assessments, resident-centered care planning, administration and documentation of pain medications, timely re-evaluation of pain within one hour after medication, and physician notification for new-onset or unrelieved pain, which were not followed in this case.
Failure to Implement Fall-Prevention Footwear Intervention
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement an existing At Risk for Fall care plan for one resident. The resident’s admission record showed diagnoses including osteoarthritis, schizophrenia, anxiety, chondrocostal junction syndrome, and gait and mobility abnormalities. An MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for moderate assistance with toileting, showering, and dressing, and supervision for walking. The resident’s At Risk for Fall care plan, initiated 4/10/2025, included an intervention to ensure the resident wore appropriate footwear when ambulating. A Fall Risk Evaluation dated 10/6/2025 indicated the resident was at risk for a fall. On 10/9/2025, a Change of Condition Note documented that the resident was found sitting on the floor by the bed and reported losing balance and falling while returning from the restroom to the bed. A Post Fall Evaluation from the same date indicated the resident was barefoot at the time of the fall. During an interview and concurrent record review with an RN on 1/27/2026, the resident’s progress notes from 10/2025 and the At Risk for Fall care plan were reviewed, and the progress notes lacked documentation that the resident’s footwear was monitored. The RN stated that, because there was no documented monitoring of footwear, the intervention could not be verified as implemented and that this lack of effective implementation of the care plan placed the resident at increased risk for a fall. The facility’s Comprehensive Person-Centered Care Planning policy required development and implementation of a comprehensive care plan with measurable objectives and timeframes to meet identified needs.
Unauthorized Use of Linen as a Physical Restraint
Penalty
Summary
The deficiency involves the use of physical restraints without a physician’s order when a CNA tied a resident to the bed using linen. The resident had diagnoses including schizophrenia and hyperlipidemia and, per a recent MDS, had severe cognitive impairment, required partial/moderate assistance for ADLs such as bathing, and needed supervision or touching assistance for movements like rolling and changing positions. According to the facility’s five-day investigation report, the CNA acknowledged placing linen to the bed of this resident to protect and ensure the resident did not sustain a fall while the CNA attended to another resident. In a later interview, the CNA stated they had tied linen across the resident’s breast and ankles to the bed to ensure the resident would not fall while the CNA was occupied elsewhere. Multiple staff interviews confirmed that using linen in this manner restricted the resident’s movement and constituted a restraint. CNA 1 stated staff should not use an object across a resident’s lap to keep them in bed because it takes away the resident’s right to move, stand, and walk. LVN 1 stated staff should not use linen across a resident because it restricted movement, even if the resident was a fall risk. The PT stated that tying the resident to the bed using linen across the lap was a type of restraint that required a doctor’s order and that the facility does not use blankets as restraints. CNA 2 acknowledged that tying the resident to the bed was a form of restraint and could have affected the resident’s dignity, and that they should have called other staff for help instead. The DON, referencing the facility’s Restraints and Resident Rights policies, stated that CNA 2 did not follow policy by not honoring the resident’s right to move freely, and the written policies indicated residents have the right to be free from restraints imposed for reasons other than treatment of medical symptoms and to be treated with kindness, respect, and dignity.
Failure to Follow Ambulation Policy Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's ambulation policy and procedure for a resident with a history of falls, abnormal gait, osteoporosis, and moderately impaired cognition. The resident required moderate assistance with walking and was identified as being at risk for falls. On the day of the incident, the resident attempted to get out of bed to use the restroom, and a CNA, who was monitoring the resident, approached to assist. Instead of following the policy, which required staff to stand on the resident's weakest side and slightly behind during ambulation, the CNA walked in front of the resident while leading her to the restroom. The CNA stated that the resident did not like to be touched or held, and as the CNA reached for the restroom door, the resident lost her balance and fell. Because the CNA was in front, she was unable to catch the resident or prevent the fall. As a result of the fall, the resident sustained a laceration above the right eyebrow, requiring transfer to an acute care hospital for evaluation and sutures. The facility's Director of Rehab and Director of Nursing confirmed that the staff member should have walked next to or slightly behind the resident to provide proper supervision and assistance, as outlined in the facility's ambulation policy.
Failure to Protect Resident from Physical Abuse and Lack of Incident Reporting
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident reported being struck by another resident who entered his room. The resident who committed the act had a documented history of severe cognitive impairment, fluctuating behavior, agitation, aggression, and previous incidents of intrusive and aggressive actions toward others and staff. Despite these behavioral concerns and a recent wrist fracture of unknown origin, there was no documentation in the clinical records regarding the altercation, no updated care plans, and no evidence of protective interventions implemented after the incident. Multiple staff interviews revealed that two certified nursing assistants (CNAs) witnessed the aggressive resident attempting to strike the other resident, who was in bed at the time. The CNAs responded to calls for help and intervened to prevent further aggression. The incident was reported to the charge nurse, but not to the administrator or other required parties. The charge nurse and registered nurse supervisor both denied knowledge of the altercation, and there was no documentation or reporting of the event in the clinical records for either resident. The social services representative and director of nursing also confirmed they were unaware of the incident and emphasized that such events should be reported and investigated promptly. The facility's own policy prohibits any form of resident abuse and requires reporting and intervention. However, the lack of documentation, failure to update care plans, and absence of protective measures following the altercation demonstrate a breakdown in communication and adherence to policy. The incident left the affected resident feeling violated and unsafe, and the facility did not take the necessary steps to address or prevent further abuse.
Failure to Timely Report Resident-to-Resident Altercation to Authorities
Penalty
Summary
The facility failed to report a witnessed resident-to-resident altercation involving two residents to the California Department of Public Health (CDPH), as required by law and facility policy. The incident involved one resident with severe cognitive impairment and fluctuating behavior, who attempted to strike another resident with moderate cognitive impairment and a history of delusions. The altercation was witnessed by two Certified Nursing Assistants (CNAs), who responded to calls for help and observed the aggressive behavior. Both CNAs reported the incident to a Licensed Vocational Nurse (LVN), but the LVN did not notify the administrator, document the incident, or initiate a report to CDPH. A review of the clinical records for both residents revealed no documentation of the altercation, and interviews with the LVN and Registered Nurse Supervisor (RN) confirmed they were unaware of the incident. The LVN only reported a complaint of wrist pain as an injury of unknown origin, without linking it to the altercation. The Director of Nursing (DON) stated that any allegation of abuse, including resident-to-resident altercations, should be reported within two hours, and acknowledged that yelling for help should have triggered an abuse report. The facility's policies require prompt reporting and investigation of all allegations of abuse, including resident-to-resident altercations. However, the lack of documentation, failure to notify appropriate authorities, and absence of timely reporting delayed an onsite investigation by CDPH and did not ensure the safety and protection of all residents in the facility.
Failure to Investigate and Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its Abuse Reporting and Investigations policy by not thoroughly investigating allegations of resident abuse involving two residents. Both residents had significant cognitive and mental health impairments, with one resident having severe dementia and fluctuating decision-making capacity, and the other diagnosed with major depressive disorder, psychosis, and schizophrenia. Despite these vulnerabilities, there was no documentation in the clinical records regarding a resident-to-resident altercation that occurred between them. Certified Nursing Assistants (CNAs) reported witnessing an incident where one resident attempted to strike another while the latter was in bed. The CNAs responded to calls for help and observed aggressive behavior, subsequently reporting the incident to a Licensed Vocational Nurse (LVN). However, the LVN denied knowledge of the altercation, did not notify the administrator, failed to document the incident, and did not initiate a report to the California Department of Public Health (CDPH). The Registered Nurse Supervisor (RN) was also unaware of the incident, and there was no clinical documentation of the event. Interviews with facility leadership confirmed that abuse allegations should be investigated promptly, with intervention required for any type of abuse. The facility's policies require prompt reporting, investigation, and documentation of resident-to-resident altercations. However, the lack of documentation, failure to notify appropriate personnel, and absence of an investigation into the reported altercation constituted a failure to follow established procedures, resulting in a delay in the onsite investigation by CDPH and a deficiency in protecting residents from potential abuse.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident who required oxygen therapy. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), schizoaffective disorder, and interstitial lung disease, was admitted and readmitted to the facility with orders for oxygen administration at two liters per minute via nasal cannula to maintain oxygen saturation at or above 92%. Despite these medical needs and physician orders, a review of the resident's electronic record revealed that no care plan addressing oxygen administration was created. Interviews with facility staff, including an LVN and the DON, confirmed that a care plan for oxygen therapy should have been developed to provide guidance on monitoring, interventions, and the specifics of oxygen delivery. The facility's policies and procedures also required comprehensive, person-centered care planning based on physician orders and resident needs. The absence of a care plan for oxygen therapy meant there was no documented guidance for staff on how to manage the resident's oxygen needs.
Failure to Administer Oxygen Therapy Safely and According to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not administering oxygen therapy according to the physician's orders and not following infection control protocols. Observations revealed that the resident was receiving oxygen at varying flow rates of 5 LPM and 3 LPM, while the physician's order specified oxygen at 2 LPM via nasal cannula to maintain oxygen saturation at or above 92%. Additionally, the nasal cannula in use was not labeled with an open date, contrary to facility policy, which requires nasal cannulas to be changed weekly and labeled to ensure proper infection control. Interviews with nursing staff confirmed that the oxygen flow rate was not set according to the doctor's order and that the nasal cannula lacked the required date label. The staff acknowledged that licensed nurses are responsible for setting oxygen as prescribed and for labeling and changing nasal cannulas as per policy. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and cognitive impairment, requiring supervision and assistance with daily activities. The facility's policy and procedure on oxygen therapy emphasized the need for safe administration and proper labeling of equipment, which was not followed in this instance.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Follow Physician Order for 1:1 Monitoring
Penalty
Summary
The facility failed to follow physician orders for one resident who had a documented need for 1:1 monitoring. The resident, who had diagnoses including polyarthritis and severe cognitive impairment due to unspecified dementia with behavioral disturbances, was involved in a resident-to-resident altercation. Following this incident, physician orders were issued for 1:1 monitoring and additional 30-minute checks every shift for a specified period. However, staff interviews and record reviews revealed that the facility did not assign staff to provide 1:1 monitoring on at least two days, and there was no documentation that the resident's behaviors were evaluated or that the physician was contacted to clarify the ongoing need for 1:1 monitoring. Further review indicated that the care plan and physician orders were clear about the need for 1:1 monitoring, but the facility did not have a policy stating that such orders should automatically end after a certain period. The Director of Nursing and Director of Staff Development both acknowledged that staff should have reassessed the resident and communicated with the physician regarding the continuation of the order. The facility's policy required licensed nurses to ensure physician orders were clear and complete, including the duration when appropriate, but this was not followed in this case.
Failure to Implement Care Plan Intervention for Wandering Behavior
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as an elopement risk. The resident, who had diagnoses including schizophrenia, type 2 diabetes mellitus, and anemia, was noted to have fluctuating capacity for decision-making and moderately impaired cognitive skills, requiring supervision for daily activities. Although the care plan specified that wandering behavior should be documented and diversional interventions attempted, staff did not monitor or document any episodes of wandering, as they believed the resident had not exhibited such behavior. This lack of documentation and monitoring occurred despite the care plan's directive and the resident's identified risk factors. Interviews with facility staff, including a registered nurse and the assistant director of nursing, confirmed that the intervention to document wandering behavior was not followed. The staff acknowledged the importance of documenting such behaviors to prevent incidents and ensure continuity of care. The facility's policy required comprehensive, person-centered care planning, but there was no evidence that the specified intervention was implemented, resulting in the resident leaving the facility unnoticed.
Failure to Prevent Resident Elopement Due to Lapses in Gate Inspection and Documentation
Penalty
Summary
The facility failed to prevent a resident from eloping by not conducting regular inspections of the exterior gate and by not documenting the resident's wandering behavior as required by the care plan. The resident, who had diagnoses including schizophrenia, type 2 diabetes mellitus, and anemia, was admitted with fluctuating capacity to understand and make decisions. The Minimum Data Assessment indicated the resident had moderately impaired cognitive skills and required supervision for daily activities, but had not previously exhibited wandering behavior. Despite this, the care plan identified the resident as an elopement risk and required documentation of wandering episodes. On the day of the incident, the resident was last seen early in the morning and was later found missing. Interviews revealed that the Director of Maintenance had not kept a documented log of routine inspections for the exterior gate, which was secured with an old padlock and chain. The padlock was found to be disengaged, likely due to force applied by the resident. Additionally, nursing staff did not monitor or document the resident's wandering behavior as outlined in the care plan, and there was no evidence of tracking or reporting these episodes. Facility policies required both regular maintenance inspections and documentation of elopement risks and interventions, but these were not followed, resulting in the resident leaving the facility unsupervised.
Failure to Notify Responsible Party of Abuse Allegation
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident following an abuse allegation involving another resident. The resident in question had a history of schizoaffective disorder, major depressive disorder, and anxiety disorder, and was assessed as having moderately impaired cognition. Although the resident could make needs known, medical records indicated that the resident could not make medical decisions, and the RP was listed as the first emergency contact. On the date of the incident, the resident reported being grabbed by the neck and hit on the head by another resident. However, the RP was not informed of this allegation or the resident's condition following the event. Interviews with staff revealed that the licensed nurse responsible for the resident did not notify the RP, as the resident's face sheet incorrectly listed the resident as their own RP. The nurse relied on this inaccurate documentation and did not contact the RP, despite facility policy requiring notification of the RP in such situations. The Director of Nursing confirmed that the RP should have been notified, as they were responsible for making medical decisions and being involved in the resident's care plan. The facility's policy also specified that the RP must be informed of abuse allegations and assessment findings.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during care. The resident, who had diagnoses including schizophrenia, hypertension, and dysphagia, and was assessed as having moderately impaired cognition and being dependent on staff for activities of daily living, reported that the CNA was rough and abrupt while assisting her back into bed after personal hygiene care. The resident stated that the CNA spoke in a disrespectful tone, did not provide care gently, and did not offer further assistance or reassurance after the resident voiced discomfort and a headache. The CNA later acknowledged being abrupt and not as gentle or respectful as required, citing a desire to finish tasks quickly before the end of her shift. The CNA also failed to notify the nurse of the resident's complaint of head pain at the time. The incident was reported by the resident to social services staff, who confirmed the resident's concerns about future care from the CNA. The registered nurse was informed and assessed the resident, who reiterated that the CNA had been rough and disrespectful. Facility policy required staff to treat residents with kindness, respect, and dignity, and to report any complaints of pain or distress immediately. The actions and inactions of the CNA did not align with these policies, resulting in the resident feeling unvalued and disrespected.
Failure to Revise Care Plan and Implement Interventions After Smoking Restriction Order
Penalty
Summary
The facility failed to revise the comprehensive care plan and implement new interventions for a resident after receiving a neurologist's order instructing the resident to avoid smoking due to medical risks. The resident, who had diagnoses including dementia, schizoaffective disorder, major depressive disorder, diabetes mellitus, and anxiety, continued to smoke despite the new medical order. The resident's Minimum Data Set indicated moderately impaired cognition and a need for moderate assistance with activities of daily living. The resident was able to make needs known but could not make medical decisions. Interviews and record reviews revealed that the neurologist's order to avoid smoking was not incorporated into the resident's care plan, and no new interventions such as smoking cessation education or behavioral support were implemented. The Interdisciplinary Team did not conduct a conference to address the new order, and there was no documentation of care plan revision or additional support measures. The responsible party expressed concern that the facility was not following the neurologist's order or providing necessary support to help the resident comply. Facility staff, including the RN and DON, acknowledged that the care plan should have been updated and interventions put in place following the new order.
Failure to Implement Physician Orders for Dental, Podiatry, and Drug Testing Services
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident by not implementing physician's orders for dental and podiatry services, and by not clarifying and carrying out a neurologist's order for drug testing. The resident, who had diagnoses including dementia, schizoaffective disorder, major depressive disorder, diabetes mellitus, and anxiety, was moderately cognitively impaired and required moderate assistance with activities of daily living. Physician orders for dental and podiatry consultations were in place, and care plans indicated the need for these services, but there was no documented evidence that the resident received either service since readmission. During observation, the resident was found to have long, irregular toenails with debris and reported discomfort, expressing a need to see a podiatrist. The resident also reported tooth discomfort and a need for dental evaluation. The responsible party confirmed that the resident had not been seen by a podiatrist or dentist since readmission and expressed concern about the lack of follow-through on these services. Social Services staff confirmed that they were responsible for arranging such services and acknowledged that no appointments had been made, placing the resident at risk for foot discomfort, infection, and worsening dental pain. Additionally, a neurologist's order for weekly drug testing was not clarified or implemented. The nurse attempted to clarify the order by contacting the neurologist's office but did not follow up after leaving a message, and no drug testing was performed. Facility policy required that unclear orders be clarified and documented, and that outside services be coordinated as ordered by the physician, but these procedures were not followed in this case.
Failure to Prevent Resident Elopement Due to Inadequate Window Security and Risk Assessment
Penalty
Summary
A resident with diagnoses including paranoid schizophrenia, COPD, anxiety, hypertension, and type 2 diabetes mellitus, who was noted to be confused and have severe cognitive impairment, was able to elope from the facility through a window. The window in the resident's room was not properly secured with a screw on the top track, which allowed the resident to lift and open the window, remove the screen, and exit the building. The maintenance supervisor later confirmed that the window did not have the required screw, and that all windows should have been secured to prevent such incidents. The facility failed to thoroughly and accurately assess the resident's risk for elopement. The elopement evaluation completed at admission did not identify the resident as being at risk, and staff did not interview the responsible party, who later reported that the resident had a history of elopement from other facilities. The assessment relied on the resident's own denial of elopement history, despite the resident's severe cognitive impairment, and did not include input from the responsible party or a review of prior incidents. Additionally, the facility did not monitor the resident's known triggers for elopement, such as confusion and agitation, as outlined in the care plan. Staff interviews revealed that behaviors related to elopement risk were not actively monitored, and staff were unaware of the need to check window security. The resident was last seen by a roommate, who observed the resident leaving through the window, and staff only became aware of the elopement after being alerted by another resident.
Failure to Implement Physician Orders for Medication and Specialist Consult
Penalty
Summary
The facility failed to implement physician's orders for a resident who had been diagnosed with encephalopathy and cellulitis of the lower limbs. The resident, who had moderate cognitive impairment and required partial to moderate assistance with activities of daily living, developed a generalized body rash. The physician ordered hydrocortisone 1% cream to be applied daily for 30 days to treat dermatitis, but the Treatment Administration Record showed that the medication was not administered for several days following the order. Additionally, when the resident developed redness in both lower legs, the physician ordered a dermatology consult, but this order was not entered or implemented. Interviews with nursing staff confirmed that the orders for both the hydrocortisone cream and the dermatology consult were not transcribed or carried out as required. The Director of Nursing stated that all physician orders should be implemented on the day they are received, and facility policy requires licensed nurses to transcribe and implement orders promptly. Review of the resident's records and facility policies confirmed that these steps were not followed, resulting in the deficiency.
Residents Left Unattended During Deep Cleaning with Hazards Present
Penalty
Summary
Housekeeping staff failed to ensure a safe environment for two cognitively impaired residents who were at risk for falls by leaving them in their room during a deep cleaning process. The floor was wet, and a bottle of Clorox spray, a powerful bleach-based cleaner, was left unattended on a bedside table. Both residents had documented diagnoses of dementia, abnormalities of gait and mobility, and lack of coordination, and required varying levels of assistance with activities of daily living. Their care plans identified them as being at risk for falls due to confusion and poor safety awareness, with interventions to anticipate and meet their needs. During the deep cleaning, the housekeeping staff left the room to attend to another task, leaving the residents exposed to wet floors and cleaning chemicals. The registered nurse, housekeeping staff, housekeeping supervisor, and director of nursing all confirmed that residents should not have been present during deep cleaning and that cleaning supplies should not have been left unattended. Facility policies required staff to be considerate of residents and to keep cleaning equipment out of residents' way, as well as to ensure a safe and sanitary environment.
Failure to Implement Person-Centered Care Plan for Resident Requesting Female CNAs
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident who had a documented request and physician order to receive care only from female CNAs. The resident, who had diagnoses including psychosis, epilepsy, and anxiety disorder, alleged inappropriate touching by a male CNA during a shower. Despite a care plan intervention and a physician order specifying that only female CNAs should provide care, facility records and assignment sheets showed that male CNAs were assigned to the resident on multiple shifts. Documentation from these shifts confirmed that male CNAs were assigned and documented care activities for the resident. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Staffing, confirmed that the assignment of male CNAs to the resident was contrary to the resident's expressed wishes and the care plan. The facility's own policies require person-centered care and respect for resident rights, including freedom of choice in care preferences. The failure to follow the care plan and physician order resulted in the resident experiencing fear and anxiety related to potential abuse.
Failure to Revise Care Plan with Fall Prevention Interventions
Penalty
Summary
The facility failed to revise the care plan to include safety interventions for a resident who was at high risk for falls and had already sustained two falls within the facility. The resident had significant medical conditions, including abnormalities of gait and mobility, lack of coordination, and a contracture of the right forearm, and was determined to lack the capacity to make medical decisions. The Minimum Data Set indicated the resident required partial to moderate assistance with activities of daily living and needed supervision or assistance with transfers and walking. Despite these needs and two documented falls—one witnessed and one unwitnessed—resulting in injuries such as abrasions, swelling, and a laceration, the care plan was not updated to include specific safety measures to prevent further falls. Interviews with nursing staff confirmed that the care plan did not reflect necessary safety interventions following the resident's falls. The facility's policies required that care plans be updated after every fall and upon changes in condition, but this was not done for the resident in question. The lack of timely revision and inclusion of fall prevention interventions in the care plan was identified as a deficiency, as it did not provide adequate guidance for staff to address the resident's increased risk of falls.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH). The resident, who had cognitive impairment and required substantial assistance with activities of daily living, was observed with bruises on the right and left sides of the face and a swollen left cheek. Despite these observations, there was no documented evidence that the injuries were reported to CDPH, as required by the facility's policy. The Director of Nursing acknowledged that the injuries should have been reported to the State agency, Ombudsman, and police, but they were not, as the facility considered the issue more medical than abuse-related. Interviews with various staff members, including a Licensed Vocational Nurse, Registered Nurses, and a Certified Nurse Assistant, revealed that the injuries were noticed and reported internally, but the necessary external reporting was not completed. The facility's policy mandates that injuries of unknown origin be reported to outside agencies within 24 hours, but this protocol was not followed. The failure to report these injuries resulted in a delay in investigation by CDPH and placed the resident at risk for further injuries.
Inadequate Skin Care and Monitoring for Resident with Dermatitis
Penalty
Summary
The facility failed to provide appropriate skin care and adequate skin reassessment for a resident with generalized body dermatitis. The resident, who was admitted with diagnoses including unspecified dementia and dermatitis, had a care plan intervention to apply triamcinolone acetonide cream and monitor its efficacy. However, the facility did not ensure proper documentation and assessment of the resident's skin condition, as evidenced by incomplete weekly skin checks that lacked descriptions of whether the skin condition was improving or worsening. Interviews with staff revealed that the resident's rash had been present since October 2024 and had worsened by February 2025. Despite the care plan's directive to monitor the treatment's effectiveness, the facility's documentation did not reflect this, leading to a lack of awareness among nurses about the treatment's progress. The Director of Nursing confirmed that the skin should have been monitored more closely following a change of condition, with detailed narrative descriptions in the assessments. The facility's policy required weekly documentation of treatment effectiveness, which was not adhered to, resulting in the resident's delayed, non-healing skin condition.
Failure to Consult Psychiatrist Before Resident's Leave
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards by not consulting with the psychiatrist before the resident went out on pass (OOP), as required by the facility's policy and procedure. The resident, who was admitted with diagnoses including schizoaffective disorder, anxiety disorder, and the presence of a cardiac pacemaker, went OOP on multiple occasions without the necessary psychiatric consultation. The resident's Minimum Data Set indicated they had clear speech and comprehension but required partial assistance with activities of daily living. The facility's policy required both the attending physician and psychiatrist to determine if a resident could participate in activities outside the facility. However, the psychiatric nurse practitioner confirmed that they were not consulted, and the registered nurse supervisor acknowledged the lack of documentation for a psychiatric consult. This oversight had the potential to negatively affect the resident's psychosocial well-being and posed a risk of harm or danger to the resident and others while OOP.
Failure to Provide Medications During Resident's Leave
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician while the resident was Out on Pass (OOP). The resident, who had diagnoses including schizoaffective disorder and anxiety disorder, was prescribed Divalproex Sodium and Gabapentin to be administered three times a day. However, during several OOP instances, the facility did not provide the resident's Responsible Party (RP) with the necessary medications to administer while the resident was away from the facility. The Medication Administration Record (MAR) inaccurately documented that the medications were administered at the facility during times when the resident was OOP. This discrepancy was noted on multiple dates, and there was no supporting documentation to indicate that the medications were given to the RP for administration. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the lack of documentation and the importance of ensuring that medications are provided to the RP when the resident is OOP. The facility's policies and procedures for medication administration and OOP were not followed, as there was no documentation of the provision of medications to the RP. The failure to accurately document medication administration and provide medications to the RP as per the facility's policy had the potential to result in medication errors and worsening of the resident's condition.
Failure to Notify Doctor of Dialysis Refusal
Penalty
Summary
The facility failed to notify the doctor when a resident refused dialysis treatment on multiple occasions. The resident, who was diagnosed with end-stage renal disease and required hemodialysis twice a week, refused treatment on three separate dates. Despite the resident's refusal, there was no documentation indicating that the doctor was informed of these refusals, which is a requirement according to the facility's policy. The resident's medical records showed that the last dialysis treatment was received on 12/13/2024, and the next scheduled treatment was on 12/23/2024, resulting in a ten-day gap without dialysis. The resident's condition included moderate cognitive impairment and dependency on renal dialysis. The lack of communication with the doctor about the missed treatments placed the resident at risk for medical complications. Interviews with the Registered Nurse and the Director of Nursing confirmed that there was no documentation of the doctor's notification, and the facility's policy on refusal of treatment was not followed. The resident was eventually transferred to a hospital for further evaluation and treatment after experiencing shortness of breath.
Failure to Send Pre-Dialysis Evaluation
Penalty
Summary
The facility failed to complete and send a pre-dialysis evaluation to the dialysis center for a resident with end-stage renal disease who was dependent on renal dialysis. The resident was admitted with multiple diagnoses, including major depressive disorder and moderate cognitive impairment, requiring supervision and partial assistance for various activities of daily living. The resident's medical orders indicated a decrease in hemodialysis frequency to twice a week, with a preference for Mondays and Fridays. However, on a specific date, the facility did not send the necessary pre-dialysis evaluation to the dialysis center, which was confirmed during a review of the resident's dialysis records. Interviews with the facility's staff, including a registered nurse and the Director of Nursing, revealed that the pre-dialysis evaluation was not sent on the specified date, resulting in a lack of communication between the facility and the dialysis provider. The facility's policy and procedure for dialysis management required a licensed nurse to complete a pre-dialysis evaluation, which was not adhered to in this instance. The Director of Nursing acknowledged the oversight and explained the importance of the pre-dialysis evaluation in facilitating communication between the nursing home and the dialysis center.
Failure to Document Scalp Assessment and Intervention
Penalty
Summary
The facility failed to document the assessment and interventions for a resident who complained of an itchy scalp. The resident, who was admitted with diagnoses including schizophrenia, major depressive disorder, and hyperlipidemia, had fluctuating capacity to understand and make decisions. The Minimum Data Set indicated the resident had moderate cognitive impairment and required supervision for all activities of daily living. On a specific date, the resident complained of itchiness on the scalp, and a Licensed Vocational Nurse (LVN) checked the resident's head, finding dryness and dandruff but no nits or lice. The LVN contacted the resident's doctor, who ordered a Selenium Sulfide shampoo for the condition. However, the LVN did not document the assessment of the resident's scalp or the notification to the doctor in the resident's clinical record. The Director of Nursing confirmed the lack of documentation and stated that the LVN should have recorded the assessment and doctor notification. The facility's policy on alert charting documentation required special monitoring and documentation for changes in medical condition, which was not followed in this case.
Failure to Notify Family of Resident's Condition Changes and Hospital Transfer
Penalty
Summary
The facility failed to effectively notify both designated emergency contacts for a resident when significant changes in the resident's condition occurred. The resident, who had a history of paranoid schizophrenia, dementia, and anxiety, exhibited a change of condition on October 17, 2024, which included aggressive behavior. The licensed nurses did not attempt to contact the second family member listed on the resident's Admission Record, and only left a voicemail for the first family member, without making further attempts or notifying the second contact. Additionally, the facility did not obtain informed consent from the resident's responsible party for a newly prescribed medication, hydroxyzine hydrochloride, intended to manage the resident's anxiety and aggressive behavior. The consent form was signed by two licensed vocational nurses, but one of them admitted to not following the normal process to obtain verbal consent over the phone, assuming the other nurse had notified the family member. Furthermore, the facility failed to notify either of the resident's emergency contacts when the resident was transferred to a General Acute Care Hospital on October 18, 2024, for a 72-hour psychiatric hold. The first family member only became aware of the transfer upon visiting the facility the following day. The facility's policy and procedure required prompt notification of the legal representative or appropriate family member in such situations, but this was not adhered to, leading to the deficiency.
Resident Lacked Pillowcase, Violating Comfort and Dignity
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 1, had a pillowcase on their pillow, which is a basic requirement for a safe, clean, and comfortable environment. Resident 1, who has diagnoses including paranoid schizophrenia, dementia, and anxiety, was observed without a pillowcase on their pillow. This was confirmed during an interview with Resident 1, who stated that they had to sleep without a pillowcase and had informed the nursing staff of their need for one, but no action was taken. The deficiency was further corroborated by a Certified Nursing Assistant (CNA) who acknowledged that all residents should have a pillowcase to maintain comfort and dignity. The facility's policy, titled 'Resident Rights - Accommodation of Needs,' mandates that residents are provided with a clean and comfortable bed, including a pillowcase. The lack of a pillowcase for Resident 1 was a violation of this policy, as observed and reported by both the resident and the CNA.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs of five residents by not ensuring that their call lights were within reach. This deficiency was observed during multiple instances where residents were unable to access their call lights, which are essential for requesting assistance from staff. For example, Resident 91 was found with the call light on the floor, out of reach, despite having a care plan that required the call light to be accessible due to their risk of falls and cognitive impairments. Similarly, Resident 196's call light was observed on the floor under another resident's bed, making it inaccessible. This resident also had a care plan that specified the need for the call light to be within reach due to their impaired balance and cognitive skills. Staff interviews confirmed that the call light should have been attached to the bed and accessible to the resident to prevent delays in care and potential safety risks. Other residents, such as Resident 80, Resident 156, and Resident 255, also experienced similar issues with their call lights being out of reach. These residents had various medical conditions, including amputations, cognitive impairments, and mobility issues, which necessitated the need for accessible call lights as part of their care plans. Staff members acknowledged the importance of ensuring call lights were within reach and the potential consequences of failing to do so, such as delayed care and increased risk of injury.
Lack of Bedside Tables Compromises Resident Comfort and Dignity
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as observed during a survey. Resident 211 did not have a bedside table during mealtimes, resulting in the resident having to eat off a walker. This arrangement was uncomfortable for Resident 211, as the food tray was at a lower height and too far away, causing the resident to drop food while eating. Despite requesting a bedside table, Resident 211 was informed by staff that there were not enough tables available for every resident. Similarly, Resident 225 was observed without a bedside table, using the bed for coloring activities and the nightstand for meals. This setup required Resident 225 to reach uncomfortably to access the food tray. The resident expressed a desire for a table for both mealtimes and activities, but staff indicated that no extra tables were available. Resident 225 noted that other residents had bedside tables, highlighting the inconsistency in accommodations. Interviews with facility staff, including a CNA, LVN, and RN, confirmed that not all residents had bedside tables, and it was acknowledged that eating off nightstands or walkers was inappropriate and unsafe. The facility's policy emphasized the importance of providing an environment that meets residents' individual needs, yet the lack of bedside tables for these residents did not align with this policy, compromising their comfort, safety, and dignity.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. Resident 148, who was admitted with multiple diagnoses including schizophrenia, COPD, and atrial fibrillation, did not have care plans for oxygen administration, respiratory therapy, or the use of a suction device. Despite having active orders for these treatments, the absence of care plans meant there was no communication to staff on how to properly care for the resident, as confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Similarly, Resident 15, who was readmitted with respiratory failure and COPD, lacked a care plan for oxygen administration. The resident's medical chart did not include a care plan despite having an order for oxygen via nasal cannula. A Registered Nurse (RN) acknowledged that a care plan should have been developed to guide the nursing staff in setting goals and interventions for the resident's care. Resident 274, admitted with idiopathic peripheral neuropathy and bipolar disorder, experienced a new onset of hand tremors, which was not addressed in a care plan. The absence of a care plan for this change of condition was noted by an LVN and an RN, who emphasized the importance of care plans in informing staff about resident issues and interventions. The facility's policy required comprehensive, person-centered care plans to address health and safety concerns, but this was not adhered to for the residents in question.
Improper Inflation of Low-Air-Loss Mattresses
Penalty
Summary
The facility failed to ensure that low-air-loss mattresses (LALMs) were properly inflated according to the residents' actual weights, which is crucial for preventing pressure ulcers. Observations and interviews revealed that the LALMs for five residents were set incorrectly, with the mattresses inflated based on significantly higher weights than the residents' actual weights. This improper inflation could lead to inadequate pressure relief and increased risk of pressure ulcer development. Resident 155's LALM was inflated for a weight of 350 pounds, while the resident weighed 222.4 pounds. Similarly, Resident 206's mattress was set for 320 pounds, but the resident weighed 147.8 pounds. Resident 255's LALM was also set for 350 pounds, despite the resident weighing only 106.2 pounds. These discrepancies were confirmed through observations and interviews with nursing staff, who acknowledged the incorrect settings and the potential risk for pressure ulcer development due to improper mattress inflation. Further investigation showed that the facility's policy required staff to ensure mattresses were inflated properly and checked routinely. However, interviews with staff indicated a lack of adherence to these protocols, as licensed nurses were responsible for adjusting the LALM settings but failed to do so according to the residents' current weights. This oversight in following the facility's procedures contributed to the deficiency in providing appropriate pressure ulcer care.
Inadequate Restorative Nursing Aide Services Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to provide adequate Restorative Nursing Aide (RNA) services for three residents, leading to deficiencies in maintaining and improving their range of motion (ROM) and mobility. The report highlights that the facility did not ensure sufficient staffing of Certified Nursing Assistants (CNAs), which resulted in RNAs being utilized for both CNA and RNA duties. This staffing issue led to gaps in the provision of RNA services and a lack of documentation for the services provided to the residents. Resident 132, who has severe cognitive impairment and multiple diagnoses including Parkinson's Disease and severe protein-calorie malnutrition, did not receive passive range of motion (PROM) exercises for the upper extremities as ordered. The RNA assigned to Resident 132 was unaware of the orders due to a lack of access to the electronic medical record (EMR) and relied solely on the task screen, which did not display the necessary RNA orders. This oversight resulted in the resident not receiving the prescribed exercises for two months. Similarly, Resident 223, with severe cognitive impairment and contractures, did not receive the application of a right knee extension splint for three months, and there were multiple days when no RNA services were provided. Resident 166, also with severe cognitive impairment and a contracture, did not have the right knee extension splint and Prafo splint applied as ordered for approximately three months. The Director of Staff Development acknowledged that RNA orders were mistakenly assigned to the CNA task list, preventing RNAs from documenting and performing the tasks. The Director of Rehabilitation confirmed that the lack of services could lead to a decline in the residents' conditions.
Failure to Monitor and Record Urine Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to monitor and record urine output from indwelling catheters for two residents, which is a deficiency in providing appropriate catheter care. Resident 246, who has diagnoses including dementia, major depression, schizophrenia, and Alzheimer's disease, was observed with an empty urine collection bag on multiple occasions. The Certified Nursing Assistant (CNA) responsible for Resident 246's care did not record the urine output and was unaware of the requirement to do so. The Director of Staff Development indicated that licensed nurses should monitor and record the urine output, but there was no documentation of this in the Medication Administration Record (MAR). Resident 71, with diagnoses including chronic kidney disease, obstructive uropathy, benign prostatic hyperplasia, dementia, and schizophrenia, also had issues with urine output monitoring. The Treatment Administration Record (TAR) showed missing documentation for catheter care on several shifts. A CNA stated she recorded the urine output on paper and reported it to the charge nurse, but did not know how to enter it into the electronic charting system. The Licensed Vocational Nurse (LVN) and Registered Nurse (RN) involved were unaware of where to find the urine output records, and the MAR and nurses' notes lacked documentation of urine output. The facility's policy required monitoring and recording of intake and output for residents with indwelling catheters for 30 days, but this was not followed. The failure to document urine output could lead to undetected issues such as urinary retention or infection. The care plans for both residents indicated the need for monitoring and documentation, but these interventions were not implemented by the nursing staff.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 15 and Resident 148, as per professional standards. Resident 15 was observed receiving oxygen at a rate higher than the physician's order, which was set at 2 liters per minute (LPM) via nasal cannula. The nasal cannula was not dated, and there was no signage indicating oxygen use outside the resident's room. Interviews with nursing staff revealed a lack of awareness regarding the correct oxygen settings and the importance of dating the nasal cannula for infection control purposes. Resident 148, who had multiple diagnoses including COPD, was not receiving oxygen at the time of observation despite having an active order for oxygen at 2 LPM. The respiratory equipment, including the nasal cannula, oral suction device, and nebulizer mask, had not been changed since 9/8/2024, contrary to the facility's policy of changing them weekly. There was also no signage indicating oxygen use outside Resident 148's room. Interviews with nursing staff and the Infection Preventionist confirmed the oversight in changing the equipment and the absence of necessary signage. The facility's policy and procedure for oxygen therapy, effective since November 2017, mandates that oxygen is administered under safe and sanitary conditions, with equipment changed every seven days and signage displayed where oxygen is stored or administered. The Director of Nursing acknowledged the deficiencies, noting the importance of weekly equipment changes and proper signage to prevent potential hazards.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications to Resident 50 in accordance with physician orders, specifically regarding the timing and conditions under which the medications were to be given. Resident 50, who has diagnoses including Type 2 Diabetes Mellitus, hypertension, low back pain, and osteoarthritis, was supposed to receive Metformin and Naproxen with food at specific times. However, the medications were consistently administered over 60 minutes after the scheduled time and without food, increasing the risk of adverse reactions. During a medication pass observation, it was noted that Metformin was administered without food, contrary to the physician's orders, and Naproxen was not administered at the scheduled time. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) revealed that the staff did not verify whether Resident 50 had eaten before administering the medications, which is crucial for preventing gastrointestinal upset and managing diabetes effectively. The LVN also failed to notify the physician about the late administration of medications. The Director of Nursing (DON) confirmed that the medications were not administered as per the physician's orders, which required them to be given with food to prevent gastrointestinal side effects. The facility's policies on medication administration and error reporting were not followed, as the errors were not promptly reported to the necessary parties. The Medication Administration Record (MAR) showed discrepancies in the timing of medication administration, further highlighting the facility's failure to adhere to prescribed medication schedules.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 14.81% error rate during a medication administration observation. This deficiency was identified when four medication errors were noted out of 27 opportunities for one resident. The errors involved the improper administration of metformin and naproxen without food, and the late administration of lactulose and a lidocaine patch, contrary to physician orders. Resident 50, who has a history of Type 2 Diabetes Mellitus, hypertension, low back pain, and osteoarthritis, was observed during a medication pass. The resident was administered metformin and lactulose without food, and a lidocaine patch was applied late. Additionally, naproxen was not administered at the scheduled time and was given later without notifying the physician. The resident expressed stomach discomfort, which was not adequately addressed by the attending nurse. Interviews with the LVN and the Director of Nursing revealed a lack of adherence to the facility's medication administration policy, which requires medications to be given within an hour of the scheduled time and with meals when specified. The failure to follow these protocols increased the risk of adverse reactions for Resident 50, as the medications were not administered as ordered by the physician.
Medication Error: Carvedilol Administered Outside Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering carvedilol outside the parameters ordered by the physician. Specifically, the medication was given to a resident with a systolic blood pressure (SBP) below the threshold of 110 mmHg on three separate occasions. The resident, who had a history of hypertension, major depressive disorder, schizoaffective disorder, and bipolar disorder, was at risk of experiencing adverse effects due to this error. The medication administration record (MAR) for September 2024 showed that carvedilol was administered when the resident's SBP was 102 mmHg, 108 mmHg, and 85 mmHg, contrary to the physician's order to hold the medication if SBP was less than 110 mmHg. During an interview, an LVN acknowledged that carvedilol should not have been administered with an SBP of 85 mmHg, as it could further lower the resident's blood pressure. The facility's policy required medications to be administered according to the physician's written orders, which was not followed in this case.
Medication Storage Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of medication storage temperatures in one of the three medication storage rooms, specifically the Advance Care (AC) Unit. During an observation, it was noted that the medication storage refrigerator lacked a thermometer, and the room temperature was not being monitored as per the facility's policy. The refrigerator contained various insulin medications and an emergency medication kit, with visible water droplets on the packages, indicating potential temperature issues. The temperature log for the refrigerator was inaccurately documented, with temperatures recorded in advance for shifts that had not yet occurred. This practice made it impossible to determine when the refrigerator temperature moved out of range, raising concerns about the safety and effectiveness of the medications stored. An infrared thermometer check revealed that the refrigerator temperature was significantly higher than the acceptable range, indicating a malfunctioning thermometer inside the refrigerator. Interviews with staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the medication refrigerator temperature was out of range and that room temperatures had not been monitored for years. The facility's policy required medications to be stored at specific temperature ranges to maintain their integrity and potency, which was not adhered to, potentially compromising the effectiveness of the medications for residents.
Deficiencies in Kitchen Staff Training and Competency
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency skills, particularly in the preparation of puree diets and the testing of Quaternary ammonium compounds (Quat) sanitizer concentration. During an interview, a cook admitted to not following the recipe for puree diets because she was unaware of its existence, despite the importance of maintaining consistency for resident safety and nutrition. Observations confirmed that the puree seasoned brown rice was runny and did not maintain its shape, and the fruit cup was watery, indicating that recipes were not followed. The Registered Dietitian and Food Service Director acknowledged that the failure to follow recipes could lead to choking hazards and dissatisfaction among residents. The facility's policies and procedures required the use of standardized recipes to ensure nutritionally adequate and consistent meals. However, the cook's job description and competency checklist did not include specific training or questions related to puree diets. The facility's training records also showed no in-service training for puree recipes, highlighting a gap in staff education and competency evaluation. In addition to issues with puree diets, the facility also failed to ensure proper testing of Quat sanitizer concentration. Dietary aides demonstrated incorrect procedures for testing the sanitizer, resulting in readings that did not meet the manufacturer's guidelines. The Registered Dietitian emphasized the importance of proper sanitizer concentration to prevent foodborne illnesses. Despite job descriptions and orientation checklists indicating responsibilities for maintaining a safe and sanitary environment, there was no in-service training for Quat sanitizer concentration testing, further indicating a lack of adequate staff training.
Failure to Follow Puree Diet Recipes Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to adhere to the prescribed menu and did not meet the nutritional needs of residents on puree diets. Specifically, the seasoned brown rice was found to be runny, and the fruit cup was watery, which did not meet the required consistency for puree diets. This issue was identified during a review of the facility's daily menu and through interviews with staff. The cook responsible for preparing the meals admitted to not following the standardized recipes, as she was unaware of their existence and had not received training on preparing pureed diets. The Registered Dietitian and Food Service Director confirmed that the food did not achieve the correct consistency, which could lead to potential risks such as choking. The facility's policies and procedures, as well as the diet manual, emphasize the importance of following standardized recipes to ensure the nutritional adequacy and consistency of meals. However, the staff did not adhere to these guidelines, resulting in meals that did not meet the required standards. The facility's policies outlined the need for standardized recipes to be used and adjusted for therapeutic and consistency modifications, but these were not followed in practice. The deficiency affected 23 residents receiving puree diets, putting them at risk of difficulty in eating, chewing, swallowing, and potential weight loss due to inadequate nutrient intake.
Deficient Food Preparation Practices
Penalty
Summary
The facility failed to prepare food by methods that conserved flavor and appearance, as observed during a review of the facility's daily menu and subsequent observations. The seasoned brown rice served to residents was found to be too sticky, with the rice grains not separated as they should be. Additionally, the broccoli, which was supposed to have a sesame flavor, tasted bland and lacked the expected sesame taste. These observations were made during a tray line inspection and a regular diet test tray evaluation with the Registered Dietitian (RD) and Food Service Director (FSD), who confirmed the deficiencies in food preparation. The facility's policies and procedures, including the Dietary Department-General and Standardized Recipe guidelines, were reviewed and indicated that meals should be nutritionally adequate, attractive, and well-balanced, utilizing standardized recipes. However, the facility's execution of these policies was inadequate, as evidenced by the issues with the rice and broccoli. The facility's standardized recipes for the seasoned rice and sesame broccoli were not followed correctly, leading to the deficient practice that placed 260 of 284 residents at risk of unplanned weight loss due to poor food intake.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. In the walk-in refrigerator, four out of seven racks were found to have cracks, chips, and rust, which could harbor harmful bacteria. The walk-in freezer had dried ice cream drippings on the floor, two axes, a bowl, ice buildup, and torn door gaskets, all of which could lead to food contamination. Additionally, baking pans were observed with burnt particles, and clear storage containers had blue tape residues and were not air-dried before stacking. Further observations revealed that chopping boards in the clean area were scratched and sticky, and three dented cans were stored with non-dented cans, posing a risk of botulism. The internal parts of the ice machine had black dirt particles, indicating inadequate cleaning. The low-temperature dish machine was operating at 110 degrees Fahrenheit, below the acceptable range, compromising the sanitation of dishes. The concentration of quaternary ammonium compounds used for sanitizing was not within the acceptable range, potentially leaving surfaces inadequately sanitized. The resident's refrigerator and freezer temperatures were not maintained within acceptable standards, with the freezer at 18 degrees Fahrenheit instead of 0 degrees, and the refrigerator temperature range was 32-45 degrees Fahrenheit instead of the required 32-40 degrees. These deficiencies in food storage and preparation practices had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illness to the residents.
Improper Waste Disposal in Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in the dumpster area on multiple occasions. The dumpster was not completely covered, and trash, including black garbage bags, used plastic cups, and other debris, was found on the surrounding floor. This was noted during observations on two separate days, indicating a persistent issue with waste management in the facility. Interviews with the Food Service Director and housekeeping staff confirmed that the dumpster was not fully covered, which they acknowledged was not acceptable due to the risk of contamination and attracting pests. The Environmental Services Supervisor also confirmed that the dumpster was not completely covered and needed to be to prevent attracting pests like mice and flies. The facility's Waste Management Policies and Procedures, as well as the Food Code 2022, require that food waste be placed in covered receptacles to reduce the risk of contamination. Despite these guidelines, the facility did not maintain the dumpster area in accordance with these standards, potentially exposing residents to health risks.
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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