Lomita Post-acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lomita, California.
- Location
- 1955 Lomita Blvd, Lomita, California 90717
- CMS Provider Number
- 055262
- Inspections on file
- 24
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Lomita Post-acute Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to respond promptly to call lights and provide timely ADL assistance for three cognitively intact residents who required varying levels of help with toileting, transfers, and incontinence care. One resident reported waiting 30–60 minutes at night for assistance with bathroom use and water, and another reported similar delays for incontinence care. A third resident, fully dependent for toileting and always incontinent, was observed with the call light on requesting to urinate while an ADM and a CNA instructed her to void in her brief instead of offering a bedpan or bedside commode, despite her stating she was continent and disliked being left wet. Staff interviews, including a CNA, an LVN, and the DON, confirmed that all staff were expected to answer call lights promptly and that the observed and reported delays and directions to use briefs were inconsistent with facility policies on call light response and perineal care.
A resident with a history of stroke and left side paralysis, who was dependent on staff and had a care plan for pain management, reported pain in her left arm and hand during showering and transfer. Staff did not provide timely pain relief or report the pain as required, resulting in unmanaged pain despite facility policy and care plan interventions.
A facility failed to post a contact precaution sign indicating necessary PPE for visitors of a resident who tested positive for C. Diff. Although staff instructions were present, visitor instructions were missing, which was acknowledged by an RN. The resident had a history of surgical amputation and type 2 DM, and tested positive for C. Diff. Facility policies emphasized infection control, but the lack of visitor signage represented a policy adherence failure.
The facility failed to maintain an effective pest control program, leading to a gnat infestation in various areas, including residents' rooms and the kitchen. Observations revealed unsanitary conditions, such as undated food containers and a strong odor in the shared refrigerator. Staff and family members reported gnats emerging during meal times, with potential contamination risks for residents. Despite efforts to address the issue, the facility's response was delayed, and pest control measures were not promptly implemented.
The facility failed to complete accurate PASARR assessments for three residents diagnosed with mental illnesses prior to admission. These residents were prescribed psychotropic medications, but their PASARR assessments did not reflect their diagnoses, potentially impacting their care. The DON acknowledged the inaccuracies, which could delay necessary treatment and services.
A resident's hearing status was inaccurately documented as adequate in the MDS, despite being hard of hearing and requiring specific communication interventions. Interviews with staff and the resident confirmed the need for hearing aids, and both the MDS Nurse and DON acknowledged the error, emphasizing the importance of accurate MDS documentation.
A resident on Eliquis for venous thrombosis and undergoing renal dialysis was not monitored for bleeding as required by their care plan. Despite the care plan's directives and the facility's policy on anticoagulation management, there was no documentation of monitoring for signs of bleeding, leading to a deficiency in care.
A resident with a hip fracture and other medical conditions was not provided necessary assistance with ADLs, leading to feelings of abandonment. The resident requested a shower due to a wet diaper, but the CNA encountered difficulties with the transfer and did not follow through with promised care. Lack of communication and coordination among staff contributed to the unmet needs.
A resident with a history of a ruptured popliteal artery did not receive a timely venous and arterial doppler test as ordered by the physician due to the unavailability of an x-ray technician. The facility failed to notify the physician of the delay, and there was inadequate monitoring of a hematoma on the resident's left leg, as it was only visually checked without accurate measurement. This lack of communication and assessment could have delayed diagnosis and treatment.
A resident with anxiety and major depressive disorder was not provided access to necessary hearing services despite being hard of hearing. The care plan noted communication issues, and staff confirmed the resident's need for hearing aids. The facility's policy required assessment for ancillary services, but the resident did not receive the needed audiology services.
A resident at risk for falls had a bedside table placed on top of landing pads intended to cushion falls, posing a potential injury risk. Facility staff acknowledged the inappropriate placement and the potential hazard it created.
The facility failed to maintain up-to-date employee files, resulting in missing TB tests, skills competency checklists, performance evaluations, health exams, and background checks for several staff members. The DSD and DON acknowledged these deficiencies, which could impact resident care and safety.
Two residents were affected by the facility's failure to monitor and justify medication use. One resident was on methenamine without proper testing or history of UTIs, risking antibiotic resistance. Another resident on Eliquis lacked monitoring for adverse effects, risking bleeding and anemia. Facility policies on medication management were not followed.
Two residents were administered psychotropic medications without proper non-pharmacological interventions or reevaluation of medication appropriateness. One resident received Ativan without documented anxiety episodes or attempts at non-pharmacological interventions, while another resident's medication regimen was not reviewed despite recommendations. Facility policies on medication administration were not followed, leading to potential unnecessary medication use.
A medication cart was left unlocked and unattended by an LVN during medication administration, posing a risk of unauthorized access and accidental ingestion by residents. Interviews with the RNS and DON confirmed the importance of securing the cart, as outlined in the facility's policy.
The facility failed to follow infection control protocols for two residents by not changing and labeling nasal cannulas as per policy. A resident's outdated nasal cannula was not replaced weekly, and another resident's nasal cannula and humidifier were not labeled upon admission, increasing infection risk.
The facility lacked a qualified Infection Preventionist (IP) with the necessary CDC-required training. The IPN held a 16-hour Boot Camp certificate, insufficient for the 19.75-hour requirement. The IPN and DON acknowledged the certification gap, and no policy outlined the required qualifications. The facility's job description mandated compliance with CDC and OSHA regulations, which was not achieved.
The facility failed to meet the required square footage per resident in 12 rooms, with some rooms housing two residents each measuring between 68.75 to 77.6 square feet per resident, and single-resident rooms not meeting the 100 square feet requirement. Despite this, observations showed residents had sufficient space for movement and care, with no adverse effects on privacy, health, or safety noted.
Failure to Provide Timely ADL Assistance and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs) and to respond promptly to call lights for three residents who required staff help. Surveyors observed a resident’s call light illuminated while an LVN, PT, and CNAs walked past the room without responding. Facility policy on call lights stated they were to be answered within a reasonable time, and the DON, LVN, and CNA interviewed all stated that all staff were responsible for answering call lights as soon as they were activated. One resident with diabetes, gait abnormalities, and coordination problems required substantial to maximal assistance with lower body dressing, toileting hygiene, transfers, and bed mobility, and was cognitively intact and able to communicate needs. This resident reported that on unspecified dates it sometimes took 30 minutes to one hour for night-shift nurses to respond to call lights for assistance with bathroom use and obtaining water. Another resident with diabetes, gait abnormalities, and a right below-knee amputation, who required supervision or touching assistance for ADLs and was frequently incontinent of urine and occasionally incontinent of bowel, stated that it sometimes took one hour for night-shift nurses to respond to call lights for incontinence care. A third resident with COPD, diabetes, gait abnormalities, and muscle weakness was totally dependent on staff for toileting, showering, and lower body dressing, was always incontinent of bowel and bladder, and was care planned for nursing assistance with toilet use. During observation and interview, this resident was seated in a chair with the call light on, stating a need to urinate. The ADM and CNA told the resident to urinate in the incontinence brief, and the resident reported that staff typically took about 30 minutes to respond to call lights, that she considered herself continent, that staff told her to urinate in her brief, and that she had not been provided a bedside commode and did not like being left wet while waiting to be changed. CNA and LVN interviews confirmed that telling the resident to urinate in the brief instead of offering a bedpan or bedside commode was not appropriate and that leaving residents wet or with unanswered call lights for extended periods was inconsistent with facility expectations and policies for perineal care and call light response.
Failure to Provide Timely Pain Management for Resident with Known Pain History
Penalty
Summary
A deficiency occurred when a resident with a history of cerebrovascular accident (CVA) and left side hemiplegia, who was known to experience acute and chronic pain, reported pain in her left arm and hand during care activities. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, informed a CNA that her left hand was in pain after it became caught in the shower chair and again when it was stuck behind her during a mechanical lift transfer. Despite the resident's complaints, she was told to wait until after the shower, and her pain was not addressed at the time. The CNA stated she informed the LVN of the resident's pain, but the LVN reported being unaware of any pain complaints. Additionally, a restorative nursing assistant present during the transfer did not report the pain to anyone. The resident was not premedicated prior to care, despite her known history of pain and a care plan that called for administering pain medication before activities likely to cause discomfort. The facility's policy required prompt assessment and intervention for pain, but these steps were not followed, resulting in unmanaged pain for the resident.
Failure to Post Visitor PPE Instructions for C. Diff Positive Resident
Penalty
Summary
The facility failed to ensure that a contact precaution sign indicating the necessary personal protective equipment (PPE) for visitors was posted for a resident who tested positive for Clostridium difficile (C. Diff). This oversight was identified during an observation and interview with a Registered Nurse (RN) in front of the resident's room. Although a stop sign was present, instructing staff to follow contact isolation procedures and apply PPE, it did not provide instructions for visitors to wear PPE. The RN acknowledged the absence of visitor instructions and emphasized the importance of such signage to prevent the spread of C. Diff to other residents, visitors, and staff. The resident involved was admitted to the facility with diagnoses including orthopedic aftercare following surgical amputation and type 2 Diabetes Mellitus. The resident's lab results confirmed a positive test for C. Diff. The facility's policy and procedure documents, including the Infection Prevention and Control Program and Transmission-Based Precautions, as well as the Visitation policy, were reviewed. These documents indicated the facility's commitment to implementing infection control measures and establishing guidelines for visitors to prevent the transmission of communicable diseases. However, the lack of appropriate signage for visitors in this case represented a failure to adhere to these policies.
Facility Fails to Control Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of gnats throughout the premises. Observations revealed gnats in various areas, including the residents' shared refrigerator, Resident 3's room, and the kitchen storage room. The shared refrigerator was found to contain numerous gnats, undated food containers, and a strong odor, indicating a lack of sanitation. Resident 3, who has cognitive impairments and requires assistance with daily activities, was observed swatting gnats away from her food, highlighting the potential for contamination. Interviews with staff and family members confirmed the presence of gnats during meal times, with reports of gnats emerging when food was present. The Dietary Manager and Maintenance Director acknowledged the issue, noting that the gnats were primarily originating from the kitchen drainage and bad fruits in the pantry. Despite efforts to clean and pour hot water down the drains, the infestation persisted. The Maintenance Director admitted that the facility's response was delayed, and pest control measures, such as fogging the kitchen, were not immediately implemented. The facility's pest control policy was not effectively enforced, as evidenced by the lack of UV fly traps in key areas and the improper maintenance of existing traps. The Director of Nursing and other staff members recognized the ongoing issue, with reports of gnats in residents' rooms and dining areas. The facility's failure to adhere to its policies on food storage and environmental sanitation contributed to the infestation, posing a risk of food contamination and discomfort for residents and staff.
Failure to Complete Accurate PASARR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that three residents, who were diagnosed with mental illnesses prior to admission, had a Preadmission Screening and Resident Review (PASARR) assessment completed. This federal requirement is intended to prevent inappropriate placement in nursing homes and ensure residents receive necessary psychiatric services. The deficiency was identified during interviews and record reviews, revealing that the PASARR assessments for these residents were either inaccurately completed or not reviewed, potentially impacting their care and treatment. Resident 22 was admitted with diagnoses including major depressive disorder and psychosis, and was prescribed multiple psychotropic medications. However, the PASARR Level 1 assessment did not reflect these diagnoses or medications. The Director of Nursing (DON) acknowledged the inaccuracies and the potential impact on the resident's care. Similarly, Resident 24, with diagnoses of major depressive disorder, psychosis, and bipolar disorder, had a PASARR that incorrectly indicated no mental illness, which the DON admitted was documented incorrectly. Resident 13, diagnosed with psychosis and prescribed psychotropic medication, also had a PASARR that failed to indicate the diagnosis. The DON confirmed the PASARR was completed inaccurately, which could affect the resident's care. The facility's policy requires accurate PASARR screenings, but the deficiencies in these cases suggest a failure to adhere to this policy, potentially delaying necessary treatment and services for the residents involved.
Inaccurate MDS Documentation of Resident's Hearing Status
Penalty
Summary
The facility failed to ensure the accurate documentation of a resident's hearing status in the Minimum Data Set (MDS), a federally mandated resident assessment tool. The resident, who was admitted with diagnoses including anxiety and major depressive disorder, was documented in the MDS as having adequate hearing. However, the resident's care plan indicated a communication problem related to being hard of hearing in both ears, with interventions such as repeating messages aloud and using non-verbal communication cues. Interviews with the resident, a Certified Nurse Assistant (CNA), and a Registered Nurse Supervisor (RNS) confirmed that the resident was hard of hearing and would benefit from hearing aids. The Minimum Data Set Nurse (MDSN) acknowledged that the MDS inaccurately reflected the resident's hearing as adequate instead of minimal, which was necessary to ensure the resident received appropriate care and services. The Director of Nursing (DON) also confirmed that the MDS should have been marked as minimal for the resident's hearing. The MDS Nurse's job description emphasized the importance of accurate MDS completion and validation of medical record documentation to support MDS coding, highlighting the deficiency in this case.
Failure to Implement Anticoagulant Monitoring Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for a resident receiving anti-coagulant therapy, specifically Eliquis, which is used to prevent or treat blood clots. The resident, who was admitted with diagnoses including venous thrombosis, embolism, and undergoing renal dialysis, had a care plan that required monitoring for signs and symptoms of bleeding, such as blood in urine, black tarry stools, and bruising. However, during interviews and record reviews, it was found that there was no documentation of monitoring for these symptoms, indicating that the care plan was not followed. Licensed Vocational Nurse (LVN) 3 and Registered Nurse Supervisor (RNS) 1 both acknowledged the lack of documentation and monitoring for bleeding, despite the resident's increased risk due to renal dialysis. The Director of Nursing (DON) also confirmed the importance of following the care plan to monitor for bleeding. The facility's policy on General Anticoagulation Management outlined the need for evaluation of bleeding, but this was not implemented for the resident, leading to a deficiency in care.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to Resident 163, who was dependent on staff for showering and toileting hygiene. Resident 163, who had a displaced intertrochanteric fracture of the left femur and other medical conditions, required substantial assistance with mobility and dressing. On the day of the incident, Resident 163 requested a shower due to a wet diaper, but the Certified Nursing Assistant (CNA1) encountered difficulties transferring the resident to the shower chair because of the resident's inability to bend her left leg. CNA1, who was inexperienced in transferring Resident 163, returned the resident to bed with the help of another staff member and promised to provide a bed bath after lunch. However, CNA1 did not follow through with this promise, leaving Resident 163 feeling abandoned and neglected. The resident used the call light for assistance but did not receive the necessary care in a timely manner. CNA1 admitted to not seeking additional help or information on how to properly assist Resident 163, which contributed to the resident's unmet needs. Interviews with other staff members, including CNA2, LVN2, and the Director of Nursing (DON), revealed a lack of communication and coordination in addressing Resident 163's needs. The Physical Therapist (PT1) and RN Supervisor (RNS1) indicated that proper assistance and communication were necessary to prevent such incidents. The facility's policies on resident rights and ADL care emphasize the importance of timely and respectful care, which was not upheld in this case.
Failure to Conduct Timely Medical Test and Monitor Hematoma
Penalty
Summary
The facility failed to provide necessary care and services to Resident 32 by not ensuring a venous and arterial doppler test was conducted in a timely manner as ordered by the physician. The physician had ordered the test on 10/28/2024 to assess circulation in the resident's left leg due to pain and swelling. However, the test was not performed because the x-ray technician was unavailable, and there was no documentation indicating that the physician was notified of this delay. This lack of communication and follow-up could have led to a delay in diagnosis and treatment for the resident. Additionally, the facility did not adequately monitor and assess the size of a hematoma on Resident 32's left leg. The hematoma was first documented on 9/16/2024, and although it was visually checked, there was no accurate measurement to determine if it was increasing or decreasing in size. The resident had a history of a ruptured popliteal artery and was experiencing discomfort, yet the assessment of the hematoma was not specific, and the licensed nurse did not measure its size. The facility's policies and procedures require that the nurse supervisor notify the resident's attending physician when there is a significant change in the resident's condition or treatment. However, in this case, there was no documentation of such notification, and the resident was not informed of the delay in the medical test. This oversight in communication and assessment could have resulted in a delay in addressing potential complications related to the resident's condition.
Failure to Provide Hearing Services to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, received access to necessary hearing services. Resident 12 was admitted with diagnoses including anxiety and major depressive disorder. Despite the Minimum Data Set (MDS) indicating normal hearing, the resident's care plan noted a communication problem related to being hard of hearing in both ears. The care plan included interventions such as repeating messages aloud and using non-verbal communication methods. However, interviews with the resident and staff, including a CNA, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that Resident 12 was hard of hearing and would benefit from hearing aids. The resident expressed a desire for hearing aids to improve her ability to hear, especially when watching television. The facility's policy on ancillary services stated that residents should be assessed for needs such as audiology services upon admission and reassessed quarterly or as needed. Despite this policy, the facility did not provide Resident 12 with access to hearing services, resulting in her continued difficulty in hearing. The staff acknowledged the resident's hearing issues and the potential benefits of hearing aids, yet no action was taken to address this need, leading to the deficiency noted in the report.
Inadequate Fall Risk Precaution for Resident
Penalty
Summary
The facility failed to provide appropriate safety precautions for a resident at risk for falls. Specifically, the resident, who had a history of transient ischemic attack, cardiac pacemaker, dementia, and anxiety, was on fall risk precaution with landing pads placed on the side of the bed. However, a bedside table was observed to be placed on top of the landing pads, which could potentially cause injury if the resident were to fall out of bed and hit their head on the table. Interviews with facility staff, including a CNA, LVN, RNS, and the DON, confirmed that the landing pads were intended to provide a cushioned landing to prevent injury in the event of a fall. The staff acknowledged that the placement of the bedside table on the landing pads was inappropriate and could pose a risk of injury to the resident. The facility's policy on falls indicated that interventions should be identified to prevent falls and address risks, but the presence of the bedside table on the landing pads was contrary to this protocol.
Deficiencies in Employee File Management and Competency Assessments
Penalty
Summary
The facility failed to ensure that employee files were reviewed and kept up to date, resulting in deficiencies in several key areas. Specifically, the facility did not conduct Tuberculosis (TB) tests upon hire and annually for several staff members, including the Director of Staff Development (DSD), Registered Nurse Supervisor (RNS) 1, Licensed Vocational Nurses (LVNs) 3, 4, and 5, and Certified Nurse Assistants (CNAs) 5 and 6. Additionally, these employees did not have a skills competency checklist at the time of hire and annually, nor did they receive annual performance evaluations. Health examinations were also not completed upon hire and annually, and background checks were not conducted prior to the hire date for these employees. During interviews, the DSD acknowledged the lack of TB tests, background checks, and annual competency skills assessments. The Director of Nursing (DON) confirmed that it was the DSD's responsibility to maintain up-to-date employee files to ensure staff competency and performance. The DON emphasized the importance of these records in maintaining resident care and safety, noting that the absence of annual health exams, including TB testing, could potentially expose residents and staff to TB. The facility's job descriptions for LVNs and RNs required evidence of being free of tuberculosis infection upon hire, which was not adhered to in these cases.
Failure to Monitor and Justify Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, leading to potential adverse effects. Resident 8 was prescribed methenamine for urinary tract infection prophylaxis without adequate monitoring or justification. The resident's records indicated no history of urinary tract infections, and no urinalysis or culture and sensitivity tests were conducted to confirm the need for the medication. Interviews with the Infection Preventionist Nurse and the Director of Nursing revealed that the prolonged use of methenamine could lead to antibiotic resistance and other adverse effects, such as diarrhea and the destruction of normal flora. Resident 32 was prescribed Eliquis for deep vein thrombosis prophylaxis, but the facility failed to monitor for potential adverse effects of the anticoagulant. The resident's care plan included monitoring for signs of bleeding and other complications, but there was no documentation of such monitoring in the Medication Administration Record. Interviews with nursing staff confirmed that the lack of monitoring placed the resident at risk for preventable conditions like bleeding and anemia. The facility's policies on medication regimen review and antibiotic stewardship were not followed, contributing to the deficiencies. The policies required that each resident's medication regimen be free from unnecessary drugs, with adequate monitoring and indications for use. The failure to adhere to these policies resulted in the inappropriate use of medications for both residents, highlighting a lapse in the facility's medication management practices.
Failure to Ensure Residents Are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 11, the facility did not provide non-pharmacological interventions before administering Ativan, a psychotropic medication, as needed for anxiety. Despite having a care plan that included non-pharmacological interventions, the Medication Administration Record (MAR) showed that these interventions were not documented or provided before administering the medication. Interviews with the Licensed Vocational Nurse (LVN) and the RN Supervisor confirmed that Ativan was given without documented episodes of anxiety, and non-pharmacological interventions were not attempted, which could lead to unnecessary medication use and potential side effects. Resident 22's case involved a failure to reevaluate the appropriateness of psychotropic medications. The resident was prescribed multiple psychotropic medications, including Abilify and Quetiapine Fumarate, for psychosis and depression. A Consultant Pharmacist's Medication Regimen Review recommended evaluating the use of these medications due to their similar actions, but this recommendation was not followed up. The Director of Nursing (DON) acknowledged that the psychiatrist referral was needed but not called, leading to a delay in evaluating the resident's condition and the appropriateness of the medications. This oversight could result in the use of unnecessary medications. The facility's policies and procedures on medication regimen review and psychotropic medications were not adhered to in these cases. The policies indicated that non-pharmacological interventions should be attempted before administering psychotropic drugs and that residents should not receive unnecessary medications. The failure to follow these policies resulted in the administration of psychotropic medications without proper assessment and documentation, placing the residents at risk for adverse effects.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that the medication cart was locked and secure during the administration of medications to residents. During an observation, a Licensed Vocational Nurse (LVN) left the medication cart unlocked and unattended while performing handwashing in another room and while entering a resident's room to administer medications. The LVN acknowledged the failure to lock the cart after preparing medications and before administering them to residents. Interviews with the Registered Nurse Supervisor (RNS) and the Director of Nursing (DON) confirmed that the medication cart should be locked when unattended to prevent unauthorized access and potential accidental ingestion of non-prescribed medicines by residents, particularly those with cognitive impairments. A review of the facility's policy and procedure on the security of the medication cart indicated that the cart must be locked before the nurse enters a resident's room or when out of the nurse's view.
Infection Control Deficiency in Nasal Cannula Management
Penalty
Summary
The facility failed to adhere to its infection control measures for two residents, leading to potential risks of infection. Resident 17, who was admitted with acute respiratory failure and atrial fibrillation, had a nasal cannula that was not changed according to the facility's policy. The nasal cannula was observed to be outdated, as it was dated 10/20/2024, despite the policy requiring a change every seven days. This oversight was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged the importance of changing the nasal cannula to prevent infection. Similarly, Resident 168, admitted with a displaced intertrochanteric fracture and traumatic subdural hemorrhage, had a nasal cannula and humidifier that were not dated or labeled upon admission. This was contrary to the facility's policy, which mandates dating and labeling to ensure timely replacement. The Infection Prevention Nurse and the Director of Nursing both emphasized the necessity of changing the nasal cannula weekly to prevent infections, which could lead to serious health issues such as pneumonia.
Inadequate Infection Preventionist Certification
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) on staff with the necessary qualifications and specialized training in Infection Control and Prevention. During a record review, it was found that the Infection Prevention Nurse (IPN) held a 16-hour Boot Camp certificate for Long Term Care Facilities, dated 6/5/2018, which did not meet the required 19.75 hours of training as specified by the Centers for Disease Control and Prevention (CDC). In an interview, the IPN admitted to not having the correct certification and was unaware of the specific requirements. The Director of Nursing (DON) confirmed that the IPN did not possess the appropriate certification. Additionally, there was no policy or procedure in place regarding the required certification for the IP role. The facility's Infection Preventionist Job Description, dated 12/17/202, indicated the need for compliance with CDC, OSHA, and local regulations concerning infection control, which was not met.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that 12 resident rooms met the required square footage per resident, as mandated by regulations. Specifically, rooms 1, 2, 3, 5, 6, 7, 9, 12, 14, and 15, which housed two residents each, did not meet the 80 square feet per resident requirement, with measurements ranging from 68.75 to 77.6 square feet per resident. Additionally, rooms 4 and 17, which housed one resident each, did not meet the 100 square feet requirement, with room sizes of 149.5 and 155.25 square feet, respectively. This deficiency was identified through observations and a review of the Client Accommodations Analysis form provided by the facility's Maintenance Supervisor. Despite the deficiency in room size, observations conducted from October 29 to November 1, 2024, indicated that residents had sufficient space to move around freely, and nursing staff had adequate space to provide care. The rooms were equipped with necessary furniture and resident care equipment, and there were no adverse effects noted on the residents' privacy, health, or safety due to the room sizes. A Room Waiver letter dated October 19, 2023, indicated that no residents had complained about the available space, and there was no evidence suggesting that the room size variation adversely affected the residents' health and safety.
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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