Las Flores Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardena, California.
- Location
- 14165 Purche Ave., Gardena, California 90249
- CMS Provider Number
- 555057
- Inspections on file
- 46
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Las Flores Convalescent Hospital during CMS and state inspections, most recent first.
Two residents with intact cognition became involved in a verbal and physical altercation on a smoking patio after one resident reportedly blocked a doorway with a wheelchair and was insulted by the other. One resident threw coffee into the other’s face, and in response the second resident stood up from a wheelchair and punched the first resident in the face, causing a nosebleed, forehead hematoma, and later‑confirmed nasal and orbital fractures that required ED evaluation. Facility records and interviews confirmed the sequence of events, while the facility’s abuse prevention policy stated that residents must be free from abuse and that staff must not permit anyone to engage in physical abuse.
A resident with severe cognitive impairment and mobility dependence developed multiple pressure ulcers after staff failed to implement and update a care plan with necessary interventions such as regular repositioning and offloading. Inconsistent skin assessments and missing documentation further contributed to delayed identification and management of skin breakdown, resulting in the progression of pressure injuries.
A resident with a history of malnutrition and dysphagia experienced severe unplanned weight loss after staff failed to consistently document meal intake, provide supplements when intake was low, and implement the RD's recommendations for large-portion meals. The care plan was not updated after significant weight loss, and an IDT meeting was not conducted to address the issue, resulting in the resident requiring hospitalization and feeding tube placement.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, resulting in the presence of hazards and insufficient oversight.
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 plan to meet a resident's most immediate needs was not created or implemented within 48 hours of admission, as required. Surveyors found no documentation or evidence that such a plan was developed for the newly admitted individual.
Staff were not provided with education on dementia care or instructed on what constitutes abuse, neglect, and exploitation, nor were they informed about how to report these incidents.
The facility failed to replace opened Emergency-Kits (E-Kits) within the required 48-72 hours, risking delays in emergency medication administration. Additionally, the facility did not follow its policy for the disposal of controlled substances, as 24 medications were destroyed without the required nurse's signature, raising concerns about potential diversion and theft. The DON admitted to not signing the destruction forms due to being busy, compromising the medication disposal process.
The facility failed to adhere to professional standards by not accurately obtaining orthostatic blood pressure readings for two residents, administering medication to the wrong site for a resident, and not following physician parameters for administering Midodrine HCI to another resident. These deficiencies could potentially lead to adverse reactions or harm.
The facility failed to complete initial and annual skills competencies for RNAs, crucial for maintaining residents' mobility. Additionally, an LVN lacked understanding of orthostatic hypotension procedures, leading to inaccurate blood pressure readings. The DON emphasized the importance of accurate readings for medication management.
The facility failed to store insulin properly, with unopened Lantus and Glargine YFGN found in a medication cart instead of refrigerated, risking decreased potency. Additionally, a soiled Clear Lax container was found, posing an infection control issue. Both the LVN and DON acknowledged these practices could negatively impact resident health.
A facility failed to implement laboratory orders for three residents, leading to delays in care and potential health risks. One resident with acute kidney failure did not have required blood tests conducted, while another with Vitamin D deficiency missed metabolic panels. A third resident with epilepsy did not receive monthly Keppra level blood draws, risking seizure management. Staff interviews confirmed these oversights, highlighting a lapse in following the facility's policy for timely laboratory services.
The facility failed to follow proper food storage practices, as observed with loosely tied cereal bags and unlabeled pancake mix and syrup in the kitchen. The Dietary Aide acknowledged the risk of pest contamination and the need for labeling to prevent serving expired products. The Dietary Service Supervisor confirmed that facility policy required proper storage and labeling.
The facility failed to include a contingency plan in its Facility Assessment, which is crucial for identifying necessary resources during regular operations and emergencies. The Administrator admitted the assessment was incomplete, lacking a plan for staffing needs during emergencies. The facility's policy indicated the assessment should guide contingency planning for events affecting resident care, such as staffing availability. CMS guidance requires facilities to document assessments for competent care during all operations.
The facility failed to provide documentation of QAPI efforts to address repeat deficiencies in Resident Rights, Laboratory Services, and Pharmacy Services. The Administrator acknowledged the absence of meeting minutes and the importance of developing a QAPI program to address these issues. The facility's policy indicated that meeting minutes should be recorded and shared, but this was not done, placing residents at risk if deficiencies were not addressed.
The facility failed to properly store five wheelchairs and one geriatric chair, leaving them outside in the rain, which could damage the equipment and prevent safe use. The DOR noted difficulties in maintaining wheelchairs, and a custom wheelchair for a resident was unusable due to being wet. The Maintenance Supervisor confirmed a lack of covered storage space, and the DON stated that medical equipment should not be stored outside.
A facility failed to obtain informed consent for psychoactive medications for a resident with diabetes, CKD, and bipolar disorder. Despite the resident's capacity to understand and make decisions, there was no documented consent for Seroquel and Duloxetine HCI in the resident's chart. Interviews with staff confirmed the requirement for informed consent, which was not met, potentially leading to the resident receiving medication without being fully informed.
A resident with COPD, hypertension, and CHF was not invited to participate in care planning meetings, despite being capable of making medical decisions. The facility's policies require residents to be invited to these meetings, but the staff failed to notify the resident, violating her rights.
Two residents in the facility were found with call lights out of reach, hindering their ability to communicate needs to staff. One resident with COPD and hemiplegia, and another with mobility issues and CHF, had call lights on the floor behind their beds. Staff, including a CNA, RN, LVN, and DON, confirmed the importance of keeping call lights accessible to prevent delays in care and ensure safety. The facility's policy mandates call lights be within reach to facilitate prompt communication.
A resident's preference for showers was not honored, despite being cognitively capable and having approval from the PT. The resident, admitted with urinary retention and dysphagia, was scheduled for showers twice a week but reported not receiving any since admission. Staff interviews confirmed the resident's capability and the facility's policy supported resident choice, yet the request was unmet, potentially affecting the resident's psychosocial well-being.
A facility failed to provide a resident's representative with the Notice of Medicare Non-Coverage (NOMNC) form within the required timeframe. The resident, who had diagnoses including dementia and required assistance with daily activities, was not given the opportunity to appeal the end of Medicare Part A skilled services due to the late delivery of the form. The facility's policy requires the NOMNC to be delivered at least two days before services end, but it was provided only one day prior.
A facility failed to submit a resident's MDS assessment within the required 14-day period after completion. The resident, admitted with conditions such as DM, CVA, and anemia, had an MDS assessment indicating total dependence on staff for certain activities. The assessment, dated 10/21/2024, was submitted late on 11/21/2024, as confirmed by the MDSN. This delay resulted in incorrect data transmission to CMS, potentially affecting care continuity.
A facility failed to create a care plan for a resident receiving Seroquel and Duloxetine, despite the resident's clear comprehension and decision-making capacity. Staff interviews and policy reviews confirmed the necessity of such a plan for individualized care, yet it was absent, indicating a lapse in policy adherence.
A resident with severe cognitive impairment and functional limitations was not provided with a necessary wheelchair for mobility, despite repeated requests. The facility failed to assess and provide the equipment upon admission, impacting the resident's ability to participate in activities and potentially affecting their physical and mental well-being. Staff interviews revealed a lack of encouragement for the resident to get out of bed, and the facility lacked a policy for providing necessary equipment.
A resident with hemiplegia, hemiparesis, and epilepsy felt isolated due to the facility's failure to provide activities outside her room. Despite her desire to participate in group activities and go outside, she was primarily offered one-on-one activities in her room. The facility's policy required activities to meet residents' needs and preferences, which was not adequately fulfilled for this resident.
Two residents with limited ROM did not receive appropriate care to prevent further decline. One resident missed timely quarterly assessments, while another did not have a prescribed elbow splint applied on several occasions. These deficiencies could hinder early detection of contractures and lead to further decline in joint mobility.
A resident with a history of GERD, dysphagia, and gastrostomy was observed lying flat during enteral tube feeding, contrary to the facility's policy requiring the head of the bed to be elevated at least 30 degrees to prevent aspiration. An LVN confirmed the oversight, acknowledging the risk of aspiration pneumonia.
A resident with a PICC line for intravenous medication was not properly monitored, as the facility failed to assess the insertion site every shift and change the dressing every seven days. The resident, who had a history of sepsis, diabetes, and hypertension, was dependent on staff for personal care. The Director of Nursing confirmed the oversight, which was against the facility's policy requiring regular monitoring to prevent infection.
A resident experienced unnecessary pain due to the facility's failure to manage their pain in a timely manner. The resident's call light was out of reach, preventing them from requesting prescribed pain relief. Despite the care plan's instructions to keep the call system accessible and respond promptly to pain complaints, these measures were not followed, leading to a delay in addressing the resident's pain.
A resident with glaucoma and cataracts did not receive prescribed eye drops due to a failure in following physician orders. The orders for Latanoprost and Cosopt were faxed but not documented or initiated, despite facility policies on handling telephone orders.
A resident's personal food item, creamy horseradish, was improperly stored at the bedside without refrigeration or labeling, contrary to facility policy. The resident, who was cognitively intact and had a history of GERD, confirmed the item was brought by her sister. Staff interviews revealed a lack of adherence to the policy requiring perishable items to be labeled, dated, and refrigerated, posing a risk of foodborne illness.
A facility failed to document a resident's transfer to a hospital from a dialysis center due to unresponsiveness. The resident, with End Stage Renal Disease and other conditions, was initially stable but later transferred without proper documentation. A nurse admitted to forgetting to document the event, which is against the facility's policy requiring such communications to be recorded.
A resident with Type 2 Diabetes Mellitus, who was cognitively intact, was forcibly administered insulin by an LVN despite refusing the treatment. The resident's blood sugar was high, and the LVN attempted to educate the resident but proceeded without consent, violating the facility's policy on resident rights. The DON confirmed that the resident's right to refuse treatment was not honored.
A CNA in an LTC facility failed to treat four residents with respect and dignity. The CNA was reported to be rude, demanding, and harsh, refusing to stay with a resident during a bowel movement and repositioning another in a hurried manner. The residents had various medical conditions requiring assistance with ADLs, and the facility's policy on resident rights was not followed.
The facility failed to maintain proper sanitation in the kitchen, as the floors were not swept and mopped according to the Cleaning Schedule. Observations revealed food residue and debris in various areas, and interviews with dietary staff confirmed lapses in cleaning practices. The Dietary Supervisor acknowledged that some areas were not cleaned daily, contrary to the facility's policy.
A resident with a history of elopement and multiple medical conditions was not adequately monitored, leading to unsupervised departures from the facility. The care plan lacked specificity in supervision type and monitoring frequency, resulting in the resident's location and behavior not being consistently checked or documented. Staff interviews confirmed the failure to perform required visual checks and update the care plan with necessary interventions.
A facility failed to report an alleged abuse incident to the state agency as required by its abuse prevention policy. A family member reported to an LVN that a CNA raised their hand as if to hit a resident, but no physical contact occurred. The LVN informed an RN, who sent the CNA home, but the incident was not reported to the state agency. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis, was at risk due to this oversight.
A resident with dementia and other conditions experienced a left humerus dislocation, which was considered an injury of unknown source. The facility submitted the initial report to CDPH but failed to provide the final investigation results within the required 5-day period, as confirmed by the DON and ADM. This was against the facility's policies and state and federal regulations.
Three residents in an LTC facility were found with smoking materials, including lighters, in their possession, contrary to the facility's smoking policy. Despite having care plans that required supervision and safe storage of smoking materials, the facility failed to implement these measures, posing significant safety risks. The residents, with varying degrees of cognitive and physical impairments, were able to access and use lighters unsupervised, highlighting a critical oversight in the facility's safety protocols.
The facility failed to report an incident of unwanted physical contact between two cognitively impaired residents to CDPH within the required two-hour timeframe, as per their policy. This delay in reporting, acknowledged by both the DON and Administrator, resulted in a delayed investigation by CDPH.
A resident with a urinary catheter experienced bladder distention and infection due to the facility's failure to document and implement physician orders. The staff did not monitor the resident's urinary output correctly and failed to document signs of a UTI. Additionally, a physician's order to flush the catheter was not documented or executed, leading to the resident's transfer to a hospital for further treatment.
A resident with a right leg cast did not receive proper cast care for five months due to lapses in initial assessment, documentation, and follow-up by the facility staff. The facility failed to adhere to its policies and procedures for cast care, leading to inadequate care for the resident's condition.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Facial Fractures
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the face during an altercation on the smoking patio. The injured resident had intact cognition, capacity to make decisions, and was dependent on staff for ADLs and transfers, using a wheelchair and mechanical lift due to his size and functional status. According to the change of condition evaluation, the resident was involved in an altercation with another resident that resulted in him being hit in the face, causing a nosebleed and a raised area on the forehead. The resident reported that he threw coffee on the other resident after being cursed at and called fat. He was transferred to a GACH for evaluation, where ED documentation noted a nosebleed, a forehead hematoma, pain, headaches, and dizziness, and a CT scan showed an undetermined nasal bone fracture and a left orbital wall medial fracture. The other resident involved in the altercation had intact cognition, capacity to make decisions, and was largely independent with ADLs, using a wheelchair for mobility but able to walk independently. Documentation indicated that this resident and the injured resident were involved in a verbal and physical altercation in which the injured resident threw coffee on the other resident’s face, after which the other resident stood up and hit him in the face. In an interview, the second resident stated he hit the first resident in the nose because coffee had been thrown in his face and that the first resident had blocked the door with his wheelchair and threatened to throw coffee again if called names. The facility’s abuse prevention and prohibition policy stated that each resident had the right to be free from abuse, neglect, and mistreatment and that staff must not permit anyone to engage in verbal, mental, or physical abuse, but the altercation occurred and resulted in physical harm to the first resident.
Failure to Prevent Pressure Ulcers Due to Inadequate Assessment and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to prevent the development of pressure ulcers in a resident who was at high risk due to severe cognitive impairment, hemiparesis, and dependence on staff for mobility and activities of daily living (ADLs). The resident was admitted without any skin breakdown and was identified as being at risk for pressure ulcers through the Braden Scale and Minimum Data Set assessments. Despite this, the care plan did not include specific interventions such as regular turning and repositioning, use of offloading devices, or strategies to address the resident's tendency to reposition himself onto the affected side. The care plan also lacked updates after the resident began exhibiting behaviors that increased his risk, such as removing pillows used for offloading pressure. The facility's staff did not consistently monitor or document the resident's skin condition as required by policy. There were multiple instances of missing documentation in the ADL Skin Observation Logs across all shifts, and shower sheets were not filed in the resident's chart. Staff interviews confirmed that if documentation was missing, it meant the skin was not checked, which could delay the identification of new or worsening wounds. The facility's policy required CNAs to inspect skin during ADL care and for licensed nurses to document the effectiveness of pressure ulcer prevention techniques, but these steps were not reliably followed. As a result of these failures, the resident developed multiple pressure-related injuries, including dark purple discolorations on the heel and foot, deep tissue pressure injuries, and a Stage III pressure ulcer on the hip. The interdisciplinary team did not convene as required to address the resident's skin breakdowns or revise the care plan to include more effective interventions. The lack of timely assessment, documentation, and care plan updates directly contributed to the resident's skin breakdown and the progression of pressure injuries.
Failure to Prevent Severe Weight Loss Due to Incomplete Nutrition Monitoring and Care Plan Implementation
Penalty
Summary
A deficiency occurred when the facility failed to prevent a resident from experiencing unplanned severe weight loss by not implementing multiple aspects of the resident's care plan and not following the registered dietician's (RD) recommendations. The resident, who had a history of hemiplegia, hemiparesis, protein-calorie malnutrition, and dysphagia, was identified as malnourished and at risk for further nutritional decline. The care plan required staff to monitor and document meal intake percentages for each meal and to offer nutritional supplements if intake was below 50%. However, meal intake was not consistently recorded, and there was no documentation that supplements were provided when intake was low. The RD had recommended providing large-portion meals for the resident on two separate occasions, but these recommendations were not reflected in the physician's orders, nor was there evidence that the recommendations were communicated to or implemented by the physician. Additionally, after significant weight loss was identified, there was no documentation that an interdisciplinary team (IDT) meeting was conducted to address the resident's actual weight loss or to update the care plan accordingly. The facility's policy required notification of the physician and dietician for significant weight changes and updating the care plan, but these steps were not documented as completed. As a result of these failures, the resident experienced severe weight loss over a short period, ultimately requiring transfer to an acute care hospital for further intervention, including the placement of a feeding tube. Interviews with facility staff confirmed that meal intake was not consistently documented, supplements were not always offered as required, and RD recommendations were not followed through with physician orders. The Director of Nursing acknowledged that the facility's policies and procedures for managing resident weights and nutritional care were not followed in this case.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. 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 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 Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency was identified based on the absence of documentation or evidence that such a plan was developed and put into place for newly admitted residents, as required. The lack of a timely plan meant that the resident's immediate needs upon admission were not formally assessed or addressed within the specified timeframe.
Lack of Staff Training on Dementia Care and Abuse Reporting
Penalty
Summary
Staff did not receive education on dementia care, nor were they trained on the definitions of abuse, neglect, and exploitation, or the procedures for reporting such incidents. This lack of training and education was identified as a deficiency during the survey.
Failure to Replace E-Kits and Document Controlled Substance Disposal
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the replacement of portable container non-antibiotic medication Emergency-Kits (E-Kits) within the stipulated 48-72 hours. During an observation and interview, it was found that two E-Kits with red zip ties, indicating they had been opened, were not replaced in a timely manner. One E-Kit had been opened since February 25, 2025, and the other since December 23, 2024, yet neither had been replaced. The Licensed Vocational Nurse (LVN) acknowledged the importance of having the E-Kit available for emergencies to prevent delays in treatment. The Director of Nursing (DON) confirmed the lack of documentation or monitoring logs to ensure E-Kits were checked daily, which could lead to delays in care during emergencies. The facility also failed to implement its policy on the disposal of medications and medication-related supplies, specifically regarding the destruction of controlled substances. During an inspection, it was revealed that 24 resident medications were disposed of without the required signature of a licensed nurse witnessing the destruction. The DON admitted to being the only licensed nurse responsible for the destruction process and failed to sign the Controlled Drug Record sheets due to being occupied with other tasks. This oversight left the destruction process undocumented, raising concerns about potential diversion and theft of medications. The facility's policy indicated that controlled substances should be securely locked until destroyed by a DEA representative or by the facility's DON and/or consultant pharmacist. However, the DON's failure to follow this procedure and the absence of a second signature on the destruction forms compromised the integrity of the medication disposal process. The lack of adherence to these policies placed residents at risk of not receiving necessary medications during emergencies and increased the potential for loss or diversion of controlled substances.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Director of Nursing had the facility's Emergency kit (E-Kit) replaced. There were no negative or adverse outcomes noted related to this deficient practice. On 3/6/25, the Director of Nursing (DON) presented the facility's Controlled Drug Record dated 12/12/2024 without the signature of a licensed nurse witnessing the destruction of the medications. Medication was destroyed in the presence of the Pharmacist. There were no negative outcomes as a result of this deficient practice. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/7/25, the Infection Control Preventionist conducted a visual round to ensure all E-kits were not expired. No other residents were affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the past quarter of medication destruction sheets. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Medication Ordering and Receiving from Pharmacy," undated, with emphasis on emergency needs for medication being met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The in-service included nursing calling the pharmacy as soon as possible for replacement of the kit/dose and flagging the kit with a color-coded lock to indicate need for replacement of kit/dose. The in-service also emphasized that if exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening, and if replacing used medications, the replacement doses are added to the kit within 72 hours of opening. On 3/12/25, the facility created an E-Kit monitoring log and in-serviced Nursing Staff, including but not limited to LVNs and RNs, on how and when to complete it. The DON/designee will conduct audits daily for five days weekly for two weeks, then monthly for three months to ensure E-kits are not expired and logs are completed for monitoring. On 3/17/25, the facility's assigned Pharmacist from Star Pharmacy in-serviced the Director of Nursing (DON) and Registered Nurse (RN) on the facility's policy and procedure titled, "Disposal of Medications and Medication-Related Supplies," with emphasis on controlled substances being retained in a securely locked area with restricted access until destroyed by a Drug Enforcement Administration (DEA) representative or by the facility director of nursing and/or consultant pharmacist and/or administrator. The in-service also included ensuring signatures of licensed nurses witnessing the destruction of the medications. The Medical Records Director will conduct an audit on the medication destruction sheets monthly and as needed (PRN) to ensure signatures include the signature of a licensed nurse witnessing the destruction of the medications. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility's E-kits not being expired for three months or until compliance is met. The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance with medication destruction and disposal, ensuring a signature of a licensed nurse witnessing the destruction of the medications, for three months or until compliance is met.
Failure to Adhere to Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to meet professional standards of nursing practice by not properly obtaining accurate orthostatic blood pressure readings for two residents. For Resident 25, the orthostatic blood pressure readings were suspiciously identical on multiple occasions, indicating a potential error in measurement. The Director of Staff Development noted that the readings for both lying and sitting positions were the same on several dates, which is unlikely as there should always be a difference. Similarly, for Resident 1, the orthostatic blood pressure readings were also found to be the same for lying and sitting positions on different dates, and a Licensed Vocational Nurse admitted to not knowing how to properly take these measurements. The facility also failed to ensure that medication was administered to the correct site as ordered by the physician for Resident 96. The resident was supposed to receive Diclofenac Sodium External Gel 1% applied to both knees for pain, but it was instead applied to the right shoulder. The Licensed Vocational Nurse acknowledged the error and admitted to not realizing there was no order for the shoulder application, which could potentially lead to adverse reactions or harm to the resident. Additionally, the facility did not administer Midodrine HCI according to the physician's parameters for Resident 55. The medication was given even when the systolic blood pressure was above the specified limit, and the 10:00 p.m. dose was administered despite instructions not to give it after the evening meal or less than 3-4 hours before bed. The Director of Nursing confirmed that the medication should have been held when the blood pressure was above the limit and that the 10:00 p.m. dose should not have been given, as it could cause potential harm to the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, License Vocational Nurse (LVN) 4 received one-on-one in-servicing with return demonstration by the Director of Nursing and Director of Staff Development to ensure she understood the definition of orthostatic hypotension and how to perform orthostatic hypotension monitoring. On 3/17/24, Resident 55 started Midodrine HCI 5 mg, give 5 milligrams (mg) orally every 8 hours for hypotension; hold if systolic (top number in a blood pressure reading) blood pressure (SBP) is greater than 110, not to be taken after the evening meal or less than 3-4 hours before bed. Resident 55 was noted to have received medication Midodrine HCI 5 mg outside of parameters. No adverse or negative outcome was noted for Resident 55 as a result of this deficient practice. On 3/10/25, Licensed Vocational Nurse (LVN) 4 received an on-one-one in-service on administering medication per physician order. There were no negative or adverse outcomes for Resident 96 as a result of this deficient practice. On 3/14/25, LVN 4 received an order from Resident 96's Primary Physician for pain medication (Diclofenac Sodium External Gel 1%) to be administered to the left shoulder. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Record Director conducted an audit on residents receiving orthostatic hypotension monitoring to ensure orthostatic hypotension monitoring was being recorded accurately. There was 1 other resident affected by this deficient practice. The residents affected by this deficient practice experienced no negative outcome. On 3/10/25, the Director of Nursing conducted interviews on residents who have topical pain medication orders to ensure residents are receiving topical pain medication as ordered. No other residents were affected by this deficient practice. On 3/24/25, the Medical Records Director conducted an audit on residents with blood pressure medication orders to ensure medication is being administered within parameters ordered by the physician. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/19/25, the Director of Nursing and Director of Staff Development in-serviced Nursing Staff including, but not limited to LVNs and Registered Nurses on the facility's policy and procedure titled, "Blood Pressure, Measuring" with emphasis on orthostatic hypotension being defined as 20 millimeters of mercury (mmHg) decline in systolic blood pressure (the contraction phase of the heart) or a 10 mmHg decline in diastolic blood pressure (relaxing phase of the heart) upon standing and to measure orthostatic hypotension, note the changes in both the systolic and diastolic blood pressure in the standing position compared to the sitting position. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter for 3 months to ensure residents' orthostatic hypotension monitoring is being recorded accurately. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on testing and taking of vital signs, upon which administration of medications or treatments are conditioned, performing required tests, and recording results. The in-service also included when administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record. The in-service emphasized reviewing the resident's MAR for allergies and/or special considerations for administration, including vital sign parameters and lab results as appropriate. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with blood pressure medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on providing professional standards of practice for safe administration of medications for residents in the facility, including following information about any medication they are administering, the drug's route of administration, the drug's indication for use, and desired outcome. The in-service also emphasized the seven "rights" of medication when administering medication: right medication, right amount, right resident, right time, right route, right indication, and right outcome, and the "rule of 3" (performing 3 checks): comparing the physician's order, pharmacy label, and medication administration record (MAR). On 3/31/25, the Director of Nursing/ designee revised orders for residents with pain medication being administered topically to include documentation requirements for where the licensed nurse administered the medication to ensure medication is being administered to the site as ordered. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with topical pain medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orthostatic hypotension monitoring being monitored accurately, following parameters for administering medication for residents with blood pressure medication orders, and medication administration related to pain medication being administered to the correct site as ordered for three months or until compliance is met.
Deficiencies in Staff Competency and Orthostatic Hypotension Procedures
Penalty
Summary
The facility failed to complete initial and annual skills competencies for four Restorative Nursing Aides (RNAs), which are crucial for maintaining residents' mobility and preventing contractures. During interviews and record reviews, it was revealed that the Director of Staff Development (DSD) acknowledged the absence of these competencies in the employee files of the RNAs. The DSD emphasized the importance of these competencies in ensuring that RNA staff are up-to-date with their skills and can perform their tasks correctly. The Director of Rehabilitation confirmed that no initial or annual skills competencies were completed for the RNA staff, and the Director of Nursing (DON) reiterated the necessity of these competencies for the proper execution of the RNA program. The facility also failed to ensure that a Licensed Vocational Nurse (LVN) understood the purpose and procedure for checking orthostatic hypotension. During interviews, the LVN admitted to not knowing how to take orthostatic blood pressures and not seeking guidance. The DON explained that accurate orthostatic blood pressure readings are essential for managing medication and treatment plans. The facility's policy on measuring blood pressure indicated specific criteria for identifying orthostatic hypotension, which the LVN did not follow. Another LVN also demonstrated a lack of understanding regarding the procedure for obtaining orthostatic blood pressure readings. The LVN incorrectly described the process and purpose of these readings, which was confirmed by the DSD as inaccurate. The facility's policy outlined the correct method for measuring orthostatic hypotension, which involves noting changes in blood pressure from sitting to standing positions. The LVN's failure to follow this procedure resulted in inaccurate documentation of blood pressure readings, as evidenced by identical readings recorded on multiple occasions.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/11/25, the Director of Rehabilitation (DOR) conducted annual competencies for the facility's Restorative Nursing Assistants (RNAs). On 3/10/25, License Vocational Nurse (LVN) 4 and LVN 2 received one-on-one in-servicing with return demonstration by the Director of Staff Development to ensure they understood the definition of orthostatic hypotension and how to perform orthostatic hypotension monitoring. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/17/25, the Director of Staff Development (DSD) conducted an audit on the facility's Restorative Nursing Assistant (RNA) employee files to ensure all Restorative Nursing Assistants had competencies completed. No other residents were affected by this deficient practice. On 3/19/25, the Medical Record Director conducted an audit on residents receiving orthostatic hypotension monitoring to ensure orthostatic hypotension monitoring was being recorded accurately. There was 1 other resident affected by this deficient practice. The resident affected by this deficient practice experienced no negative outcome. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the Director of Nursing and Director of Staff Development in-serviced the DOR, Physical Therapist, Occupational Therapist, and Speech Therapist on the facility's policy and procedure titled, "Restorative Nursing Program Guidelines," with emphasis on nursing aides being trained in the techniques that promote resident involvement in the activity. The in-service included completing initial and annual competencies and any training needed when areas of improvement are identified. The Administrator will conduct audits on new hires, RNAs, and current employees who receive new certifications for Restorative Nursing Assistant employee files, to ensure employees have initial competencies as needed. The DSD will conduct audits to ensure RNAs receive their annual competencies when due. On 3/19/25, the Director of Nursing and Director of Staff Development in-serviced Nursing Staff including, but not limited to LVNs and Registered Nurses, on the facility's policy and procedure titled, "Blood Pressure, Measuring," with emphasis on orthostatic hypotension being defined as a 20 millimeters of mercury (mmHg) decline in systolic blood pressure (the contraction phase of the heart) or a 10 mmHg decline in diastolic blood pressure (relaxing phase of the heart) upon standing and to measure orthostatic hypotension, noting the changes in both the systolic and diastolic blood pressure in the standing position compared to the sitting position. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' orthostatic hypotension monitoring is being recorded accurately. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Staff Development will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for RNAs' initial and annual competencies being completed, for three months or until compliance is met. The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orthostatic hypotension monitoring being monitored accurately, for three months or until compliance is met. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' orthostatic hypotension monitoring is being recorded accurately.
Improper Storage of Insulin and Contaminated Medication Container
Penalty
Summary
The facility failed to properly store medications, specifically insulin, as per the manufacturer's guidelines. During an observation, an unopened Lantus insulin pen, an unopened insulin vial, and an insulin pen of Glargine YFGN were found stored in a medication cart instead of being refrigerated. The Licensed Vocational Nurse (LVN) acknowledged that all insulin should be refrigerated until opened. The Director of Nursing (DON) confirmed that storing unopened insulin outside the refrigerator could decrease its potency and effectiveness, potentially leading to uncontrolled blood sugar levels in residents. The facility's policy indicated that medications requiring refrigeration should be kept in a refrigerator with a thermometer for temperature monitoring. Additionally, a multi-dose medication container of Clear Lax was found soiled and unclean in the medication cart. The LVN identified this as an infection control issue, stating that the medication bottle should always be clean to prevent contamination. The Registered Nurse (RN) and the DON both emphasized the importance of keeping medication containers clean to avoid bacterial contamination, which could make residents sick. The facility's policy stated that contaminated or soiled medication containers should be immediately removed from stock and disposed of according to procedures.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/6/25, Licensed Vocational Nurse (LVN) 4 removed the unopened insulin from the cart. On 3/6/25, LVN 4 re-ordered the insulin. On 3/6/25, LVN 4 removed and discarded the multi-dose bottle of clear lax from the medication cart. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/6/25, the Director of Staff Development (DSD) made visual rounds on the facility’s medication carts to ensure no other unopened insulin was being stored on the cart. No other residents were affected by this deficient practice. On 3/6/25, the DSD conducted visual rounds on the licensed nurse medication carts to ensure multi-dose medications were clean and free from any particles. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications." On 3/6/25, LVN 4 removed and discarded the multi-dose bottle of clear lax from the medication cart. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/6/25, the DSD made visual rounds on the facility’s medication carts to ensure no other unopened insulin was being stored on the cart. No other residents were affected by this deficient practice. On 3/6/25, the DSD conducted visual rounds on the licensed nurse medication carts to ensure multi-dose medications were clean and free from any particles. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications," with emphasis on medications and biologicals being stored safely, securely, and properly, following manufacturer’s recommendations or those of the suppliers. This includes medications requiring "refrigeration" or "temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit" being kept in a refrigerator with a thermometer to allow temperature monitoring. The Director of Nursing (DON)/designee will conduct rounds on the facility’s medication carts daily for five days weekly for two weeks and monthly thereafter to ensure an unopened insulin is not being stored in the medication cart. On 3/12/25, the DON conducted an in-serviced nursing staff, including but not limited to LVNs and RNs, on the facility’s policy and procedure titled, "Medication Storage in the Facility; Storage of Medications," with emphasis on outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures. These should be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy. The Director of Nursing/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure multi-dose medications are clean and free from particles. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for proper storage of insulin and multi-dose medication being clean and free from particles for three months or until compliance is met.
Failure to Implement Laboratory Orders for Residents
Penalty
Summary
The facility failed to implement laboratory orders for three residents, leading to delays in care and potential health risks. Resident 25, who was admitted with acute kidney failure, anemia, severe obesity, and Type 2 diabetes, did not have a complete blood count (CBC), complete metabolic panel (CMP), and Hemoglobin A1C (Hgb A1C) drawn as ordered every three months. This oversight was confirmed during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN), who acknowledged that the tests were not conducted in February, preventing the physician from identifying any potential issues with the resident's blood work. Similarly, Resident 42, who was admitted with Vitamin D deficiency, hyperlipidemia, and gastro-esophageal reflux disease, did not have a CMP conducted in September and December as ordered. The resident's care plan emphasized the importance of obtaining and monitoring laboratory work to prevent poor food intake, weight loss, and dehydration. During an interview, the LVN confirmed that the CMP was not done, which could have prevented the doctor from detecting any abnormal results. Resident 100, diagnosed with respiratory failure, epilepsy, and polycystic kidney disease, was supposed to have monthly Keppra level blood draws to monitor therapeutic levels and prevent seizures. However, the last recorded draw was in November, with subsequent months missed. A Registered Nurse (RN) confirmed the oversight, acknowledging that the lack of blood draws could worsen the resident's epilepsy disorder. The facility's policy and procedure indicated the responsibility for ensuring timely laboratory services, which was not adhered to in these cases.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 25 and Resident 42 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. On 3/12/25, Resident 100 labs were drawn. The Primary Physician was made aware of the results with no new orders noted. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/13/25, the Medical Records Director conducted an audit on active resident lab orders to ensure all residents are receiving their labs as ordered, unless otherwise refused. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/26/25, the Director of Nursing (DON) in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Laboratory, Diagnostic and Radiology Services," with emphasis on laboratory, diagnostic, and radiology services being provided to meet resident needs and the facility being responsible for the quality and timeliness of services provided by the laboratory. The in-service also included that laboratory services ordered are documented on the 24-hour report or electronic health record, to ensure that services are coordinated, and results are received, with notification of results to the Primary Physician including any refusals. The Medical Records Director will audit residents' lab orders daily for five days weekly for two weeks and monthly thereafter to ensure residents are receiving lab draws as ordered, unless otherwise noted by a refusal. There were 2 residents affected by this deficient practice. On 3/15/25, the Director of Nursing/designee re-ordered the missing labs for those affected residents. There were no negative or adverse outcomes to this deficient practice. The measures to prevent recurrence include the same in-service training and ongoing audits as described above. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for providing laboratory services as ordered for three months or until compliance is met.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage practices in the kitchen, as observed during a survey. Specifically, three bags of dry cereal were found with plastic wrap tied loosely around them, leaving the bags open and susceptible to pest entry and contamination. Additionally, an opened gallon of pancake mix and waffle syrup were observed without labels indicating the date they were opened. During an interview, the Dietary Aide acknowledged that the improperly tied cereal bags could allow pests to contaminate the food and that the pancake mix and syrup should have been labeled with the opened date to prevent serving expired products to residents. The Dietary Service Supervisor confirmed that the facility's policy required opened products to be stored in containers with tight-fitting lids and labeled with the date of opening.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, the Dietary Manager discarded the three bags of dry cereal that were loosely tied with plastic wrap, the open gallon of pancake mix, and the open gallon of waffle syrup that did not have a label indicating the date it was opened. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, the Administrator conducted visual rounds throughout the facility's kitchen to ensure that all items that were opened were properly stored in containers with tight fitted lids or sealed tightly, and labeled with open dates. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the Dietary Manager in-serviced Dietary Staff, including but not limited to, dietary cooks and aids, on the facility's policy and procedure titled, "Food Storage" with emphasis on opened products being placed in storage containers with tight fitting lids and storage products being labeled and dated. The Administrator will conduct rounds in the facility's kitchen daily for five days, weekly for two weeks, and monthly thereafter to ensure products are being properly stored in tight, fitted containers or sealed tightly and labeled and dated. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for food storage, including being properly labeled and dated for three months or until compliance is met.
Facility Lacks Contingency Plan in Assessment
Penalty
Summary
The facility failed to ensure a contingency plan was developed and included in the Facility Assessment, which is necessary for identifying the resources needed to provide care and services during both regular operations and emergencies. During an interview and record review, the Administrator acknowledged that the Facility's Assessment was incomplete and did not include a contingency plan addressing staffing needs during emergencies that could affect resident care. The Administrator noted that the Facility Assessment should provide an overview of the resident population and reflect the services provided by the facility, including identifying risks and ensuring the facility can operate fully without delay during unforeseeable events. The facility's undated policy and procedure titled 'Facility Assessment' indicated that the assessment should inform contingency planning for events that do not require activation of the facility's emergency plan but could still impact resident care, such as the availability of direct care nurse staffing. Additionally, a review of CMS guidance clarified that facilities must conduct and document a facility-wide assessment to determine necessary resources for competent resident care during both day-to-day operations and emergencies. The lack of a contingency plan in the Facility Assessment had the potential to hinder the facility's ability to respond effectively during unexpected circumstances, potentially impacting resident care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/12/25, the Administrator held a meeting that included the Medical Director, the Director of Nursing, Social Services Director, Activities Director, a Registered Nurse Supervisor, a License Vocational Nurse, two Certified Nursing Assistants to revise the facility's facility assessment to include a contingency plan. The contingency plan included having a pool of on-call staff to assist in providing additional staff needed in a case of events that does not require the facility to activate its emergency plan. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/14/25, the Administrator reviewed the facility's reported incidents to identify any events that required the facility to activate its facility assessment related to the contingency plan. There were no facility reported incidents that required an activation of the facility assessment's contingency plan. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing and Director of Staff Development in-serviced the Administrator on the facility's policy and procedure titled, "Facility Assessment," with emphasis on the facility using the Facility Assessment to inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to the availability of direct care nurse staffing or other resources needed for resident care. The in-service also included the "Revised Guidance for Long-Term Care Facility Assessment Requirements" with emphasis on conducting and documenting a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations including nights and weekends and emergencies. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility assessment having a contingency plan for three months or until compliance is met.
Lack of QAPI Documentation for Repeat Deficiencies
Penalty
Summary
The facility failed to provide meeting minutes or evidence of Quality Assurance and Performance Improvement (QAPI) program efforts to address three repeat deficiencies in Resident Rights, Laboratory Services, and Pharmacy Services. These deficiencies were previously identified during a recertification survey conducted by the California Department of Public Health (CDPH) in 2024. During an interview, the Administrator acknowledged the absence of documentation and emphasized the importance of discussing and developing a QAPI program to address these deficiencies. The lack of documentation indicated that the facility did not effectively investigate, analyze, or implement corrective actions to improve performance in these areas. A review of the facility's undated policy and procedure (P&P) titled QAPI Plan revealed that the QAPI Steering committee is responsible for analyzing performance and identifying areas for improvement. The P&P also stated that meeting minutes should be recorded and shared with the QAPI Steering committee, executive leadership, and staff. However, the facility did not adhere to these guidelines, as evidenced by the absence of meeting minutes or any documentation of QAPI activities related to the identified deficiencies. This lack of documentation and follow-up placed residents at risk for harm if the areas identified were not adequately addressed.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/24/25, the Quality Assurance (QA) Nurse reviewed the facility's "Statement of Deficiencies (SOD)," dated 3/8/2024, related to Resident Rights, Laboratory Services, and Pharmacy Services. On 3/24/25, the QA Nurse developed a Quality Assurance and Performance Improvement (QAPI) plan for the current deficiencies. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the facility's Statement of Deficiencies, dated 3/8/24, to ensure each deficient practice noted had a QAPI developed with a root cause, interventions, goals, and how the facility would monitor and audit the program. There was 1 deficiency without a developed QAPI plan. On 3/24/25, the Administrator and QA Nurse developed a QAPI from the facility's previous deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Administrator in-serviced the QA Nurse on the facility's policy and procedure, titled "QAPI Plan," with emphasis on the QAPI Steering committee analyzing performance to identify and follow up on areas of opportunity, with meeting minutes being recorded and shared with the QAPI Steering committee, executive leadership, and staff. The in-service emphasized the facility continually identifying opportunities for improvement and using the criteria to prioritize opportunities such as aspects of care affecting large numbers of residents, regulatory requirements, SOD from complaint visits, and surveys. The in-service also included ensuring the facility's QAPI plans include a root cause, interventions, goals, and how the facility would monitor and audit the program. The Administrator will conduct monthly and as-needed (PRN) audits on the facility's QAPI plans to ensure facility-identified problems or deficient practices on a Statement of Deficiencies are QAPI and maintained. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility developing a Quality Assurance and Performance Improvement plan for deficient practices for three months or until compliance is met.
Improper Storage of Wheelchairs and Geriatric Chair
Penalty
Summary
The facility failed to ensure that five wheelchairs and one geriatric chair were stored properly, as they were found outside under the rain. This practice had the potential to damage the medical equipment and prevent their safe use for residents. During an interview, the Director of Rehabilitation (DOR) mentioned difficulties in maintaining and keeping track of wheelchairs, as they often get lost. The DOR also noted that a wheelchair prepared for a resident was stored outside in the rain, rendering it unusable for the day due to its wet condition. The resident required a custom wheelchair, and no alternative was available. Further observations revealed that four wheelchairs and one geriatric chair were left in an outdoor area exposed to the elements. The Maintenance Supervisor acknowledged that the covered shed was full and primarily used for activity equipment, leaving no covered storage space for the medical equipment. The Director of Nursing confirmed that wheelchairs and other medical equipment should not be stored outside in uncovered areas. Additionally, the Medical Records Supervisor stated that the facility lacked a policy regarding the storage of medical equipment.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25 the Maintenance Director and Maintenance Assistant removed all wheelchairs and geriatric chairs from the patio. On 3/5/25, the facility began storing all wheelchairs and geriatric chairs inside the facility in the newly designated area. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the Administrator and Maintenance Director made visual rounds on the outdoor areas of the facility to ensure medical equipment is not being stored in uncovered areas. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/27/25, The Director of Staff Development in-serviced Vocational Nurses (LVN), and Certified Nursing Assistants (CNA), along with the Maintenance Department and Housekeeping Department were in-serviced on having and maintaining proper covered storage for resident equipment. The Maintenance Director/designee will conduct rounds on the facility outside areas daily for 5 days weekly for 2 weeks and monthly thereafter to ensure resident equipment is not being stored in non-covered areas. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for proper storage of resident equipment for three months or until compliance is met.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was informed in advance of the risks and benefits of psychoactive medication. This deficiency was identified for one resident who was receiving Seroquel and Duloxetine HCI. The resident, who had a history of diabetes mellitus, chronic kidney disease, and bipolar disorder, was assessed to have the capacity to understand and make decisions. Despite this, there was no informed consent documented in the resident's chart for the administration of these medications. Interviews with facility staff, including a registered nurse, the assistant director of nursing, and the director of nursing, confirmed that informed consent should have been obtained and documented before administering the medications. The facility's policies and procedures also required informed consent to be documented in the resident's medical record. The absence of informed consent documentation meant that the resident might have been administered medication without being fully informed or having the opportunity to decline it.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Minimum Data Set Nurse (MDSN) Assistant clarified Resident 46 psychotropic medication and received informed consent from Resident 46 to administer Seroquel and Duloxetine psychotropic medication. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/11/25, the Medical Records Director conducted an audit on all active residents' psychotropic medications to ensure psychotropic informed consents were completed. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to License Vocational Nurses and Registered Nurses, on the facility's policy and procedure titled, "Informed Consent," with emphasis on ensuring the facility respects the resident's right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. The in-service also included ensuring the informed consent/notice be documented, and placed in the resident's medical record for verification that consent/notice was given. On 3/10/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to License Vocational Nurses and Registered Nurses, on the facility's policy and procedure titled, "Psychotherapeutic Drug Management," with emphasis on obtaining consent for use of psychotherapeutic drugs, informing the resident of the risks and benefits for the use of these medications, and ensuring the consent remains in place until medication is discontinued or until consent is revoked by the resident/responsible party. The Medical Records Director will conduct audits on psychotropic consent forms daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents have received informed consent prior to the administration of psychotropic medication. How the facility plans to monitor its performance to make sure that solutions are maintained: The Social Service Director will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for receiving informed consent prior to the administration of psychotropic medication for three months or until compliance is met.
Resident Excluded from Care Planning Meetings
Penalty
Summary
The facility failed to ensure that Resident 275 participated in care planning meetings, which is a violation of the resident's rights. Resident 275, who has a medical history of chronic obstructive pulmonary disease, hypertension, and congestive heart failure, was admitted to the facility and was capable of understanding and making medical decisions. Despite this, the resident was not invited to attend care plan meetings, as confirmed by both the resident and the Director of Nursing (DON). The DON acknowledged that it was the responsibility of the nursing or social service staff to notify and invite the resident to these meetings. The facility's policy and procedure on care planning, dated 10/24/2022, states that residents should be invited to care planning meetings if they are capable, and efforts should be made to schedule these meetings at convenient times for the resident and their family. Additionally, the facility's policy on resident rights, dated 5/1/2023, emphasizes the resident's right to be fully informed and participate in their treatment. The failure to include Resident 275 in the care planning process was identified as a deficiency by the surveyors.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/11/25, the Interdisciplinary Team (IDT) met with Resident 275 and conducted a care conference meeting. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/20/25, the Medical Records Director conducted an audit on all new admissions and re-admissions within the last 30 days to ensure residents had attended their baseline care conference meeting. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development in-serviced the Interdisciplinary Team (IDT), including but not limited to Minimum Data Set Nurse and Assistant, Social Services Director and Assistant, Director of Rehabilitation (DOR), Activities Director, and Dietary Manager on the facility's policy and procedure titled, "Care Planning" with emphasis on inviting the resident, if capable, and their family to the care planning meetings and scheduling the care planning meetings at the time of convenience for the resident and family. On 3/18/25, the Director of Nursing and Director of Staff Development in-serviced the IDT, including but not limited to Minimum Data Set Nurse and Assistant, Social Services Director and Assistant, DOR, Activities Director, and Dietary Manager on the facility's policy and procedure titled, "Resident's Rights" with emphasis on the resident having the right to be fully informed and participate in their treatment in a language that they can understand. The Medical Records Director will conduct an audit daily for 5 days, weekly for 2 weeks, and monthly thereafter on all new admissions and re-admissions to ensure baseline care plans are scheduled and the resident and/or resident representative are included in the development of the care plan. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for residents' rights to attend and participate in care plan meetings for three months or until compliance is met.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a critical component for residents to communicate their needs to the nursing staff. Resident 36, who was admitted with chronic obstructive pulmonary disease, hemiplegia, and muscle weakness, was observed with the call light on the floor behind the bed, out of reach. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the protocol to keep the call light within reach to prevent falls and ensure timely assistance. The Registered Nurse (RN) also confirmed that the call light should be near the resident to avoid delays in service and care. Similarly, Resident 224, who had difficulty walking, muscle weakness, asthma, and congestive heart failure, was found with the call light device behind the bed on the floor, not within reach. The CNA and Licensed Vocational Nurse (LVN) both stated that the call light should be accessible to the resident for safety and to alert staff in emergencies. The Director of Nursing (DON) reiterated the importance of having the call light within reach to meet the resident's needs promptly. The facility's policy and procedure on the call system also indicated that call cords should be placed within the resident's reach to enable prompt communication with nursing staff.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, Certified Nursing Assistant (CNA) 3 removed the call light from the floor and placed it within reach of resident 36. On 3/4/25, Certified Nursing Assistant (CNA) 5 removed the call light from behind resident 224's bed and placed it within reach of resident 224. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, Department Managers, including but not limited to the Administrator, Director of Nursing, Director of Staff Development (DSD), Social Services Director, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set (MDS) Coordinator and Assistant, and Quality Assurance (QA) Nurse conducted visual rounds to ensure no other resident call light was not within reach. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Nursing and Director of Staff Development in-serviced facility staff, including but not limited to Certified Nursing Assistants, Licensed Vocational Nurses, and Registered Nurses, and Department Managers on the facility's policy and procedure titled "Communication-Call System" with emphasis on the facility providing a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities and promptly communicate their needs. The in-service also included placing the call cords within the residents' reach. Department Managers, including but not limited to the DSD, Social Services Director and Assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, MDS Coordinator and Assistant, and QA Nurse, will conduct room rounds daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents' call lights are in reach. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, Department Managers, including but not limited to the Administrator, Director of Nursing, Director of Staff Development (DSD), Social Services Director, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set (MDS) Coordinator and Assistant, and Quality Assurance (QA) Nurse conducted visual rounds to ensure no other resident call light was not within reach. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Nursing and Director of Staff Development in-serviced facility staff, including but not limited to Certified Nursing Assistants, Licensed Vocational Nurses, and Registered Nurses, and Department Managers on the facility's policy and procedure titled "Communication-Call System" with emphasis on the facility providing a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities and promptly communicate their needs. The in-service also included placing the call cords within the residents' reach. Department Managers, including but not limited to the DSD, Social Services Director and Assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, MDS Coordinator and Assistant, and QA Nurse, will conduct room rounds daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents' call lights are in reach. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager room rounds and will report to the Quality Assurance and Improvement Committee during its monthly meeting the status of the compliance for call lights being in reach for three months or until compliance is met.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's preference for a shower, which was a violation of the resident's right to self-determination. Resident 273, who was admitted with conditions including urinary retention, dysphagia, and a urinary tract infection, expressed a desire for showers instead of bed baths. Despite having the cognitive ability to make decisions and requiring only moderate assistance with personal hygiene, the resident's request for showers was not fulfilled. The facility's shower schedule indicated that the resident was to receive showers on Mondays and Thursdays, but the resident reported not having received a shower since admission. Interviews with staff revealed that there was no valid reason for denying the resident's request for a shower. A CNA confirmed that the resident had approval from the Physical Therapist to have showers, and the Director of Rehab stated that the resident required minimal assistance with transfers and was capable of standing and walking. The facility's policy stated that residents should be offered showers at least once a week and according to their requests, and the resident rights policy emphasized the importance of honoring residents' choices regarding personal care. The failure to provide the requested showers had the potential to affect the resident's psychosocial well-being, as noted by the Director of Staff Development.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25 Resident 273 was given a shower by assigned CNA. Social Services Director followed up with resident 273 in regards to receiving a shower. Resident 273 expressed no further adverse reaction or negative outcome from not receiving a shower. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25 Social Services Director and Social Services Assistant conducted resident interviews to ensure residents are receiving a shower. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25 the Director of Staff Development (DSD) in-serviced Nursing Staff, including but not limited to License Vocational Nurse, Registered Nurses, Certified Nursing Assistants (CNA), and Restorative Nursing Assistants (RNA) on the facilities policy and procedure titled, "Showering a Resident" with emphasis on ensuring residents are offered a shower at a minimum of once weekly and given per resident request. On 3/11/25, the DSD in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Resident Rights," with emphasis on residents being allowed to choose activities, schedules and health care that are consistent with their interest, assessments and plan of care including personal care needs such as bathing methods and grooming styles. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25 Social Services Director and Social Services Assistant conducted resident interviews to ensure residents are receiving a shower. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25 the Director of Staff Development (DSD) in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Showering a Resident" with emphasis on ensuring residents are offered a shower at a minimum of once weekly and given per resident request. On 3/11/25, the DSD in-serviced Nursing Staff, including but not limited to LVNs, RNs, CNAs, and RNAs on the facilities policy and procedure titled, "Resident Rights," with emphasis on residents being allowed to choose activities, schedules and health care that are consistent with their interest, assessments and plan of care including personal care needs such as bathing methods and grooming styles. Department Managers will conduct rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents are receiving a shower as scheduled. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager rounds and will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for showers given to residents for three months or until compliance is met.
Failure to Timely Provide NOMNC Form
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form to the representative of a resident, identified as Resident 32, within the required timeframe. Resident 32 was admitted with diagnoses including unspecified dementia, cerebrovascular accident, and dysphagia. The Minimum Data Set (MDS) assessment indicated that Resident 32 had moderately impaired cognitive skills and required assistance with daily activities. The Business Office Manager (BOM) acknowledged that the NOMNC form was given to the resident's representative only one day before the end of Medicare Part A skilled services, instead of the required 48 to 72 hours prior. The facility's policy, titled Medicare Denial Process, mandates that the NOMNC form be delivered at least two calendar days before the end of Medicare-covered services. However, the BOM admitted that the form was provided late, which deprived the resident's representative of the opportunity to appeal the decision regarding financial coverage for continued skilled care services. This oversight had the potential to result in the resident unknowingly incurring expenses for non-covered care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25 the Business Office Manager (BOM) contacted the responsible party for Resident 52 and issued the Notice of Medicare Non-Coverage (NOMNC) with the correct dates of the last covered day and first non-covered day for Resident 52. Resident 52's responsible party verbalized understanding and did not have any further questions or concerns at that time. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/10/25 the Administrator conducted an audit of active residents who received a NOMNC within the last six months. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25 the Administrator in-serviced the Business Office Manager on the facility's policy and procedure titled, "Medicare Denial Process," with emphasis on delivering the NOMNC at least two calendar days before Medicare covered services end or the second to last day of services if care is not being provided daily as referenced in the NOMNC instructions (CMS-10123). The Administrator will conduct audits on residents who are receiving NOMNCs daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure that NOMNCs are being provided at least two calendar days before Medicare coverage services end or the second to last day of services if care is not being provided daily. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for NOMNC given to residents for three months or until compliance is met.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for a resident within the required 14-day period after the assessment was completed. The resident, who was admitted with diagnoses including diabetes mellitus, cerebrovascular accident, and anemia, had an MDS assessment dated 10/21/2024. This assessment indicated that the resident was independent in cognitive skills for daily decision-making but totally dependent on staff for eating, oral hygiene, and personal hygiene. However, the MDS was not submitted to the Centers for Medicare and Medicaid Services (CMS) until 11/21/2024, which was beyond the 14-day submission requirement. During an interview and record review, the Minimum Data Set Nurse (MDSN) confirmed that the MDS assessment was submitted late and acknowledged the importance of timely submission to comply with regulations. The facility's policy, dated 1/2018, mandates that resident assessments be conducted and submitted in accordance with federal and state timeframes. The delay in submission resulted in incorrect data being transmitted to CMS, potentially affecting the continuity of care for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, the Minimum Data Set Nurse (MDSN) reviewed Resident 93's Minimum Data Set (MDS) assessment, dated 10/21/2024. MDSN noted Resident 93's MDS Assessment Reference date was 10/21/2024 and had been submitted late to the CMS on 11/21/2024. There were no negative outcomes related to this deficient practice for Resident 93, who discharged home on 11/7/24. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the past quarter's MDS submissions. There were 2 residents affected by this deficient practice. There were no negative outcomes noted for residents affected. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the facility Consultant and Administrator in-serviced the Director of Nursing, MDSN, and MDSN Assistant on the facility's policy and procedure titled, "MDS Completion and Submission Timeframes," with emphasis on the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes, including but not limited to submitting MDS assessments within 14 days after the completion to the Centers of Medicare and Medicaid Services (CMS). The Medical Records Director will conduct an audit on MDS assessments daily for five days weekly for two weeks and monthly thereafter to ensure MDS assessments were transmitted to CMS within 14 days after completion. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for submitting MDS assessments to CMS within 14 days after completion for three months or until compliance is met.
Failure to Develop Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement a care plan for a resident receiving Seroquel and Duloxetine, which are psychotropic medications. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted to the facility with diagnoses including diabetes mellitus, chronic kidney disease, and bipolar disorder, was assessed to have clear comprehension and the capacity to make decisions. Despite this, there was no care plan in place for the administration of these medications, as confirmed by a registered nurse during a record review. Interviews with the Minimum Data Set Nurse and the Director of Nursing revealed that care plans are essential for providing individualized care and ensuring that residents' needs are met. The facility's policy and procedure documents also indicated that a comprehensive, person-centered care plan should be developed for each resident, including those receiving psychotropic medications. The absence of a care plan for the resident's psychotropic medication use was acknowledged by the staff, highlighting a lapse in the facility's adherence to its own policies and procedures.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Minimum Data Set Nurse (MDSN) Assistant care planned the psychotropic medication, Seroquel and Duloxtine, for Resident 46. The care plan included the use of the psychotropic medication being a risk, the goal that Resident 46 will remain free of psychotropic drug-related complications, and the interventions including, but not limited to, providing a safe and calm environment, monitoring for side effects of the use of psychotropics, and encouraging activities of preference. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/11/25, the Medical Records Director conducted an audit on care plans for psychotropic medications, including, but not limited to, Seroquel and Duloxetine. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced Licensed Nurses, including but not limited to Licensed Vocational Nurses, including MDSN Supervisor and Assistant, and Registered Nurses on the facility's policy and procedure titled, "Care Planning," with emphasis on a comprehensive person-centered care plan being developed for each resident based on their individual assessed needs, which includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. On 3/10/25, the Director of Nursing in-serviced Licensed Nurses, including but not limited to Licensed Vocational Nurses, including MDSN Supervisor and Assistant, and Registered Nurses on the facility's policy and procedure titled, "Psychotherapeutic Drug Management," with emphasis on nursing responsibility to implement and update the care plan as indicated. The in-service also included not administering psychotherapeutic medication until an informed consent has been obtained and documented by the Attending Physician/LHP (Licensed Healthcare Professional) from the resident and/or surrogate decision maker. The Medical Records Director will conduct an audit daily for 5 days, weekly for 2 weeks, and monthly thereafter on psychotropic medication being care planned. How the facility plans to monitor its performance to make sure that solutions are maintained: The Social Services Director will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for care planning psychotropic medication use for three months or until compliance is met.
Failure to Provide Necessary Equipment for Resident Mobility
Penalty
Summary
The facility failed to provide a resident, identified as Resident 104, with the necessary care and services to perform activities of daily living, specifically by not providing an appropriate wheelchair for transfers and out-of-bed activities. Resident 104 was readmitted to the facility with diagnoses including muscle weakness and lack of coordination. Despite having the capacity to understand and make decisions, the resident was noted to have severe cognitive impairment and functional limitations in both upper and lower extremities, requiring dependent assistance for bed-to-chair transfers. The care plan for Resident 104 indicated a need for necessary equipment to improve functional abilities, yet no wheelchair was provided. Observations and interviews revealed that Resident 104 had been asking for a wheelchair since admission but had not received one, preventing participation in activities and going outside. The Director of Rehabilitation acknowledged the importance of providing proper equipment like a wheelchair to prevent muscle atrophy and promote environmental stimulation. However, the process of assessing and providing a wheelchair was delayed, with the Director admitting that the facility should have initiated this process upon the resident's admission. Further interviews with staff, including a CNA and LVN, highlighted a lack of encouragement for the resident to get out of bed, which is crucial for preventing health issues such as pneumonia. The Director of Nursing emphasized the importance of residents getting out of bed for mental and physical health benefits. It was also noted that the facility lacked a policy and procedure for providing wheelchairs and equipment, contributing to the deficiency in care for Resident 104.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/6/25 Resident 104 was provided with a wheelchair. On 3/6/25, the Director of Rehabilitation (DOR) offered Resident 104 to get out of bed with the provided wheelchair; however, Resident 104 refused to get out of bed. On 3/7/25, the DOR offered Resident 104 to get out of bed with the provided wheelchair; however, Resident 104 refused to get out of bed. On 3/21/25, Resident 104 was offered to get out of bed by the DOR; however, Resident 104 refused. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/10/25, the DOR conducted an audit to ensure all residents who can have a wheelchair have a wheelchair. Wheelchair tags were provided for each resident to identify their wheelchair. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the DOR in-serviced the Therapy Department on assessing and providing a resident with a wheelchair. The DOR/designee will evaluate new admissions and re-admissions on their functional ability to use a wheelchair. The DOR/designee will then provide the new admission or re-admission with the appropriate wheelchair. The Medical Records Director will audit daily for 5 days weekly for 2 weeks and monthly thereafter to ensure new admissions and re-admissions have been provided a wheelchair if applicable. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for providing residents with a wheelchair for three months or until compliance is met.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide adequate activities for one of the sampled residents, Resident 24, outside of her room, leading to feelings of isolation and lack of socialization. Resident 24, who was admitted with conditions including hemiplegia, hemiparesis, and epilepsy, expressed a desire to participate in group activities and go outside for fresh air. Her Minimum Data Set (MDS) indicated that it was very important for her to engage in group activities and enjoy outdoor time when the weather permitted. Despite this, the resident reported that she only left her room when housekeeping performed deep cleaning, and the Activities Director (AD) confirmed that activities were primarily conducted one-on-one in her room. The AD noted that Resident 24 often declined invitations to join group activities, but the Director of Rehabilitation (DOR) acknowledged that the resident had expressed a desire to leave her room and the building. A custom wheelchair was ordered to facilitate her safe and comfortable participation in activities outside her room. The facility's policy on activities, revised in 2021, stated that the program should meet the needs, interests, and preferences of residents, which was not adequately fulfilled in this case, as Resident 24's care plan required a variety of activity types and locations to maintain her interests.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 24 was offered to attend group activities on the following day (3/6/25). On 3/6/25, Resident 24 attended group activities including but not limited to coffee chat, morning warm-up, daily chronicle, bowling, Soul Train, and a movie with popcorn. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/24, the Social Services Director (SSD) and Social Services Assistant (SSA) conducted resident interviews regarding group activity participation. Residents who verbalize a desire to participate in group activities responded to the survey that they do attend group activities. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development (DSD) in-serviced the Activities Department and Certified Nursing Assistants on the facility's policy and procedure titled "Activities Program" with emphasis on the facility providing an activity program designed to meet the needs, interests, and preferences of the residents and ensuring residents who express the desire for a particular activity, for example, group activities, be assisted in participation. Department Managers will conduct room rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents who have the desire to participate in group activities are assisted with attending group activities. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for assisting residents with participation in group activities for three months or until compliance is met. What systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development (DSD) in-serviced the Activities Department and Certified Nursing Assistants on the facility's policy and procedure titled "Activities Program" with emphasis on the facility providing an activity program designed to meet the needs, interests, and preferences of the residents and ensuring residents who express the desire for a particular activity, for example, group activities, be assisted in participation. Department Managers will conduct room rounds daily for five days weekly for two weeks and monthly thereafter to ensure residents who have the desire to participate in group activities are assisted with attending group activities. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for assisting residents with participation in group activities for three months or until compliance is met.
Failure to Prevent Decline in Joint Range of Motion
Penalty
Summary
The facility failed to provide appropriate services to prevent a decline in joint range of motion (ROM) for two residents with limited ROM. Resident 3 did not receive timely quarterly Rehabilitation Joint Mobility Assessments (JMA) to monitor changes in joint ROM. The Director of Rehabilitation acknowledged that the last JMA for Resident 3 was completed on 11/20/2024, and another was due by February 2024, which was not completed. This delay in assessment could hinder the early detection of contractures, which are crucial to prevent further decline in ROM. Resident 27 was supposed to have a left elbow extension splint placed five days a week, as per physician orders. However, the Medication Administration Record (MAR) indicated that the splint was not placed on several occasions in February and March 2025. Both the Restorative Nurse Assistant and a Registered Nurse confirmed the absence of documentation for the splint application on these dates, which could lead to a decline in the resident's left elbow condition. The facility's policies and procedures require staff to identify the resident's current ROM and ensure the application of splints to prevent contractures. The failure to adhere to these policies for both residents could potentially lead to further decline in their joint mobility and overall quality of life.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, the Director of Rehabilitation (DOR) completed Resident 3's joint mobility assessment. Based on the assessment, Resident 3 did not experience any negative outcome or adverse reaction in functional ability as a result of this deficient practice. On 3/7/25, Resident 27's order was clarified to allow the Restorative Nursing Assistant (RNA) to provide the extension splint as ordered. From 3/7/25 to 3/15/25, Resident 27 was provided her extension splint on 3/8/25, 3/11/25, 3/12/25, 3/13/25, 3/14/25, and 3/15/25. On 3/18/25, Resident 27 was transferred to the hospital for unrelated reasons. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the DOR/designee conducted an audit on all active residents for quarterly joint mobility assessments. No other residents were affected by this deficient practice. On 3/13/25, the Medical Records Director conducted an audit on all active residents who have splint orders and compared it to the restorative nursing assistant documentation. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/10/25, the DOR in-serviced the Therapy Department on the facility's policy and procedure titled, "Resident Mobility and Range of Motion," with emphasis on staff identifying the resident's current ROM of his or her joints as part of the resident's assessment. The in-service also included completing joint mobility assessments on admission or re-admission and quarterly thereafter. The Medical Records Director will audit daily for 5 days weekly for 2 weeks and monthly thereafter to ensure that the therapy department is completing joint mobility assessments on a quarterly basis. On 3/13/25, the Director of Rehabilitation in-serviced RNs on the facility policy and procedure titled, "Splinting," with emphasis on preventing contractures or decreased tone and protecting joint alignment. The in-service also emphasized RNAs being responsible for applying the splint as ordered, documentation, and initialing on the schedule for splint application each time splint is applied, removed, or refused. The Medical Records Director will audit daily for five days weekly for two weeks and monthly thereafter to ensure that splint orders and RNA documentation are maintained, confirming residents are receiving their splints as ordered and that refusals are documented. How the facility plans to monitor its performance to ensure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting on the status of compliance regarding the therapy department completing quarterly joint mobility assessments and providing residents with splints as ordered for three months or until compliance is met.
Improper Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure the proper positioning of the head of the bed (HOB) for a resident receiving enteral tube feeding, which is necessary to reduce the risk of aspiration. During an observation, it was noted that the resident was lying flat on their back while the tube feeding was running, contrary to the facility's policy that requires the HOB to be elevated at least 30 degrees during feeding. This oversight was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the HOB should be elevated between 30 to 45 degrees to prevent aspiration and potential aspiration pneumonia. The resident involved had a history of gastro-esophageal reflux disease, dysphagia, and a gastrostomy, and was dependent on staff for personal care. The resident's cognitive assessment indicated limited understanding, highlighting their reliance on staff for proper care. The facility's policy on enteral feedings, dated November 2018, clearly outlines the necessity of elevating the HOB to prevent aspiration, yet this protocol was not followed during the observed incident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Licensed Vocational Nurse (LVN) 6 repositioned Resident 57 head of bed between 30-45 degree angle. LVN 6 evaluated Resident 57 for any negative or adverse outcomes. There were no negative or adverse outcomes related to this deficient practice for Resident 57. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the Director of Nursing (DON) made visual rounds to ensure all residents receiving enteral feeding head of bed were between 30 to 45 degrees. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/20/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to, LVNs and Registered Nurses and on the facility policy and procedure titled, "Enteral Feedings-Safety Precautions," with emphasis on ensuring the safe administration of enteral nutrition and preventing aspiration by elevating the HOB at least 30 degrees during tube feeding and at least one hour after feeding. The DON/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. Department Managers will complete weekday rounds to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting on the status of the compliance for residents receiving enteral feeding head of bed is at 30 to 45 degrees for three months or until compliance is met. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/20/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to, LVNs and Registered Nurses and on the facility policy and procedure titled, "Enteral Feedings-Safety Precautions," with emphasis on ensuring the safe administration of enteral nutrition and preventing aspiration by elevating the HOB at least 30 degrees during tube feeding and at least one hour after feeding. The DON/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. Department Managers will complete weekday rounds to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. The status of the compliance for residents receiving enteral feeding head of bed is at 30 to 45 degrees will be monitored for three months or until compliance is met.
Failure to Maintain and Assess PICC Line
Penalty
Summary
The facility failed to properly assess and maintain a Peripherally Inserted Central Catheter (PICC line) for a resident, identified as Resident 21. The deficiency involved the lack of assessment of the PICC line insertion site at least once every shift and the failure to change the dressing every seven days. This oversight was identified during a review of the resident's records and an interview with the Director of Nursing (DON), who confirmed that the site had not been assessed by a Registered Nurse (RN) and the dressing had not been changed since insertion. The facility's policy required regular monitoring and documentation of the PICC line site to prevent infection and ensure resident safety. Resident 21 had a medical history that included sepsis, diabetes mellitus, and hypertension, and was dependent on staff for personal hygiene. The resident was prescribed Meropenem intravenously for sepsis, necessitating the use of a PICC line. The DON acknowledged the importance of monitoring the PICC line for signs of infection, such as redness, swelling, and pain, and documenting these assessments in the IV Medication Administration Record (MAR). The facility's policy on PICC line maintenance emphasized the need for regular assessments and documentation to prevent complications.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 21 PICC line orders for monitoring signs and symptoms, flushing, and maintenance including but not limited to dressing changes were inputted by the facility's Registered Nurse. There were no negative or adverse outcomes noted for Resident 21 regarding this deficient practice. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/14/25, the Medical Records Director conducted an audit on active residents to ensure residents who have PICC line/Peripheral Intravenous (IV)/Midline lines have orders for monitoring signs and symptoms, flushing and maintenance orders including but not limited to dressing changes. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced nursing staff, including but not limited to Licensed Vocational Nurses and Registered Nursing Staff, on the facility's policy and procedure titled "PICC Line Maintenance and Cleaning in a Skilled Nursing Facility," with emphasis on the facility ensuring safe and effective maintenance and cleaning of Peripherally Inserted Central Catheters (PICC lines) to prevent infection, maintain patency, and ensure patient safety. The in-serviced also included recording all assessments, dressing changes, flushing, cap changes, and any observed complications in the patient's medical records. The Medical Records Director/designee will conduct an audit on residents who are admitted or re-admitted with line orders, or receive IV orders in the facility, to ensure such residents have monitoring orders, flush orders, and maintenance orders including but not limited to dressing changes for their lines daily for 5 days, weekly for 2 weeks, and monthly thereafter. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for residents who have PICC line, Peripheral IV, midline lines, and have monitoring orders, flush orders, and maintenance orders for three months or until compliance is met.
Failure to Manage Resident's Pain in a Timely Manner
Penalty
Summary
The facility failed to manage pain for one resident, resulting in unnecessary pain. Resident 224, who was admitted with diagnoses including difficulty walking, muscle weakness, asthma, and congestive heart failure, was found to have their call light device out of reach, preventing them from requesting pain relief. The resident expressed experiencing back pain and a desire for Tylenol, which was prescribed as needed for mild pain. The care plan for Resident 224 included keeping the call system within reach and responding promptly to pain complaints, but these interventions were not followed. Interviews with facility staff, including an LVN and the DON, confirmed the importance of addressing pain promptly and the potential consequences of not doing so. The facility's policy on pain management emphasized timely intervention to prevent increased pain severity. However, the failure to ensure the call light was accessible led to a delay in addressing the resident's pain, contrary to the facility's policy and the resident's care plan.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, Licensed Vocational Nurse (LVN) 5, administered two 325mg tablets of Tylenol pain medication to Resident 224. Pain medication was noted to be effective. On 3/4/25, Certified Nursing Assistant (CNA) 5, removed call light of the floor from behind Resident 224 bed and placed within reach of Resident 224. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/18/25, Social Service Director and Social Service Assistant conducted resident interviews to ensure residents' pain was being managed. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, the Director of Nursing in-serviced Nursing Staff, including, but not limited to LVNs and Registered Nurses (RNs) on the facility's policy and procedure titled, "Pain Management," with emphasis on the facility being responsible for helping the resident obtain or maintain their highest level of well-being while working to prevent or manage the residents' pain. The in-service also included nursing staff, implementing timely interventions to reduce the increase in severity of pain which included administering pain medication as ordered. Department Managers, including but not limited to Director of Staff Development, Social Services Director and assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set Nurse and MDSN Assistant, and Quality Assurance Nurse will conduct room rounds daily for five days weekly for two weeks in monthly thereafter to ensure resident's pain is being managed. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager room rounds and will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for pain management with emphasis on administrating pain medication timely for three months or until compliance is met.
Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that the prescribed eye drops for one resident, identified as Resident 100, were administered as ordered by the ophthalmologist. Resident 100, who was admitted with diagnoses including respiratory failure, epilepsy, and polycystic kidney disease, was found to have glaucoma and age-related nuclear cataracts in both eyes. The ophthalmologist prescribed Latanoprost and Cosopt eye drops to manage these conditions. However, the orders for these medications were not carried out, as confirmed during an interview and record review with a registered nurse (RN 1). The nurse acknowledged that the orders were faxed to the facility but could not locate any documentation of clarification from the physician, and the medications were not initiated. The facility's policy and procedure for telephone orders, dated May 2018, outlines the steps to reduce errors in verbal or telephone communication of physician orders. This includes documenting the order immediately on the prescriber order form with specific details such as date, time, patient name, drug name, strength, dose, frequency, route, quantity, duration, prescriber's name, and recipient's signature. Despite these guidelines, the failure to administer the prescribed eye drops was identified, which had the potential to worsen Resident 100's eye conditions.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, the Quality Assurance (QA) Nurse called Resident 100 ophthalmologist office to clarify, eyedrop order. The order was clarified to Brimonidine 0.2% (1) drop to both eyes two times a day, Cosopt 0.2% (1) drop to both eyes two times a day, & Latanaprost 0.005% (1) drop to both eyes at hour of sleep. The order was noted and carried out. Resident 100 had no negative outcomes as a result of this deficient practice. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/25/25, the Director of Nursing (DON)/designee conducted an audit on residents who went to an appointment within the past 30 days, to ensure orders from such appointments were noted and carried out. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, DON in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN) on the facility policy and procedure titled, "Telephone Orders for Medication," with emphasis on reducing errors associated with misinterpreted verbal or telephone communication of physician orders by the receiver documenting the order immediately on the prescriber order form including the date and time order is received; patient name; drug name; strength, dose, frequency; route; quantity and/or duration; name of prescriber and the signature of the recipient. The DON/designee will conduct an audit of orders received from resident appointments daily for five days, weekly for two weeks, and monthly thereafter to ensure physician orders received from resident appointments are noted and carried out. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/25/25, the Director of Nursing (DON)/designee conducted an audit on residents who went to an appointment within the past 30 days, to ensure orders from such appointments were noted and carried out. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, DON in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN) on the facility policy and procedure titled, "Telephone Orders for Medication," with emphasis on reducing errors associated with misinterpreted verbal or telephone communication of physician orders by the receiver documenting the order immediately on the prescriber order form including the date and time order is received; patient name; drug name; strength, dose, frequency; route; quantity and/or duration; name of prescriber and the signature of the recipient. The DON/designee will conduct an audit of orders received from resident appointments daily for five days, weekly for two weeks, and monthly thereafter to ensure physician orders received from resident appointments are noted and carried out. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orders received from residents' appointments for three months or until compliance is met.
Improper Storage of Resident's Personal Food Item
Penalty
Summary
The facility failed to ensure safe and sanitary storage practices for foods brought to residents by family and other visitors, specifically for one resident. The deficiency was identified when a bottle of creamy horseradish, which required refrigeration after opening, was found on the bedside table of a resident. The bottle was not labeled with the resident's name, nor was it stored according to the manufacturer's directions. The facility's policy required perishable food items to be labeled, dated, and discarded after 48 hours if refrigerated, and discarded after 2 hours if left at the bedside. The resident involved was cognitively intact and had a medical history that included Vitamin D deficiency, hyperlipidemia, and gastro-esophageal reflux disease. During interviews, the resident confirmed that the horseradish was brought by her sister, and a Licensed Vocational Nurse acknowledged the failure to label and refrigerate the item. The Dietary Service Supervisor reiterated the policy that perishable items should not be left out for more than 2 hours and should be stored in the refrigerator if not consumed immediately. This oversight had the potential to cause foodborne illness to the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, the Infection Control Preventionist removed the items from Resident 42 bedside. The Infection Control Preventionist explained the risk versus benefits of having items unrefrigerated to Resident 42. Resident 42 verbalized understanding and agreed for items to be discarded. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, the Infection Control Preventionist conducted visual rounds in residents' rooms to ensure that perishable items left at the bedside had the resident's name and date on the item, and if the item required refrigeration, that it was not left at the bedside for more than two hours. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Staff Development and Administrator in-serviced facility staff, including but not limited to Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), Dietary Staff, and Activities Department, on the facility's policy and procedure titled, "Food Brought in by Visitors," with emphasis on perishable food requiring refrigeration being discarded after 2 hours at bedside, and if refrigerated, it will be labeled, dated, and discarded after 48 hours. The in-service also included that if the resident desires to have food brought in, the Dietary Staff would provide education regarding safe food handling practices and need to have the resident's name and date it was brought to the facility. Department managers, including but not limited to the Director of Staff Development, Social Services Director and Social Service Assistant, Activities Director, Case Manager Admissions Coordinator, Infection Preventionist, Minimum Data Set Nurse (MDSN) and MDSN Assistant, and Quality Assurance Nurse, will conduct room rounds daily for five days weekly for two weeks, and then monthly thereafter, to ensure food brought into the facility is properly stored and labeled. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assurance and Performance Improvement (QAPI) Committee during its monthly meeting the status of the compliance for food brought into the facility by visitors, including whether it is stored properly, labeled, for three months or until compliance is met.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to document in the clinical records of a resident who was sent to a General Acute Care Hospital from a dialysis center due to unresponsiveness. The resident, who was admitted to the facility with diagnoses including End Stage Renal Disease, anemia, and dysphagia, was picked up for dialysis in stable condition. However, the clinical records lacked documentation of the resident's transfer to the hospital, which was communicated to the facility by the resident's representative. During an interview and record review, a registered nurse acknowledged the omission, stating that she was busy and forgot to document the transfer. The facility's policy and procedure on nursing documentation requires that any communication with family, durable power of attorney, or physician should be noted in the nurse's notes. The failure to document the transfer had the potential to cause a delay in communication among staff and placed the resident at risk of not receiving appropriate care.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, the Director of Nursing verified with Resident 76's hemodialysis center events that led to Resident 76 being transported to the General Acute Hospital and documented in Resident 76's clinical chart as a late entry. How do the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/17/25, the Medical Records Director conducted an audit of all discharges, including but not limited to discharges to the hospital, home, or discharges to another facility. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/26/25, the Director of Nursing in-serviced the Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN), on the policy and procedure titled, "Nursing Documentation," with emphasis on any communication with family, durable power of attorney, or physician, should be noted in the nurse's notes. The in-service also included ensuring documentation is inputted in the resident chart for discharges. The Medical Records Director will conduct an audit on discharge documentation daily for 5 days weekly for 2 weeks and monthly thereafter to ensure licensed nurses and registered nurses are documenting resident discharges in the resident's clinical progress note. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for clinical/nursing documentation related to discharges for three months or until compliance is met.
Violation of Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to respect a resident's right to refuse treatment, as outlined in their operational manual on Resident Rights: Refusal of Treatment. This incident involved a resident with a diagnosis of Type 2 Diabetes Mellitus, hypertension, and hoarding disorder, who was cognitively intact and capable of making decisions. On a specific date, the resident filed a complaint alleging that a Licensed Vocational Nurse (LVN) forcibly administered insulin despite the resident's refusal. The resident's blood sugar level was recorded at 355 mg/dl, and the physician had ordered five units of insulin, which the resident received without consent. Interviews with the Director of Nursing (DON) and LVN 3 revealed that the LVN attempted to educate the resident about the high blood sugar level and the need for insulin. However, the LVN admitted to administering the insulin without the resident's consent, acknowledging that it was against the resident's rights. The facility's policy clearly states that residents should not be forced to accept medical treatment and have the right to refuse it. The DON confirmed that the LVN should have waited for the resident's agreement before administering the medication.
CNA's Disrespectful Behavior Towards Residents
Penalty
Summary
The facility failed to ensure that four residents were treated with respect and dignity, as evidenced by the actions of a Certified Nurse Assistant (CNA 4). Resident 1 reported that CNA 4 was rude and spoke in a demanding voice during care. Resident 7 stated that CNA 4 refused to stay with her when requested during a bowel movement and often complained and spoke harshly. Resident 8 described CNA 4 as having a harsh personality and speaking loudly, while Resident 9 felt that CNA 4 was not nice and repositioned her in a hurried manner. The residents involved had various medical conditions, including diabetes mellitus, dysphagia, muscle weakness, major depressive disorder, schizophrenia, hemiplegia, hemiparesis, and epilepsy. These conditions required different levels of assistance with activities of daily living (ADLs), such as toileting, dressing, and transfers. The facility's policy on resident rights emphasized treating each resident with respect and dignity, which was not adhered to in these instances, potentially affecting the residents' self-esteem and psychosocial well-being.
Failure to Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper sanitation practices in the kitchen, as observed during a survey. Specifically, the kitchen floors were not swept and mopped as required by the facility's Cleaning Schedule. During an observation, food residue, dirt, and other debris were found on the floors behind black cabinets, around the dishwashing machine, under the sink, refrigerator, and stove. This lack of cleanliness was confirmed during an interview with a Dietary Aid, who acknowledged that the daily assigned dishwasher was responsible for sweeping after washing dishes. The Dietary Aid also noted that if the kitchen floor was not cleaned properly, it could lead to food contamination and attract pests. Further investigation revealed that the facility's Daily Cleaning Schedule, which required the floors to be swept and mopped three times daily, was not consistently followed. There was no documentation to support that the floors were cleaned on several specific dates. The Dietary Supervisor, upon reviewing surveyor pictures, admitted that some areas in the kitchen did not appear to have been cleaned daily. The facility's Policy and Procedure, dated May 1, 2018, required dietary staff to maintain a sanitary environment by adhering to the routine cleaning schedule, which was not followed in this instance.
Failure to Monitor Resident Leads to Multiple Elopements
Penalty
Summary
The facility failed to implement a care plan intervention to monitor a resident routinely, which resulted in the resident eloping from the facility unsupervised on multiple occasions. The care plan did not specify the type of supervision needed or how often the resident should be monitored. This lack of specificity and monitoring led to the resident leaving the facility without staff noticing, placing the resident at risk for serious medical complications. The resident involved had a history of elopement and was diagnosed with several medical conditions, including schizophrenia, COPD, diabetes mellitus, heart failure, atrial fibrillation, and hypertension. Despite these conditions and previous elopement attempts, the facility did not adequately monitor the resident's location or behavior. The care plan interventions were vague and not individualized to the resident's needs, failing to provide clear guidance on monitoring frequency or specific supervision requirements. Interviews with facility staff revealed that the resident's location and wandering behavior were not consistently monitored or documented. The staff did not perform visual checks as required, and the resident's care plan was not updated to reflect the need for a wanderguard bracelet until after the resident's third elopement. The facility's policy and procedures for wandering and elopement were not effectively implemented, contributing to the resident's repeated unsupervised departures.
Removal Plan
- The DON contacted the physicians of residents identified for being at risk for wandering/elopement to obtain orders to monitor each resident every 2 hours. The DON contacted the physicians of the residents identified with history of elopement to obtain orders to monitor each resident every 1 hour.
- Rounding during change of shift by outgoing and oncoming nursing staff (LVN, RN, and CNA) will take place to account for all residents with emphasis on identifying the whereabouts of residents that were at risk for elopement.
- The LVN or RN will record on the Medication Administration Record (MAR) their visual check of the residents and document in the progress note the location of the residents.
- Medical Records will audit the MAR for compliance of Licensed Staff documenting on residents who have orders to monitor every 2 hours for risk for wandering/elopement and 1 hour for residents with history of elopement. The audits will be daily for one week, weekly for two weeks, and monthly for 3 months thereafter.
- Medical Records will report to the Administrator/designee the findings of the audit daily for one week, weekly for two weeks, and monthly for 3 months thereafter.
- The MDS Coordinator reviewed the care plans for the nine residents identified for being at risk for wandering to ensure residents have measurable interventions.
- Resident interventions were updated to include interventions such as but not limited to monitor residents' location every 2 hours or 1 hour, Department Managers Monday through Friday and the RN Supervisor on weekends will provide room visits daily to provide orientation for socialization and sensory stimulation and apply wander guard bracelet by Admissions or Licensed Nurse.
- Licensed staff to complete wandering/elopement assessments on admission/readmission, quarterly and when a change of condition occurs.
- The QA Nurse updates the residents special need binders/postings as residents are identified.
- The Admissions Coordinator updates the facility wanderguard binder located at each station with resident's face sheets who were identified to be at risk to elope/wander and have wander guards applied as needed.
- Wander guard binder will be checked by Admissions or QA nurse during the weekday and designated RN/LVN on the weekend.
- All residents who have been identified to be at risk for elopement/wandering will have identifiable pink color name bands.
- Residents identified to be at risk will be discussed with facility staff during daily shift huddle and weekday stand-up meetings.
- Staff will be informed of the pink color name band, special need binder/posting and wander guard binder through in-services held by the Director of Staff Development, QA nurse and/or Administrator.
- The Administrator, DON, Director of Staff Development began in servicing facility staff, which included but not limited to Nursing, Housekeeping, Maintenance, Dietary, Department Managers including front door staff and contracted rehab staff, on residents at risk for wandering/elopement and what behaviors to monitor for each resident.
- The in-service also included facility's policy and procedure titled, Wandering & Elopement and Wandering Policy.
- The in-servicing is ongoing.
- The QA nurse will audit the in-service provided to staff daily and report the findings to the Administrator.
- The Administrator will ensure all staff on assignment and currently working daily are in-serviced.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse prevention program policy by not reporting an allegation of abuse involving a resident to the California Department of Public Health. The incident involved a family member who reported to a Licensed Vocational Nurse (LVN) that a Certified Nurse Assistant (CNA) raised their hand in a motion as if to hit the resident but did not make physical contact. The LVN reported the incident to a Registered Nurse (RN), who then sent the CNA home for the rest of the shift. However, the facility did not complete and fax the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to notify the state agency, as required by their policy. The resident involved was admitted to the facility with diagnoses including hemiplegia, hemiparesis following an intracranial hemorrhage, and syncope. The resident was cognitively intact according to their Minimum Data Set assessment. Despite the facility's policy requiring immediate reporting of abuse allegations, the staff did not report the incident to the state agency within the required timeframe. The facility's administrator confirmed that all allegations of abuse must be reported to the state agency, and acknowledged that the staff failed to report the abuse allegation on the evening of the incident.
Failure to Timely Report Investigation Results to CDPH
Penalty
Summary
The facility failed to submit the results of an investigation regarding an injury of unknown source to the California Department of Public Health (CDPH) within the required 5 working days for a resident. This resident, who was diagnosed with dementia, cerebral infarction with hemiparesis, and contractures, was noted to have a left humerus dislocation without swelling, bruising, or open areas. The Director of Nursing (DON) acknowledged that the incident was considered an unusual occurrence and that the initial report was submitted to the state licensing agency on the day of the incident. However, the Administrator (ADM) did not submit the final investigation report within the 5-day timeframe, as required by both the facility's policy and state and federal regulations. During interviews, both the DON and ADM confirmed the failure to comply with the reporting requirements. The facility's policies on unusual occurrence reporting and abuse prevention clearly state the necessity of submitting a final investigative report within 5 days, which was not adhered to in this case.
Failure to Secure Smoking Materials Poses Safety Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents who were smokers. Resident 1 was found with a cigarette lighter on his bedside table, despite having severe cognitive impairment and requiring supervision during smoking times. The facility's Smoking Safety Evaluation for Resident 1 did not include a system for the safe storage of smoking materials, which was a critical oversight given the resident's condition and the potential risks involved. Resident 2, who had intact cognition but was dependent on a wheelchair for mobility, was observed with a lighter and two cigarette sticks in her purse. The care plan for Resident 2 indicated that staff should provide a safe smoking environment and monitor the resident during smoke breaks. However, the Smoking Safety Evaluation form did not specify a secure storage system for her smoking materials, allowing her to keep them in her room, contrary to the facility's policy. Resident 3, who had cognitive impairment and required supervision while smoking, was seen in the hallway with cigarettes and a lighter. The resident's care plan emphasized the need for supervision and adherence to designated smoking areas, yet the facility failed to implement a secure storage system for his smoking materials. This lack of adherence to the facility's smoking policy and procedures posed significant safety risks, as residents were able to access and use lighters unsupervised, potentially leading to accidents or fires.
Removal Plan
- The DON, Admin, and Registered Nurse (RN) 1 informed all residents, both nonsmokers and smokers, that according to the facility's Smoking Policy and Procedure, residents will not keep cigarettes, e-cigarettes, and lighters in their possession, bedside or rooms. Residents were informed all smoking materials were to be kept at the nurses' Station 1 in a locked drawer and the activity office.
- The Director of Staff Development (DSD) Assistant and Social Service Designee (SSD) checked bedsides of all residents and ensured there were no cigarettes, e-cigarettes, or lighters at the bedsides. The DSD Assistant and SSD removed any cigarettes, e-cigarettes, and lighters found.
- Residents' bedside tables and nightstands were to be checked every shift by the assigned Certified Nursing Assistant (CNA) for 2 weeks, then daily for 2 months. Results of those rounds were to be reported to the charge nurse per shift. A log will be used to record results of rounds and reported to the charge nurse per shift. Residents found with cigarettes, e-cigarettes, and lighters will be removed immediately by the assigned CNA.
- A daily census will be used by the RN shift Supervisor to record the results of room observations during rounding. Residents found with cigarettes, e-cigarettes, and lighters will be removed immediately by assigned CNA.
- Of the 27 residents identified to smoke, nine residents were assessed by the shift RN, were unable to store smoking items at the bedside and the items should be secured by staff safely.
- The DON, Admin, DSD, and Designee in-serviced staff on checking to ensure there were no cigarettes, e-cigarettes, or lighters at any of the residents' bedsides and to remove those items for the safety and security of residents.
- The DON, Admin, DSD, and SSD held Resident Council Meetings to inform residents of the facility's smoking policy, specifically the safety of properly securing cigarettes, e-cigarettes, and lighters and of the deficient practice found by California Department of Public Health (CDPH) which placed the facility in non-compliance and in Immediate Jeopardy.
- The Admin ensured all 152 staff on assignment and who worked daily were in-serviced. Non-active staff, not currently on assignment and on leave, in-serviced prior to returning to assignment/work/duty.
- The Admin, DON, DSD, Quality Assurance (QA) Nurse, and RN 1 met with facility staff to educate staff on the facility's smoking P&P specifically the safe and secure storage of cigarettes, e-cigarettes, and lighters.
- The Admin posted a notice of the IJ at the front and rear entrance door, the activity room, and at all four Nurses' Stations to inform residents, families, and staff of the following: Visitors, friends, and family were not allowed to provide cigarettes, e-cigarettes, or lighters directly to the resident. These items must be checked in with the on-duty staff nurse. The nurses will place the smoking items at Station 1 in a locked drawer until picked up by the Activity Director. All residents' cigarettes, e-cigarettes, and lighter must be kept by the facility in Station 1 drawer and in the activity office's locked cabinet. The resident's name will be labeled on the cigarettes, e-cigarettes, and lighters. Residents who smoke, should not keep cigarettes, e-cigarettes, or lighters at their bedside. The 10 smoking sessions were held on the smoking patio located by Station 2 with supervision provided by the activity staff and assigned nursing staff for residents' safety. Residents that smoked should abide by the facility's policy regarding smoking session times to ensure residents, visitors, and staff safety.
- The Activity Supervisor who was in charge of the smoking sessions will report any concerns to the facility Admin in the daily meeting or as needed.
- The QA Nurse developed the Performance Improvement Plan (PIP) to address the assessment, safety, and storage of cigarettes, e-cigarettes, and lighters to ensure residents' safety. The QA nurse will monitor findings and report to the Quality Assurance Committee monthly for three months to ensure the system's effectiveness and performance was sustained.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to adhere to its policy and procedure for reporting allegations of abuse, as outlined in their Abuse Prevention and Prohibition Program. The policy mandates that any allegations of abuse, neglect, or other incidents that qualify as a crime should be reported immediately, but no later than two hours after forming the suspicion. However, the facility delayed reporting an incident involving unwanted physical contact between two residents to the California Department of Public Health (CDPH). The incident occurred at 9:35 a.m., but the report was not faxed to CDPH until 11:50 a.m., exceeding the two-hour reporting requirement. The deficiency involved two residents with cognitive impairments. One resident, admitted with diagnoses including cerebral infarction and schizophrenia, was noted to have severe cognitive impairment but was independent with mobility. The other resident, with diagnoses including encephalopathy and transient cerebral ischemic attack, had moderate cognitive impairment and required supervision for mobility. The Director of Nursing and the Administrator both acknowledged that the incident should have been reported within the stipulated two-hour timeframe to ensure a plan of correction was in place for resident safety. The failure to report in a timely manner delayed the investigation by CDPH.
Failure to Document and Implement Physician Orders for Urinary Catheter Care
Penalty
Summary
The facility failed to document and implement a physician's telephone order for a resident with a urinary catheter, leading to significant health issues. The resident, who had a history of benign prostate hyperplasia, adult failure to thrive, and cardiomegaly, was admitted to the facility and later readmitted with bladder distention and infection. The physician had ordered the monitoring of the resident's urinary catheter, including intake and output every shift, and to document any signs and symptoms of a urinary tract infection (UTI). However, the staff did not follow these orders correctly, as they documented the resident's output based on diaper changes rather than actual measurements, and failed to document the presence or absence of UTI symptoms as instructed. Further investigation revealed that a physician's order to flush the resident's catheter tubing was not documented or carried out, which contributed to the resident's condition worsening. The resident's progress notes indicated bloody urine, and the physician had ordered the catheter to be flushed and left in place for 10-14 days. However, this order was not found in the resident's order summary report, and the staff could not recall performing the catheter flush. This oversight led to a delay in treatment, resulting in the resident being transferred to a general acute care hospital (GACH) for further evaluation and treatment. At the hospital, it was discovered that the resident's urinary catheter balloon was inflated in the urethra, blocking urine drainage. This required the removal and reinsertion of the catheter, which relieved the resident by draining a significant amount of urine. The facility's policies and procedures for documentation and catheter care were not adhered to, as the nursing staff failed to provide accurate and timely documentation of the resident's status and care, contributing to the resident's adverse health outcome.
Failure to Provide Proper Cast Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate cast/splint care for five months after being transferred to the skilled nursing facility (SNF). The resident, a 56-year-old male with multiple diagnoses including a non-displaced fracture of the lateral malleolus of the right fibula, peripheral vascular disease, and hypertensive heart disease, did not receive proper cast care from the time of his admission. The initial admission assessment and subsequent documentation failed to mention the presence of the cast, leading to a lack of necessary care and services for the resident's condition. The resident's care plan did indicate the need for cast care, but this was not implemented or followed up on by the staff. Interviews with various staff members, including the treatment nurse, occupational therapist, and RN supervisor, revealed that there was a lack of awareness and communication regarding the resident's cast, resulting in no cast care being provided until the cast was removed by a hospital five months later. The treatment nurse admitted to not being aware of the cast during the initial assessment, and the occupational therapist confirmed the presence of the cast during the resident's treatment period. The RN supervisor acknowledged that the necessary orthopedic referral was not made, and the case manager indicated that follow-up appointments were not scheduled in a timely manner. The director of nursing (DON) confirmed that the facility failed to document and follow up on the resident's cast care, which could have led to complications such as worsening wounds, pain, and nerve problems. The facility's policy and procedure for cast care required regular inspection and documentation of the casted extremity, which was not adhered to in this case. The admission assessment policy also emphasized the need for thorough observation and communication with the resident and staff, which was not effectively carried out. This deficiency highlights a significant lapse in the facility's adherence to its own policies and procedures, resulting in inadequate care for the resident's casted leg.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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