Lassen Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Susanville, California.
- Location
- 2005 River Street, Susanville, California 96130
- CMS Provider Number
- 056231
- Inspections on file
- 38
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Lassen Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a urostomy and history of UTIs had a physician order for urostomy bag changes twice weekly, but the Treatment Administration Record showed that one scheduled change was not completed as ordered. Staff interviews revealed confusion about where urostomy supplies were stored, with reports that bags had been moved between the med room, the resident’s drawer, central supply, and the treatment cart. The DON confirmed the missed treatment and that supplies could have been obtained from central supply or a local hospital if needed. The report notes that this failure had the potential to cause infection.
Three residents with significant medical conditions and severe weight loss did not receive immediate medication regimen reviews because the DON did not notify the Pharmacy Consultant as required by facility policy. As a result, no pharmacy review was conducted to assess whether medications contributed to the residents' weight loss.
Three residents with complex medical conditions were not consistently provided with physician-ordered therapeutic diets, including fortified meals and double protein portions. Observations and staff interviews confirmed that some meals were not fortified as required, and one resident did not consistently receive double protein portions, despite care plans and physician orders specifying these dietary needs.
Three residents with significant weight loss did not receive timely nutrition assessments, as required by facility policy. The RD did not attend weight variance IDT meetings or document progress notes for missed meetings, and there was no communication or collaboration between the RD and the dietary department. Both the RD and facility leadership were unfamiliar with the contract outlining their responsibilities, and the facility did not provide written notification to the RD about residents with significant weight loss.
A resident with cognitive impairment and a preference for privacy was required to eat in a group dining area despite repeated requests to return to her room. During lunch, the resident expressed discomfort and was assessed for abdominal pressure by an LN at the dining table in front of other residents, violating her right to privacy and dignity. Staff interviews confirmed awareness of the resident's preferences and acknowledged that her rights were not upheld.
A resident with a history of depression, anemia, fatigue, and neurocognitive disorder experienced a notable decline in physical function and weight loss, requiring increased assistance and use of a wheelchair. Despite these changes, staff did not complete a required MDS assessment for significant change in condition, as the MDS nurse was not informed. This resulted in a delay in reviewing and updating the resident's care plan.
A resident with multiple health conditions was prescribed Boost as a nutritional intervention for being underweight, but staff did not document the amount consumed. Interviews and record reviews confirmed that there was no system in place to record the intake of the supplement, preventing effective monitoring and evaluation of the intervention's success.
A resident with cognitive impairment and a history of depression repeatedly received large food portions and multiple chocolate-flavored supplements, despite expressing a preference for smaller portions and a dislike of chocolate. Staff were aware of the resident's complaints but did not update the dietary profile or notify the dietary department, resulting in continued provision of meals and supplements that did not match the resident's stated preferences.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment and depression had a wedding ring stolen while under the care of staff. The theft was discovered by a family member, and investigation revealed a CNA assigned to the resident had been arrested for stealing resident property, with the ring later identified through a police operation.
The facility did not report a reasonable suspicion of theft involving two residents' wedding rings by a CNA to the California Department of Public Health or the Ombudsman, as required by policy. Although the police were notified after suspicions arose, mandated reporting to state authorities was not completed for two residents with significant care needs.
The facility did not ensure that all staff attended mandatory in-services as required by policy, with several key training sessions having very low attendance or not being conducted at all. The Director of Staff Development confirmed that make-up classes were not formally provided, and missed training was only sometimes addressed informally through one-on-one education or team huddles.
Multiple residents with good cognition reported that meals were unpalatable, cold, overcooked, and contained an unpleasant spice, leading to dissatisfaction and refusal to eat. Staff and dietary management confirmed ongoing issues with food temperature, incomplete documentation of food temps, and insufficient use of warming equipment, while resident council notes reflected persistent complaints about meal quality.
Staff failed to use required PPE and perform hand hygiene during high-contact care activities for multiple residents, including those with urinary devices and wounds. In one case, a staff member touched a resident's foley catheter without gloves, and EBP signage and supplies were missing outside the room. These lapses occurred despite facility policies requiring enhanced barrier precautions for residents with certain conditions.
Multiple residents with good cognitive status reported experiencing long delays—sometimes up to two hours—for staff to respond to call lights, leading to emotional distress and requiring some to seek help in hallways or use bathroom emergency lights for faster assistance. Family members and residents raised these concerns repeatedly in Resident Council meetings, and staff interviews confirmed the ongoing nature of the problem.
A resident with a suprapubic catheter did not have a urologist's order for daily sterile water flushes implemented, and nursing staff failed to document catheter care and assessment after a reported complication. The treatment nurse confirmed the procedure was performed but not recorded, contrary to facility policy.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses and inadequate care for residents. Several residents reported long wait times for assistance, particularly during meal times, leading to incidents such as falls and being left in soiled conditions. Observations and staff interviews confirmed the issue of insufficient staffing, impacting the quality of care provided.
The facility failed to serve meals at a palatable temperature, affecting multiple residents who reported cold and bland food. Observations showed meal trays were exposed to cold air for extended periods before being served. Residents with various medical conditions expressed dissatisfaction, noting that meals were often late and unappetizing.
The facility's kitchen was found to be unclean, with a pest control device covered in a dark substance, black debris and gray patches on the floor and walls near food preparation areas, grime on storage room doors, and black stains on ceilings from dirty vents. The RD confirmed these areas should be cleaned monthly.
A facility failed to maintain effective infection control when an LVN did not perform hand hygiene during medication administration, increasing infection risk. Additionally, a resident's water tumbler was found dirty, with the facility not having a process for cleaning personal items, as confirmed by the DSD and RD.
Two residents experienced a lack of dignity during meal times. One resident was fed while facing a wall, unable to see the CNA assisting her, contrary to facility policy. Another resident received her breakfast late, as it was mistakenly delivered to her room and not brought to the dining room, causing her to feel forgotten. These incidents highlight the facility's failure to provide a dignified dining experience.
The facility failed to maintain a homelike environment and proper cleanliness of equipment. Two residents' rooms had walls that were unpainted and scratched, which the Maintenance Supervisor acknowledged needed fixing. Additionally, a Hoyer lift used for resident care was found soiled with dried matter and remained uncleaned for several days, despite being used on residents. A nurse confirmed the cleaning responsibility lay with the night shift, and the Administrator later took the lift to be washed.
A facility failed to report an allegation of abuse to CDPH when a resident claimed to have heard another resident being raped. The incident was reported to an LVN, but there was no documentation in the medical record, and the facility did not file the required report. Interviews revealed no recollection of the incident by the residents involved, and the alleged victim denied any issues. Despite police involvement, the facility did not report the allegation, risking ongoing undetected abuse.
A facility was found to have a 10% medication error rate during a medication pass, exceeding the acceptable threshold of 5%. An LVN incorrectly prepared COQ-10 and Omega-3 supplements in incorrect dosages and failed to administer Lasix due to unavailability in the medication cart. The Lasix was later confirmed to be available in the facility's Cubex but was not retrieved. The DON verified that the medication should have been administered as prescribed.
The facility did not date an open multi-dose vial of Tubersol, used for TB skin tests, as required by policy and manufacturer instructions. The vial was found in a medication room refrigerator without a date, and the DON confirmed it should not be used due to potential ineffectiveness.
The facility failed to offer snacks to residents between meals and at bedtime without requiring them to ask, affecting several residents. Observations and interviews revealed that residents were not being offered snacks, leading to hunger and discomfort. The facility's policy indicated snacks should be easily accessible, but a change in procedure required residents to request snacks, which was not well-received. A resident with intact cognition and multiple diagnoses expressed dissatisfaction with the current system.
A resident with a nephrostomy tube did not receive care according to physician's orders, as staff routinely removed the dressing during showers, leaving the site exposed. This practice was confirmed by multiple staff members, despite the importance of maintaining sterility as emphasized by a wound treatment nurse and an infection prevention nurse.
The facility failed to meet the needs of six residents, resulting in delays in toileting, showers, and hydration. Residents experienced unrelieved pain and neglect due to untimely responses to call lights across all shifts. The administration acknowledged staffing issues but did not include them in their Quality Assurance Performance Improvement plans, and the Director of Staff Development lacked time for oversight due to other responsibilities.
The facility failed to ensure sufficient staffing, resulting in delays in activities of daily living for six residents. Residents reported waiting up to an hour for call lights to be answered, leading to unrelieved pain and feelings of being forgotten. Staff confirmed the short-staffing issue, and the Administrator admitted that it was not addressed in their Quality Assurance Performance Improvement plans.
A resident with a history of severe pain conditions did not receive appropriate pain management, resulting in constant pain. The nursing staff administered incorrect pain medications multiple times, and the facility's pain management policies were not followed. Interviews revealed issues with pain assessments and slow adjustments to pain medication prescriptions.
The facility failed to provide nursing staff with necessary competencies, resulting in incorrect pain medication administration for one resident and inadequate diabetic care for another. The deficiencies led to increased pain and discomfort for both residents.
A resident experienced a six-month delay in obtaining a Urology consultation, resulting in increased pain and multiple urinary tract infections. The facility failed to coordinate and document the necessary referral, leading to a lack of timely treatment and care.
A facility failed to ensure the MD addressed and documented a medication irregularity, leading to a resident experiencing unmanaged pain. Despite recommendations from the consultant pharmacist, the MD did not act on clarifying multiple analgesic PRN orders, resulting in improper pain management. Interviews revealed that new nurses were not performing pain assessments correctly, and there was no documentation of review and action by the DON and MD.
The facility failed to ensure a resident did not receive unnecessary medication when a diabetic medication was unavailable. Instead of adjusting the medication regimen appropriately, the facility increased the doses of other diabetic medications, leading to frequent low blood sugar levels. The physician was not notified in a timely manner to adjust the medications accordingly.
A facility failed to promptly notify a physician of lab results for a resident, leading to delayed treatment and increased pain. The resident had a urinalysis ordered, but the sample was collected late, and the final urine culture report showing significant bacterial growth was not communicated to the physician. The resident experienced confusion, back pain, weight loss, and lack of appetite, and the facility did not perform or document an infection screen.
The facility failed to inform residents' representatives of significant dental issues identified by the RDHAP, including missing teeth, visible cavitation, retained roots, and general demineralization. This lack of communication prevented the RPs from participating in decision-making regarding dental care.
The facility failed to accurately evaluate and record dental assessments for four residents, leading to incorrect MDS documentation. Observations and RDHAP evaluations indicated dental issues that were not reflected in the MDS, and one resident was incorrectly coded as edentulous despite having dentures. The MDS nurse admitted to not visually inspecting the residents' mouths as required.
The facility failed to pursue routine or emergency dental services for three residents who were evaluated by a Registered Dental Hygienist of Alternative Practice (RDHAP) but were not referred to a dentist despite identified dental problems. These failures were observed through interviews, record reviews, and direct observations, indicating a lack of follow-up on identified dental issues.
Failure to Follow Physician Order for Urostomy Bag Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide urostomy care in accordance with physician orders and facility policy for one resident. The facility’s medication administration policy required that treatments be administered in accordance with physician orders, including required time frames. The resident was admitted with a history of urinary tract infections and an artificial opening of the urinary tract (urostomy). The Treatment Administration Record for January 2026 showed a physician’s order for the resident’s urostomy bag to be changed every Wednesday and Saturday, but there was no documentation that the bag was changed on Saturday 1/3/26, indicating the order was not followed. Interviews with staff revealed confusion and inconsistency regarding the storage and availability of urostomy supplies. A licensed nurse reported that urostomy bags had been moved multiple times—from the medication room, to the resident’s drawer, and then to central supply—and that at one point nursing staff believed they were out of bags before later finding them in the resident’s drawer. The central supply lead stated that urostomy bags were stored in central supply and that nurses could obtain them from a local hospital if the facility ran out. The DON confirmed that urostomy bags were kept in central supply or on the treatment cart and acknowledged that the resident’s urostomy bag should have been changed as ordered. The report states that this failure had the potential to cause infection.
Failure to Notify Pharmacy Consultant for Immediate Medication Review After Resident Weight Loss
Penalty
Summary
The facility failed to notify the Pharmacy Consultant (PC) to conduct immediate medication regimen reviews (MRR) for three residents who experienced significant weight loss. Facility policies required that the PC be alerted for an immediate MRR when a resident experienced a change in condition, such as weight loss, to evaluate whether medications could be contributing factors. However, interviews and record reviews confirmed that the Director of Nursing (DON) did not notify the PC, and there was no documentation of immediate MRRs being performed for these residents. The three residents involved had complex medical histories, including diagnoses such as major depression, Alzheimer's disease, dementia, adult failure to thrive, and type 2 diabetes with neuropathy. Each resident experienced severe weight loss over a 180-day period, as documented in their weight summaries. Despite facility policies and procedures outlining the need for prompt pharmacy review in such cases, the required notifications and reviews were not completed, and the PC confirmed no pharmacy review had been conducted regarding the weight loss for these residents.
Failure to Provide Physician-Ordered Therapeutic Diets and Fortified Meals
Penalty
Summary
The facility failed to consistently provide physician-ordered therapeutic diets to three sampled residents. Specifically, two residents with diagnoses including major depression, anemia, fatigue, dementia, and adult failure to thrive were not consistently provided with fortified meals as ordered by their physicians. Observations revealed that while some meals, such as breakfast, were fortified, other meals like lunch and dinner were not, despite the meal tray tickets indicating a fortified diet. The Certified Dietary Manager (CDM) confirmed that not all meals were fortified, and the Registered Dietician (RD) stated that every meal should have been fortified according to the care plan and physician's orders. For one resident with Alzheimer's, dementia, and type 2 diabetes with diabetic neuropathy, the facility failed to provide double portions of protein as ordered. Observations and interviews with the resident's responsible party indicated that the resident was not consistently receiving double portions of protein, particularly during dinner, and staff had to obtain additional food to meet the order. The CDM acknowledged ongoing issues with the evening cook not providing double portions and confirmed that no resident lunches had been fortified. The facility's policy required that therapeutic diets be provided as prescribed by the attending physician to support the resident's treatment and plan of care. However, the facility did not adhere to these requirements, resulting in residents not receiving the necessary fortified meals or double protein portions as ordered. These failures were confirmed through observations, interviews with staff and responsible parties, and review of physician orders and care plans.
Failure to Provide Timely Nutrition Assessments and Interdisciplinary Collaboration for Residents with Weight Loss
Penalty
Summary
The facility failed to maintain an adequate food and nutrition department for three residents who experienced significant weight loss. Timely nutrition assessments were not performed after weight loss triggered a change of condition for all three residents. In one case, a nutritional assessment was completed 26 days after severe weight loss was identified, while in another, the assessment was completed 46 days after the trigger. For the third resident, the assessment occurred 77 days after the weight loss was noted. These delays were contrary to the facility's policy, which required prompt nutritional assessments upon a change of condition that placed residents at risk for impaired nutrition. The Registered Dietician (RD) did not participate in weight variance interdisciplinary team (IDT) meetings, nor did the RD document progress notes indicating review of IDT meeting notes. The RD stated that meeting times conflicted with other obligations and was unaware of the expectation to enter weekly progress notes for missed meetings. The Director of Nursing (DON) and Administrator confirmed that the RD had not attended any weight meetings since starting at the facility, and no progress notes were entered for missed meetings. This lack of participation and documentation hindered the collaborative approach required for managing residents with weight loss. Communication and collaboration between the RD and the dietary department were also lacking. The Certified Dietary Manager (CDM) reported no direct communication with the RD regarding residents experiencing weight loss, and the RD confirmed not having spoken to the CDM. Additionally, the RD did not notify the facility of completed assessments or recommendations for the residents in question. Both the RD and the facility's Administrator were unfamiliar with the Agreement to Provide Dietetic Consultation Services contract, which outlined responsibilities such as orientation to facility policies and written notification of significant weight loss. The Administrator admitted not notifying the RD in writing about residents with significant weight loss, and the RD was unaware of the facility's policies.
Failure to Ensure Resident Privacy and Dignity During Dining and Medical Assessment
Penalty
Summary
A deficiency occurred when a resident with a history of major depression, anemia, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease was not treated with dignity and respect regarding her preferences for privacy and dining location. The resident, who was not her own responsible party, repeatedly expressed a desire to return to her room during lunch and showed clear signs of distress and refusal to eat in the RNA dining room. Despite her verbal and non-verbal refusals, staff continued to encourage her to eat and did not promptly honor her request to leave the dining area. During the lunch period, the resident complained of abdominal pressure and expressed discomfort. Instead of providing a private assessment, a Licensed Nurse assessed the resident's lower abdomen at the dining table in the presence of three other residents. The nurse also discussed the resident's need to use the bathroom in front of others, which the resident later stated should have been a private and confidential conversation. Staff interviews confirmed that the resident was more comfortable eating in her room and that her rights to privacy and dignity were not upheld during this incident. Facility policy required staff to treat residents with respect and dignity, provide privacy and confidentiality, and support residents in exercising their rights. However, staff actions did not align with these policies, as the resident's preferences were not respected, and her medical concerns were addressed publicly. The Director of Staff Development acknowledged that the resident's rights were violated during this event.
Failure to Complete MDS Assessment After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition. According to the facility's own policies, a significant change in status assessment should be performed when the interdisciplinary team determines that the resident meets the criteria, which include a decline that does not resolve on its own, requires staff intervention, impacts more than one area of health status, and necessitates review or revision of the care plan. In this case, the resident, who had a history of major depression, anemia, fatigue, and a major neurocognitive disorder, experienced a functional decline and weight loss. Documentation showed that the resident, previously independent in several activities of daily living, now required much more assistance, including the use of a wheelchair and help with transfers due to weakness and balance problems. Despite these changes, no significant change MDS assessment was completed within the required timeframe. Staff interviews confirmed that the resident's decline and weight loss should have triggered a change of condition MDS, but the assessment was not performed because the MDS nurse was not informed of the change. The absence of this assessment delayed the review and revision of the resident's care plan, as confirmed by both the MDS nurse and the facility administrator.
Failure to Document and Monitor Nutritional Supplement Intake
Penalty
Summary
Facility staff failed to monitor and document the consumption of a prescribed nutritional supplement, Boost, for a resident who was underweight and had multiple medical conditions, including major depression, anemia, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease. The care plan for this resident included an intervention to provide Boost with breakfast and lunch, as ordered by the physician. However, interviews with staff, including a CNA, LN, RD, DSD, and RNA, revealed that there was no system in place to document the specific amount of Boost consumed by the resident. The Medication Administration Record (MAR) and fluid intake reports did not include a section for recording Boost intake, and staff confirmed that only combined fluid intake was documented, not the intake of individual supplements like Boost. As a result, the facility was unable to monitor or evaluate the effectiveness of the nutritional intervention as required by their own policies and procedures. The lack of documentation meant that staff could not determine whether the resident was receiving the intended nutritional support, and there was no way to assess if the intervention was achieving its goal of addressing the resident's underweight status. The deficiency was identified through interviews and record reviews, which confirmed the absence of documentation and the inability to track the resident's supplement intake.
Failure to Honor Resident Food Preferences for Portion Size and Flavor
Penalty
Summary
The facility failed to honor a resident's food preferences regarding portion size and flavor, despite documented assessments and repeated verbalizations from the resident. The resident, who had a history of major depression, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease, was observed to consistently receive large food portions and multiple chocolate-flavored nutritional supplements, even after expressing dissatisfaction with both. Facility policy required that food preferences be assessed and communicated to dietary staff, and that staff confer with the physician if a resident was unhappy with their diet. Observations and interviews revealed that the resident repeatedly stated she was tired of chocolate and found the food portions too large, which discouraged her from eating. Despite these statements, the dietary department was not notified of her preferences, and her meal trays continued to include large portions and chocolate-flavored drinks. Staff interviews confirmed awareness of the resident's complaints, but no action was taken to update her dietary profile or consistently offer alternative flavors or smaller portions. Documentation showed that while small portions were previously ordered, this was discontinued after a noted weight loss, and the resident's ongoing preference for smaller portions was not reinstated or communicated. Multiple staff members, including CNAs, LNs, and dietary management, acknowledged the resident's dissatisfaction but did not ensure her preferences were reflected in her meal service. The resident's dietary profile still listed chocolate as a liked preference, and staff were unaware of the need to notify dietary or nursing when preferences changed. As a result, the resident continued to receive meals and supplements that did not align with her stated preferences, as evidenced by uneaten food and partially consumed supplements observed during multiple meals.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or record review, indicating that the required protocols for protecting confidential information or properly maintaining medical records were not followed as expected. No additional details regarding specific residents, staff actions, or the exact nature of the records involved are provided in the report.
Failure to Protect Resident Property from Misappropriation
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal property when the resident's wedding ring was stolen. The resident, who had severe cognitive impairment due to dementia and major depression, required significant assistance from staff for personal hygiene and dressing. Documentation confirmed that the resident possessed a yellow ring with clear stones, and the ring was listed among the resident's possessions. The resident was not their own responsible party, and the loss was first noticed by a family member, who reported the missing ring to the facility. Interviews and record reviews revealed that a Certified Nursing Assistant (CNA) assigned to the resident during the relevant shift was later arrested for stealing from residents. The administrator observed an online post by the CNA offering jewelry for sale, which raised suspicion and led to police involvement. The family member identified the ring in a photograph provided by law enforcement, confirming it belonged to the resident. The facility's policy stated residents have the right to be free from misappropriation, but this right was not upheld in this instance.
Failure to Report Suspected Theft of Resident Property to State Authorities
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime, specifically the suspected theft of two wedding rings by a Certified Nurse Assistant (CNA), to the California Department of Public Health (CDPH) and the Ombudsman's office as required by facility policy. The policy states that all allegations of suspected or actual abuse, including misappropriation of resident property, must be reported to the local police, Ombudsman, and CDPH within two hours. In this case, two residents were affected: one with severe cognitive impairment and requiring significant assistance with daily activities, and another with intact cognition but severe hearing and vision loss, also requiring substantial staff assistance. Both residents were not their own responsible parties. The events leading to the deficiency included reports from family members that the residents' wedding rings were missing, and subsequent suspicion that CNA D, who was assigned to both residents, had stolen the rings. The administrator confirmed that after noticing an online post from CNA D selling jewelry and being informed of the missing rings, the police were notified immediately. However, the facility did not report the suspicion of theft to CDPH or the Ombudsman's office as required, despite having reasonable suspicion of a crime involving resident property.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for its staff as required by its own policies and procedures. According to the facility's policy, all personnel are required to attend scheduled training classes, and make-up classes should be provided for any missed sessions. However, record review and interviews with the Director of Staff Development (DSD) revealed that attendance at several mandatory in-services was extremely low, with only two or three staff members attending each session. Specific in-services with poor attendance included topics such as Theft and Loss-Residents Personal Property, Dementia Module #2, Abuse and Neglect, and Advanced Directives and POLST. Some required in-services were not conducted at all during the year, and others were not rescheduled after being missed. The DSD confirmed that, although in-services were scheduled twice a week to allow staff a second opportunity to attend, there were no formal attempts to provide make-up classes for those who missed both sessions. Instead, missed content was sometimes addressed through one-on-one education or during team huddles, but there was no documentation or structured process for these alternatives. This lack of adherence to the facility's own training attendance policy had the potential to impact residents' ability to attain or maintain their physical, mental, and psychosocial well-being.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately tempered meals to all five sampled residents, as required by its own Food and Nutrition Services policy. Multiple residents with good cognitive status reported that the food was unappetizing, often cold, overcooked, and contained an unpleasant, pervasive spice. Observations confirmed that residents grimaced and declined to eat meals due to these issues, and staff acknowledged ongoing concerns with food quality, including tough meats and repetitive menu items such as rice. Resident Council meeting notes and suggestion forms documented repeated complaints about cold food and inadequate meal temperatures. The facility attempted to address these concerns by repairing equipment and implementing time logs for meal delivery, but interviews and records indicated that these measures were not fully effective. Residents continued to express dissatisfaction with food temperature and quality, and some reported simply not eating disliked items without informing staff. Record reviews and interviews with dietary staff revealed significant lapses in monitoring and documentation. Food temperature logs were incomplete or missing for multiple meals over several days, and cart audit logs were not consistently filled out by staff, making it impossible to determine whether cold food resulted from dietary preparation or delayed tray delivery. The Dietary Manager admitted to insufficient training on temperature log procedures and acknowledged a shortage of warming pellets, further contributing to the problem.
Failure to Follow Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow safe infection control practices for three out of four sampled residents. In one instance, a student nurse aide entered a resident's room, climbed onto a mattress without wearing any personal protective equipment (PPE), and made direct contact with the mattress using both hands and knees. The aide then adjusted her own clothing and proceeded to touch another resident in the same room without performing hand hygiene before or after resident contact. The aide confirmed that she did not use PPE as required for high-contact activities, despite signage indicating the need for gowns and gloves during such care for residents on Enhanced Barrier Precautions (EBP). The Assistant Director of Nursing, who was present, acknowledged not instructing the aide to use PPE. In another instance, a resident with a foley catheter and a wound did not have EBP signage or PPE available outside the room, as required by facility policy. During care, a certified nurse assistant handled the resident's foley catheter tube with bare hands and attempted to reattach it without gloves. The infection preventionist confirmed that the resident should have been on EBP and that the necessary signage and PPE were missing. The CNA later acknowledged that gloves should have been worn during the procedure.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for five out of five sampled residents, resulting in prolonged wait times for assistance. Multiple residents, all with good cognitive status as indicated by their BIMS scores, reported waiting up to two hours for their call lights to be answered. One resident, who had chronic obstructive pulmonary disease (COPD), major depressive disorder, and was dependent on supplemental oxygen, described having to leave her room to seek help in the hallway after her call light was not answered. Another resident confirmed witnessing this event and stated that staff were observed laughing and joking outside the room while call lights were ignored. Residents expressed frustration and emotional distress due to these delays, with one resident reporting feelings of anger, worthlessness, and a lack of motivation to eat or participate in daily activities. Family members and residents reported these concerns to facility staff and during Resident Council meetings, where the issue of delayed call light response was repeatedly raised as ongoing. Facility records and interviews confirmed that department heads were conducting daily call light audits in response to these concerns. On one occasion, the Assistant Director of Nursing found a resident in the hallway seeking help after a long wait, and staff were unable to provide documentation of timely responses or progress notes regarding the incident. The facility's policy required call lights to be answered as soon as practicable, but this standard was not met according to resident and family reports, as well as direct observations. Additional residents corroborated the ongoing nature of the problem, with one stating that while they did not frequently use the call light, other residents continued to experience long wait times. Roommates confirmed that during extended delays, they would use the bathroom emergency light to prompt a faster response from staff. Resident Council meeting notes from multiple months documented persistent concerns about untimely call light responses, indicating that the deficiency was not an isolated event but a recurring issue affecting multiple residents.
Failure to Implement Catheter Orders and Document Care
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with a suprapubic catheter. Specifically, the facility did not implement a urologist's order for daily sterile water flushes of the resident's suprapubic catheter on days when Renacidin was not used. Review of the resident's medical record and interviews with facility staff confirmed that the order for daily flushes was not entered into the electronic medical record, and nursing staff did not follow up to ensure the order was implemented. The resident had a history of urinary tract infection and obstructive and reflux uropathy, and was not their own responsible party. Additionally, the treatment nurse failed to document the care provided or an assessment after a complication was reported with the resident's suprapubic catheter. Progress notes indicated the resident had no urine output overnight and the treatment nurse was to flush the catheter, but there was no documentation of the procedure or assessment in the medical record. The treatment nurse later confirmed that the catheter was flushed and there was sediment present, but acknowledged that the procedure and outcome were not documented as required by facility policy.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient and qualified nursing staff to meet the needs of residents, resulting in delayed responses to call lights and inadequate care. This deficiency was observed in nine of the 22 sampled residents and three of five confidentially interviewed residents. The lack of timely response to call lights led to incidents such as falls, residents being left in soiled conditions, and extended waiting times for assistance, which could potentially result in adverse health outcomes. Several residents reported that call lights were not answered promptly, particularly during meal times when staff were occupied with other duties. Residents expressed concerns about inadequate staffing levels, which affected their ability to receive timely assistance. For instance, one resident mentioned having to plan their needs around staff availability, while another reported waiting over 30 minutes for help, leading to a fall. These accounts highlight the impact of staffing shortages on the quality of care provided to residents. Observations and interviews with staff further corroborated the issue of insufficient staffing. A CNA noted that some staff members did not respond to call lights if the resident was not assigned to them, and the DON acknowledged that some staff required additional coaching to fulfill their responsibilities. These findings indicate systemic issues within the facility's staffing and response protocols, contributing to the deficiency in meeting residents' needs effectively.
Cold and Unappetizing Meals Served to Residents
Penalty
Summary
The facility failed to provide meals at a palatable temperature, affecting 10 of 22 sampled residents and five confidentially interviewed residents who reported that the food was cold and bland. The facility's policy requires hot foods to be held at 135 degrees or above and cold foods at 41 degrees or below until served. However, during an observation, meal trays were placed in a tray transportation cart at 7:55 AM, and the cart arrived in the dining room at 8:06 AM. The cart doors were opened immediately, exposing the trays to cold air, and the first tray was not served until 8:22 AM, 27 minutes after the cart's arrival. The Registered Dietitian (RD) checked the food temperatures and found scrambled eggs at 126 degrees, indicating they were cold. Interviews with residents revealed consistent complaints about the food being cold and unappetizing. Resident 12, who is cognitively intact, expressed dissatisfaction with receiving food items they disliked and noted that it took an hour to receive alternatives. Resident 67, with moderate cognitive impairment, reported skipping breakfast due to cold food. Other residents, including those with conditions such as Parkinson's, dementia, and muscle weakness, also reported similar issues with meal temperatures and palatability. The deficiency was further highlighted by interviews with residents who consistently reported that meals were served cold and often late. Residents with various medical conditions, including diabetes, depression, and COPD, expressed dissatisfaction with the meal service, noting that it affected their willingness to eat. The facility's failure to adhere to its policy on meal temperatures and timely service contributed to the residents' complaints and dissatisfaction with the food quality.
Kitchen Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, as observed during a survey. An electric pest control device above a refrigerator was covered with a dark substance, indicating a lack of regular cleaning. The floor and wall near food preparation areas were found to have black debris and gray patches, further highlighting the neglect in maintaining hygiene standards. Additionally, grime was present on the door and doorknob of the food storage room, and black stains were observed on the ceiling from air blowing out of vents in two storage rooms. These conditions were confirmed by the Registered Dietitian, who acknowledged that the areas should be cleaned at least monthly according to the facility's cleaning schedule.
Infection Control Deficiencies in Hand Hygiene and Personal Item Sanitation
Penalty
Summary
The facility failed to maintain an effective infection control program as evidenced by the actions of a Licensed Vocational Nurse (LVN) who did not perform hand hygiene during medication administration. The LVN was observed administering medications, a breathing treatment, and nasal sprays to a resident without performing hand hygiene before preparing the next resident's medications. Additionally, the LVN wiped a liquid from the medication cart with her hand and dried it on her clothes, again failing to perform hand hygiene before proceeding to the next resident's room with medications. These actions were acknowledged by the LVN, who admitted that hand hygiene should have been performed to prevent the spread of infections. The facility also failed to ensure the cleanliness of a resident's personal item, specifically a water tumbler. The tumbler was observed to be covered with dust, white and brown spots, and black particles. The resident expressed a desire for the tumbler to be washed. The Director of Staff Development confirmed the tumbler's dirty condition and admitted to not knowing the process for washing it, as it was owned by the resident. The Registered Dietitian indicated that the facility had not been washing residents' personal items, which should be done to maintain sanitation.
Failure to Maintain Dignity During Meal Times
Penalty
Summary
The facility failed to maintain dignity and respect for two residents during meal times. For Resident 39, a Certified Nursing Assistant (CNA) assisted her with her lunch meal while sitting behind her, causing the resident to face the wall and be unable to see the CNA or other residents. This was contrary to the facility's policy which emphasized providing a dignified dining experience and encouraging socialization during meals. The CNA acknowledged that it would be better if Resident 39 could see her, and the Director of Nursing confirmed that the resident should face the staff member assisting her. Resident 285 experienced a delay in receiving her breakfast, which was delivered to her room instead of the assisted dining room where she was supposed to eat. The breakfast tray was placed out of her reach, and when she was brought to the dining room, her tray was not delivered. As a result, she had to wait while other residents were eating, and she expressed feeling forgotten. The Assistant Director of Nursing acknowledged that this was a dignity issue, as Resident 285 had to wait for her meal. Both incidents highlight the facility's failure to adhere to its policies regarding dignified dining experiences and proper assistance with meals. These deficiencies were observed through interviews, record reviews, and direct observations, indicating a lapse in ensuring residents' rights to dignity and self-worth during meal times.
Deficiencies in Maintaining a Homelike Environment and Equipment Cleanliness
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by the condition of the walls in two residents' rooms and the state of a Hoyer lift used for resident care. In the case of Resident 285, the wall next to the bed was covered with unpainted mud, which the resident confirmed needed painting. Similarly, Resident 76's room had a wall that was scratched and chipped, with black marks. The Maintenance Supervisor acknowledged the need for repairs, citing that the walls often get scratched by beds and that there was insufficient time to paint before residents were moved in. Additionally, the facility did not adhere to its policy on cleaning and disinfecting resident-care equipment. A Hoyer lift, observed in the hallway, was found to be soiled with dried brown and white matter. Despite being informed of the issue, the lift remained in a dirty condition for several days. A Licensed Vocational Nurse confirmed that the lift was used on residents and stated that it was the night shift's responsibility to clean such equipment. The Administrator later mentioned that the lift was taken to be washed, but it was not cleaned promptly after the issue was identified.
Failure to Report Alleged Abuse to CDPH
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) when a resident alleged that she heard another resident being raped. The incident was initially reported by the resident to a Licensed Vocational Nurse (LVN), who then informed the oncoming day shift nurse. However, there was no documentation of the incident in the resident's medical record, and the facility did not report the allegation to CDPH. The Administrator (ADM) and Director of Nursing (DON) confirmed during interviews that the facility conducted an investigation but did not substantiate the claim and did not file the required SOC-341 (Elder Abuse) report with CDPH. The residents involved had varying levels of cognitive function, with the alleged victim and the reporting resident both scoring 15 on the Brief Interview for Mental Status (BIMS) test, indicating normal mental function. The alleged perpetrator scored 11, indicating mild cognitive impairment. Interviews with the residents involved revealed no recollection of the incident, and the alleged victim denied any problems or discomfort. Despite the police being called and involved, the facility did not follow through with the necessary reporting to CDPH, which created the potential for ongoing undetected resident abuse.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a 10% medication error rate during a medication pass, exceeding the acceptable threshold of 5%. This was observed when three medication errors occurred out of 30 opportunities. The errors involved a Licensed Vocational Nurse (LVN) who incorrectly prepared medications for a resident. The LVN prepared COQ-10 and Omega-3 supplements in incorrect dosages, providing only half of the prescribed amounts. Additionally, the LVN failed to administer Lasix, a medication for fluid retention, because it was unavailable in the medication cart. The LVN acknowledged the discrepancies in the medication dosages and the unavailability of Lasix. It was later confirmed by another LVN that the Lasix was available in the facility's Cubex, a locked cabinet for emergency medications, but was not retrieved. The Director of Nursing verified that the Lasix should have been administered as prescribed by accessing the Cubex. The facility's policy requires medications to be administered safely, timely, and as prescribed, which was not adhered to in this instance.
Failure to Date Opened Tubersol Vial
Penalty
Summary
The facility failed to ensure that an open multi-dose vial of Tubersol, a solution used for TB skin tests, was dated when opened. This oversight was identified during an observation, interview, and document review involving the Director of Nursing (DON). The open vial was found in the refrigerator of a medication room and was available for use without a date indicating when it was opened. According to the facility's policy and the manufacturer's instructions, multi-dose vials should be dated when opened and discarded within a specified timeframe, which in this case was 30 days. The DON confirmed that the vial was not dated and acknowledged that it should not be used as it might not be effective.
Failure to Provide Snacks Without Resident Request
Penalty
Summary
The facility failed to ensure that snacks were offered to residents between meals and at bedtime without the residents having to ask, affecting one of 22 sampled residents and five confidentially interviewed residents. Observations and interviews revealed that residents were not being offered snacks, leading to feelings of hunger and discomfort. One resident mentioned that snacks used to be provided but were stopped without explanation, while another resident expressed that the absence of snacks left them feeling hungry. The facility's policy on snacks, revised in September 2010, indicated that snacks should be placed within easy reach of residents to provide adequate nutrition. However, the Registered Dietitian confirmed that the facility had changed its snack distribution procedure, requiring residents to request snacks instead of having them delivered to their rooms. This change was not well-received by the residents, as they preferred the previous system where snacks were brought to their rooms. Resident 27, who had intact cognition and was admitted with diagnoses including lung disease and chronic pain, expressed dissatisfaction with the current system, preferring snacks to be delivered to his room.
Failure to Follow Nephrostomy Care Orders
Penalty
Summary
The facility failed to adhere to physician's orders regarding the care of a nephrostomy tube for a resident, leading to a deficiency. The resident, who was admitted with multiple fistulas and a history of urinary tract infections, had specific physician's orders to keep the nephrostomy site covered during showers to prevent infection. However, observations and interviews revealed that staff routinely removed the dressing before showers, contrary to the physician's instructions. This practice was confirmed by multiple staff members, including a Licensed Vocational Nurse (LVN), the Director of Nursing (DON), and a Certified Nursing Assistant (CNA), who all stated that the dressing was removed to clean the area with water and replaced afterward. Further interviews with a wound treatment nurse and an infection prevention nurse highlighted the importance of maintaining sterility at the nephrostomy site, emphasizing that the site should remain covered and sterile at all times. Despite this, the practice of removing the dressing during showers persisted, as confirmed by another LVN who believed that warm soapy water was used to clean the site. This deviation from the prescribed sterile procedure increased the risk of infection for the resident, as the nephrostomy site was left exposed during showers.
Failure to Address Staffing Issues and Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure that direct care staff met the needs of six residents, resulting in delays in activities of daily living such as toileting, showers, and hydration. This led to residents experiencing unrelieved pain, feeling closed in, and feeling forgotten. The facility's policy on grievances and complaints was reviewed, which indicated that grievances should be promptly investigated and resolved. However, the facility did not adhere to this policy, as evidenced by the lack of administrative responses or solutions to ongoing staffing issues reported in resident council meeting minutes over several months. Interviews with residents and family members revealed that call lights were not being answered timely across all shifts, leading to significant delays in receiving assistance. Residents reported waiting up to an hour for help with toileting, experiencing pain due to delayed care, and feeling neglected. One resident mentioned having to wait over nine hours to be put back into bed, resulting in severe pain. Family members also observed that urinary bags were not being emptied when full, and residents had to seek assistance themselves due to the lack of staff response. The facility's administration acknowledged the staffing issues but had not included them in their Quality Assurance Performance Improvement plans. The Director of Staff Development admitted to not having time to audit call lights or provide oversight due to other responsibilities, such as conducting CNA training and handling human resources tasks. The Administrator and Director of Nursing were unaware of the extent of the resident complaints about call light response times and had not conducted a root cause analysis to address the issue. This lack of action and oversight contributed to the ongoing deficiencies in resident care.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of six out of nine residents, resulting in delays in activities of daily living such as toileting, showers, and hydration. Residents reported waiting up to an hour for call lights to be answered, leading to feelings of being closed in and forgotten. Specific instances included residents waiting for pain medication, assistance with urinary bags, and being put back into bed, causing severe pain and embarrassment. The issue was noted across all shifts, with particular emphasis on the evening shift. Family members and residents consistently reported these delays, and the resident council meeting minutes corroborated these ongoing issues. Interviews with staff, including the Director of Social Services, Administrator, and Director of Staff Development, confirmed the facility's short-staffing problem. The facility had recently let go of five CNAs due to certification testing issues, and there was no use of registry staff to supplement the workforce. The Administrator admitted that staffing issues were not included in their Quality Assurance Performance Improvement plans, and no root cause analysis had been conducted. The Director of Staff Development also highlighted the lack of time to audit call lights and monitor staff due to her responsibilities in clinical training and human resources.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, resulting in the resident experiencing constant pain without receiving routine pain medication. The nursing staff administered the wrong pain medication for the wrong pain level multiple times, leading to the resident not being properly medicated when in severe pain. The facility's policies on pain management were not followed, and the resident's pain assessments were inconsistent and inadequately documented. The resident, who had a history of vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, reported experiencing pain frequently and rated her pain as high as 10 out of 10. Despite this, the resident did not receive scheduled pain medication and was often given PRN medications that were not effective. The resident expressed dissatisfaction with the pain management, stating that the medication did not help and that she was in constant pain. Interviews with the nursing staff and the Director of Nursing revealed that there were issues with new nurses not conducting pain assessments correctly and the Medical Director being slow to adjust pain medication prescriptions. The resident's Medication Administration Records showed numerous instances of incorrect medication administration, with pain levels not matching the prescribed medication. The facility's failure to adhere to its pain management policies and properly address the resident's pain needs led to the deficiency.
Deficiencies in Pain Management and Diabetic Care
Penalty
Summary
The facility failed to provide nursing staff with the necessary competencies and skill sets to meet the care and services for residents' needs, resulting in increased pain and discomfort for two residents. Resident 1, who had multiple diagnoses including vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, was given incorrect pain medications multiple times over several months. The medication administration records (MARs) showed numerous instances where Resident 1 was given the wrong medication at the wrong pain level. Additionally, a urinalysis ordered for Resident 1 was delayed, and the positive results indicating a urinary tract infection were not communicated to the medical director in a timely manner. Resident 1 reported constant pain and confusion, and the staff failed to perform and document an infection screen after the urinalysis was ordered and collected. Resident 2, who had type 2 diabetes and heart disease, experienced frequent low blood sugar levels that were not properly managed. The facility's pharmacy was out of Resident 2's prescribed Trulicity, leading to an increase in Metformin and Levemir dosages. Despite a downward trend in blood sugar levels, the medical director was not notified, and the medications were not adjusted when Trulicity became available again. Resident 2 reported low blood sugar levels and inadequate diabetic medication management, which was confirmed by a licensed nurse who admitted that the physician should have been notified about the blood sugar trends and medication availability. Interviews with staff and record reviews revealed that the facility had new nurses who were not performing pain assessments correctly, and there was confusion and inconsistency in the charting of Resident 1's pain medication. The medical director expressed expectations for timely reporting of changes in condition and timely processing of lab tests, which were not met. The administrator and director of nursing acknowledged the deficiencies in pain medication management and communication of lab results, contributing to the residents' increased pain and discomfort.
Failure to Ensure Timely Urology Consultation
Penalty
Summary
The facility failed to ensure a timely Urology consultation for a resident, resulting in delayed treatment, increased pain, and discomfort. The resident, who had multiple urinary tract infections and pain caused by her nephrostomy, experienced a six-month delay in scheduling and obtaining a Urology consult. The facility's policy required Social Services to coordinate referrals and document them in the resident's medical record, but this was not done in a timely manner for the resident in question. The resident was admitted with diagnoses including vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness. Despite multiple urinary tract infections and hospitalizations, the resident did not receive the necessary Urology consultation. The resident's medical records indicated multiple instances of urinary tract infections and related symptoms, but the facility did not arrange for the required specialist consultation. Interviews with staff revealed that there was a lack of communication and coordination between the facility's Social Services and nursing staff. The Director of Social Services was unaware of the resident's need for a Urology appointment, and the Director of Nursing confirmed that no plan was in place for the resident to see a Urologist. The Medical Doctor also noted that care coordination did not happen, and the resident missed an appointment due to hospitalization, further delaying necessary treatment.
Failure to Address Medication Irregularity
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) addressed and documented an identified medication irregularity for one of the residents. The consultant pharmacist had recommended clarifying multiple analgesic PRN orders with a narrative grading and/or numerical pain scale to avoid potential duplicate therapies. Despite this recommendation, the MD did not review, document, or act upon it, leading to improper pain management for the resident. The resident, who had a history of vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, experienced significant pain due to the lack of proper medication management. The resident's clinical records showed multiple instances where pain medications were administered at incorrect pain levels, resulting in inadequate pain relief. The resident reported constant pain and dissatisfaction with the pain medication, which was corroborated by her roommate and the Licensed Nurse (LN). Interviews with facility staff, including the LN, MD, and Director of Nursing (DON), revealed that the new nurses were not performing pain assessments correctly, and there was no documentation that the DON and MD had reviewed and acted upon the pharmacist's recommendations. This oversight led to the resident suffering from unmanaged pain, highlighting a significant deficiency in the facility's medication management process.
Failure to Properly Manage Diabetic Medications
Penalty
Summary
The facility failed to ensure that Resident 2 did not receive unnecessary medication when a diabetic medication, Trulicity, was unavailable. Instead of adjusting the medication regimen appropriately, the facility increased the doses of Metformin and Levemir. This adjustment was not reverted once Trulicity became available again, leading to frequent low blood sugar levels for Resident 2. The resident's blood sugar levels were often below 100 mg/dL, with a notable instance of 64 mg/dL, which is considered dangerously low according to the National Institute of Diabetes. Despite these low readings, the physician was not notified in a timely manner to adjust the medications accordingly. Resident 2, who has type 2 diabetes and heart disease, experienced frequent low blood sugar levels due to the improper management of her diabetic medications. The facility's Licensed Nurse (LN) confirmed that the physician was not informed about the downward trend in blood sugar levels or the availability of Trulicity, which should have prompted a review and adjustment of the medication regimen. This oversight resulted in Resident 2 experiencing low blood sugar levels, which could have been avoided with proper communication and timely adjustments to her medication regimen.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results for a resident, leading to delayed treatment and increased pain and discomfort. The resident had a urinalysis ordered on 4/11/2024, but the urine sample was not collected until 4/13/2024. The preliminary report of the urinalysis was sent to the physician on 4/14/2024, but the final urine culture report, which showed significant bacterial growth, was not communicated to the physician at all. The resident, who had a history of vesicovaginal fistula, congenital rectovaginal fistula, diabetes, and muscle weakness, experienced confusion, back pain, weight loss, and lack of appetite. Despite these symptoms, the facility did not perform an infection screen or document it in the resident's medical record after the urinalysis was ordered and collected. The Infection Preventionist was unaware of the positive urine culture report, and the physician was not notified of the final results. Interviews with staff revealed that the facility had issues with tracking antibiotic usage and infection screening. The physician expressed expectations for timely reporting of any changes in the resident's condition, including signs of a possible urinary tract infection. However, the facility's delays in processing and communicating lab results contributed to the resident's prolonged discomfort and untreated infection.
Failure to Inform Representatives of Dental Health Status
Penalty
Summary
The facility failed to fully inform residents' representatives (RPs) of the residents' dental health status and allow participation in decision-making for care to be provided. Specifically, the Registered Dental Hygienist of Alternative Practice (RDHAP) identified oral issues and changes in conditions for three residents, but their respective RPs were not notified of these findings or the potential need for a dentist consult. This lack of communication was evident in the cases of Resident 1, Resident 2, and Resident 3, where significant dental issues such as missing teeth, visible cavitation, retained roots, and general demineralization were documented but not communicated to the RPs. Resident 1 had several dental evaluations indicating missing teeth, visible cavitation, retained roots, and general demineralization. Despite these findings, RP 1 was not informed, and there was no discussion about dental issues during the multidisciplinary care conference. Similarly, Resident 2's dental evaluation showed several missing teeth, retained roots, general demineralization, and fractured teeth, but RP 2 was not notified, and dental issues were not addressed during the care conference. Resident 3's evaluation revealed white spot lesions, general demineralization, and visible cavitation, yet RP 3 was also not informed, and dental issues were not discussed during the care conference. Interviews with the Social Services Director (SSD) and the RDHAP confirmed that there was no communication regarding the need for further dental treatment from a dentist for these residents. The RDHAP expected that their evaluation results would be discussed during care conferences, but this did not occur. The Administrator also confirmed that no communications were made to the RPs about obtaining further dental treatment, as the RDHAP did not make any recommendations for dentist referrals. This failure to inform the RPs and involve them in decision-making regarding dental care led to a deficiency in the facility's compliance with its policy on notifying residents and their representatives of changes in medical or dental conditions.
Inaccurate Dental Assessments in MDS
Penalty
Summary
The facility failed to accurately evaluate and record assessments reflective of the dental status for four residents. Resident 1 was observed to have multiple dental issues, including cavities, missing teeth, and retained roots, which were not accurately documented in the Minimum Data Set (MDS). Despite multiple evaluations by a Registered Dental Hygienist of Alternative Practice (RDHAP) indicating these issues, the MDS inaccurately marked Resident 1 as having no cavities or broken natural teeth. Similar discrepancies were found in the records of Residents 2 and 3, where the MDS did not reflect the presence of cavities, broken teeth, or other dental issues as noted in their RDHAP evaluations. Resident 4 was incorrectly coded as edentulous in the MDS, despite having a full set of dentures. This error was confirmed during a review of the resident's face sheet and an interview with the facility's Administrator. The MDS nurse admitted that the assessments were not conducted properly, as the residents' mouths were not visually inspected as required by the facility's policy and guidance for completing Section L of the MDS. The nurse stated that the MDS should be completed by marking the appropriate boxes based on direct observation of the resident's dental status. The Administrator and Director of Nursing confirmed that the MDS for all four residents were incorrectly coded. This failure to accurately assess and document the residents' dental status had the potential to result in mismanagement of their dental health, leading to further health decline and negatively impacting their psychosocial and emotional well-being.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to pursue routine or emergency dental services for three residents who were evaluated by a Registered Dental Hygienist of Alternative Practice (RDHAP) but were not referred to a dentist despite identified dental problems. Resident 1 had cavities and retained roots but was not referred to a dentist. Resident 2 had retained roots and fractured teeth but was not referred to a dentist. Resident 3 had white spot lesions and cavities but was not referred to a dentist. These failures were observed through interviews, record reviews, and direct observations, indicating a lack of follow-up on identified dental issues. Resident 1 was admitted with diagnoses including Activated Protein C Resistance, Degenerative Disease of the Nervous System, and Anemia. Despite complaints of tooth pain and an evaluation by a dentist who identified extensive dental issues, there was a significant delay in care. The resident's representative felt that earlier dental intervention could have prevented the severity of the current dental issues. The facility's administrator and social services director confirmed that no recommendations for dental referrals were made by the RDHAP, and thus no follow-up actions were taken. Resident 2, diagnosed with Frontotemporal Neurocognitive Disorder, Urinary Tract Infection, and High blood pressure, was also not referred to a dentist despite the RDHAP identifying several dental issues. Similarly, Resident 3, with diagnoses including Systemic Involvement of Connective Tissue, Emphysema, and Epilepsy, was not referred to a dentist despite having significant dental problems. The facility's policy and procedures for dental care were not followed, as the RDHAP did not recommend further dental treatment unless there was a complaint of pain, leading to a lack of necessary dental care for these residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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