Long Beach Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3401 Cedar Avenue, Long Beach, California 90807
- CMS Provider Number
- 055364
- Inspections on file
- 62
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Long Beach Healthcare Center during CMS and state inspections, most recent first.
A resident with morbid obesity, EPS, neuropathy, generalized weakness, hypotension, and a history of falls had a care plan and MDS indicating moderate fall risk and a need for maximal assistance and a two‑person full body lift for transfers. Despite this, a CNA, who was unaware of the two‑person assist requirement and had routinely transferred the resident alone, assisted the resident from a shower chair to the bed without additional staff. The resident stood with a walker by the bed, held the bed rail, reported sudden leg weakness, and was eased to the floor, landing on her bottom with bent knees and feet. Later, the resident developed bilateral leg pain, swelling, and discoloration, and hospital evaluation revealed displaced distal fibular and bilateral bimalleolar fractures of both ankles. The DON acknowledged that assistance should have been requested and that nursing staff should have communicated the resident’s two‑person transfer needs, contrary to the facility’s fall risk policy.
A resident with intact cognition and multiple medical conditions reported that his wallet, which contained credit cards and other personal items, went missing around the time of a hospital transfer, and later discovered an unauthorized $800 charge that his bank reversed. Facility records showed the wallet was reported missing and later replaced, but key sections on the theft/loss form, such as estimated value, were left blank. The resident reported the missing wallet and unauthorized charge to social services staff, and leadership acknowledged that the circumstances suggested possible misappropriation and should have been reported to regulatory and law enforcement agencies. Despite facility policies requiring timely reporting of suspected theft or misappropriation to CDPH and other authorities, staff did not report the allegation of the missing $800 and suspected theft to CDPH.
A resident with intact cognition and multiple medical conditions reported that his wallet, which contained credit cards, identification cards, and cash, went missing while he was hospitalized, and that an unauthorized $800.00 charge was made to his bank account using one of the cards. The resident and a family member informed social services staff that the wallet and contents were missing and raised concerns that no investigation had been conducted. Although the loss was documented and the wallet itself was later replaced, key sections of the theft report were left blank, and no timely investigation or police report was initiated, despite facility policy requiring prompt and thorough investigation of all theft or misappropriation allegations.
A resident experiencing cardiac arrest and airway obstruction could not be suctioned during an emergency because the required connector for the portable suction machine was missing from the crash cart. Staff were unable to locate the missing piece, and interviews confirmed that crash cart checks had not ensured all critical components were present and functional as required by facility policy.
A resident reported being repeatedly touched and having his arm pulled by his roommate, who had cognitive impairment and psychiatric diagnoses. The incident was reported to a CNA and RN, but the administrator classified it as a grievance rather than suspected abuse and did not report it to authorities, contrary to facility policy.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, resulting in a failure to meet notification requirements.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with chronic kidney disease and diabetes mellitus reported chest pain, leading to a physician's order for a 12-lead EKG. The RN carried out the EKG order but did not assess or document the resident's chest pain or discomfort, despite facility policy requiring assessment after a change in condition. This resulted in no documentation or knowledge of the resident's medical status at the time.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple medical conditions experienced severe unplanned weight loss due to the facility's failure to implement RD recommendations, monitor and report weight changes, conduct required IDT meetings, and develop a comprehensive care plan. Staff did not follow established policies for addressing significant weight loss, and communication lapses contributed to the resident's continued decline.
Three residents with significant physical and cognitive impairments did not have clear or accurate documentation of their Restorative Nursing Aide (RNA) services. Staff used unclear notations in the electronic medical record, and documentation prompts often did not match the actual RNA tasks performed, making it impossible for facility leadership to determine if services were provided as ordered.
Surveyors observed that staff failed to properly disinfect shared cloth gait belts, did not consistently perform hand hygiene before and after resident care, and did not maintain clean environmental surfaces such as curtains. These lapses were confirmed by staff interviews and were not in accordance with facility policies or manufacturer instructions.
The facility did not perform required inspections or preventative maintenance on three types of electrical therapy equipment in the therapy gym, as confirmed by the DOR, Maintenance Director, and DON. User manuals for the devices specified regular maintenance and safety checks, which were not followed, and the facility's own policy required adherence to manufacturer-recommended schedules.
Three residents experienced deficiencies in care, including lack of documentation for missed lab draws, failure to perform a timely skin assessment after an abuse allegation, and failure to notify a physician about persistent hyperglycemia. These actions resulted in delays in care and treatment.
Staff assisted two residents with feeding while standing over them, rather than at eye level, despite both residents requiring significant help due to cognitive and physical impairments. This practice was inconsistent with facility policy and was acknowledged by both a CNA and the DON as undermining resident dignity and comfort.
A resident with severe cognitive impairment and inability to make medical decisions was asked to sign consents for psychoactive medications, including Ativan, Buspirone, and Lamictal, without proper involvement of a responsible party. Nursing staff and the DON confirmed the resident's incapacity, and facility policy requiring informed consent from a representative was not followed.
A resident with paraplegia, obesity, and depression was found to have a mattress that was too small for his bedframe, despite expressing a preference for a larger mattress and staff being aware of the issue. The LVN, Social Services Director, and DON all acknowledged the mismatch and its impact on the resident's comfort and dignity, but the request for a larger mattress was not documented or followed up, resulting in unmet needs.
A resident with diabetes and hypertension experienced three consecutive unsuccessful blood draws for ordered lab tests. Despite the repeated failures, the physician was not notified, contrary to facility policy. The resident reported frustration, and both an LVN and the DON acknowledged that the physician should have been informed to address the delay in care.
A resident who required assistance with daily activities due to multiple medical conditions did not have privacy curtains around their bed. Staff interviews revealed that the absence of curtains was known but not promptly reported or documented, resulting in a lack of privacy during personal care, contrary to facility policy.
A resident with severe cognitive impairment and multiple dependencies was administered prn Ativan for restlessness without documented non-pharmacological interventions and beyond the 14-day policy limit for psychotropic medications. Staff confirmed that the medication was given without first attempting alternative approaches and without timely physician reevaluation, contrary to facility policy.
A resident with severe cognitive impairment and dependent on staff for daily activities, who spoke only Chinese, was not provided with required alternative communication tools as outlined in their care plan. Staff relied on hand gestures and family translation, and no communication board or signage was present at the bedside, contrary to facility policy. This deficiency was confirmed through staff interviews and observations.
Two residents who were dependent on staff for activities of daily living were found with long, unclean fingernails containing unknown substances. Both residents expressed a desire for their nails to be trimmed, and staff acknowledged that nail care was sometimes overlooked due to time constraints, despite facility policy requiring daily cleaning and regular trimming to prevent infection and skin issues.
A resident with glaucoma and impaired vision did not receive a follow-up ophthalmology appointment after a referral was made for specialist care and cataract removal. The resident, who was prescribed eye medications and expressed a need for glasses, was observed without corrective lenses and reported difficulty seeing. Staff interviews confirmed the referral was not completed, contrary to facility policy requiring social services to coordinate such appointments.
A resident with left-sided hemiplegia and hemiparesis did not receive passive range of motion (PROM) exercises to the left leg as recommended by PT, due to the omission of this task from the RNA program. Staff confirmed the PROM exercises were not implemented, and the PT acknowledged forgetting to input the task, despite the resident's inability to move the left leg independently and documented ROM limitations.
Two residents receiving oxygen therapy were found to have nasal cannula tubing and oxygen humidifiers that were not labeled or dated as required by facility policy. Staff confirmed that the equipment should be labeled and changed weekly to prevent infection, but observations and interviews revealed this was not done, resulting in noncompliance with infection control protocols.
A resident with a history of cancer and neuropathy experienced a delay in receiving Norco for severe pain due to the facility's failure to reorder the medication in a timely manner and lapses in communication with the prescriber. The resident had to wait for pain relief and ultimately received medication from the emergency kit after the regular supply ran out, with documentation confirming gaps in both medication administration and pain assessments.
A deficiency was identified when a Restorative Nursing Assistant independently altered a resident's restorative program by adding exercises and activities not prescribed by therapy staff, despite clear instructions that only licensed therapists may modify such programs. The resident, who had significant physical limitations following a brain hemorrhage, received unapproved interventions including sit-to-stand transfers and use of a motorized exercise bicycle. This action was contrary to facility policy and placed the resident at risk for harm.
Two residents did not receive appropriate social services: one was not provided with a larger mattress despite repeated requests and staff acknowledgment of the need, and another, with severe cognitive impairment, was allowed to sign medication consents without the capacity to do so, as no conservatorship was pursued. These failures resulted in delays in necessary care and services.
A resident with multiple chronic conditions was administered antihypertensive and diuretic medications without established blood pressure parameters to guide medication holds. The LVN reported the absence of such parameters, indicating she would have to administer the medications as ordered unless she contacted the physician, potentially delaying care. Facility policy required vital sign checks and clear medication orders, but these were not in place for this resident, resulting in a deficiency.
A resident with multiple medical conditions, including depression and schizophrenia, continued to receive sertraline after the consultant pharmacist recommended a review for possible discontinuation or gradual dose reduction. The ADON confirmed that the pharmacist's recommendation was not communicated to the physician, and there was no documentation of a dose reduction, contrary to facility policy.
Two residents with significant medical needs did not receive timely dental services, including dentures and dental follow-up, despite documented recommendations and assessments. Staff interviews revealed that dental recommendations were not understood or acted upon, and required documentation was not completed, resulting in a lack of necessary dental care.
The facility did not effectively use its QAPI program to identify or address resident care issues, including unmonitored weight loss, failure to follow restorative nursing and infection control practices, improper feeding techniques, and lack of follow-up on a missed outpatient appointment. These deficiencies were confirmed through interviews and record reviews, with staff unaware of specific care plan issues and no interdisciplinary team meetings held to address the problems.
A resident with significant mobility limitations had their bed positioned in a way that blocked the entrance to their room, preventing the door from closing and creating a fire hazard. Staff and the maintenance director were aware of the obstruction, which was due to the resident's refusal to move belongings and limited room space, but the hazard was not resolved.
A resident with diabetes, hemiplegia, and anxiety disorder, who was cognitively intact and required moderate assistance, requested a shower before a medical appointment. Staff did not initially honor this preference, attempting to dress the resident early despite his objections. Multiple staff acknowledged the importance of resident choice, and the facility's policy supports self-determination, but the resident's request was not accommodated as required.
Two residents did not have individualized care plans implemented to address their specific needs, including repeated unsuccessful lab draws for one resident with diabetes and hypertension, and alleged physical and sexual abuse for another resident with hemiplegia and anxiety disorder. Nursing staff and the DON confirmed that care plans were not updated to reflect these issues, contrary to facility policy.
Surveyors found that multiple resident rooms did not meet the required 80 square feet per resident in shared rooms, with specific measurements showing undersized accommodations. A resident reported that his bed blocked the door, which the administrator acknowledged could create a hazard, especially during emergencies. Facility policy requires a safe and homelike environment, but observations and interviews confirmed the deficiency.
A resident on antiplatelet therapy sustained a head injury with significant bleeding, but staff failed to promptly notify the physician or obtain orders to discontinue blood thinners. The resident continued to receive Aspirin and Clopidogrel despite changes in behavior and condition, and the care plan's monitoring and reporting requirements were not followed. The resident was later hospitalized with a subarachnoid hemorrhage and required a platelet transfusion.
A resident with a fractured wrist and an open cast experienced a delay in receiving authorization to see a surgeon, despite a physician's order. The authorization request was not submitted promptly, leading to a delay in care. The facility's policy requires timely processing of such requests, which was not followed in this case.
A facility failed to provide necessary treatment and services to maintain or prevent a decline in ROM and mobility for a resident with a wrist fracture. Despite orders for AAROM exercises, the resident did not receive services for the upper extremities or mobility, and rehabilitation screenings were not conducted upon readmission from the hospital. Staff interviews indicated the resident was not regularly transferred out of bed, increasing the risk of decline in ROM and mobility.
A resident with a fracture and requiring substantial assistance with daily activities did not receive a timely physical therapy evaluation despite a physician's order. The rehabilitation screen indicated the need for therapy, but the evaluation was not completed, risking a decline in the resident's mobility.
A resident in an LTC facility was fatally injured after a CNA left the room during a verbal argument with another resident, which escalated into a physical altercation. The facility failed to investigate prior grievances, develop care plans for aggressive behaviors, and conduct follow-up visits to assess roommate compatibility, leading to the incident.
A resident with major depressive disorder was not administered their prescribed escitalopram medication as ordered, due to a failure in the facility's medication reconciliation process. Despite having the capacity to make decisions and having signed informed consent, the medication was put on hold, leading to a significant medication error.
A resident with intact cognition and the capacity to make decisions experienced a violation of her rights when the SSD forcibly took her sweater and Norco medication without permission. The incident occurred after the resident self-administered a pill, and despite being informed of facility policy against self-administration, she refused to give up the medication. The resident reported shoulder pain and fear of the SSD following the incident, which was not reported as abuse by the facility.
A facility failed to report an alleged physical altercation between the SSD and a resident to CDPH within the required timeframe. The incident involved the SSD taking a sweater from the resident without permission, causing shoulder pain and fear. Despite the resident's complaints, the facility did not report the incident as abuse, resulting in a delay in investigation. The resident had a history of bipolar disorder, atrioventricular block, and type 2 diabetes, and was found hiding narcotics in her sweater, which led to the altercation.
A resident with intact cognition and a history of bipolar disorder, AV block, and type 2 diabetes reported shoulder pain after the Social Services Director (SSD) removed a sweater from the resident's grasp without consent to confiscate a medication bottle. Despite the resident's complaint and feeling unsafe, the facility did not conduct a timely investigation or report the incident as required. Interviews revealed that the SSD and an LVN attempted to educate the resident on self-administration risks before the SSD removed the sweater, violating the resident's rights.
A resident with dementia and other health issues expressed sadness multiple times but was not seen by a psychiatrist after initial referrals. The facility's Social Services Director did not follow up on psychiatric appointments, and the QA nurse confirmed the lack of consistent psychiatric visits. The DON acknowledged the oversight, which was contrary to the facility's policies on behavioral health services.
A resident with sepsis, heart failure, and dementia frequently removed her nasal cannula, leading to a deficiency in care as the facility failed to implement a care plan with specific interventions. Despite staff awareness of the behavior, there was no guidance on how to address it, resulting in the resident not receiving oxygen as ordered. The facility's policy requires a comprehensive care plan, which was not provided, placing the resident at risk for desaturation.
A resident with diabetes and a stage 4 pressure ulcer did not receive timely incontinence care, leading to moisture-associated skin damage. Despite the care plan's instructions, the resident waited three hours for a brief change. CNA 1 did not change the brief, citing the resident's refusal due to pain, but LVN 1 was not informed of any refusal. The facility's policy required notifying a supervisor if care was refused, which was not done.
A resident with severe cognitive impairment and pressure injuries did not receive care according to physician's orders. The nasal cannula was not changed weekly as required, and wounds were cleansed with a wound cleanser spray instead of normal saline due to its unavailability. Interviews with staff confirmed these deviations, which could expose the resident to bacteria and delay wound healing.
A resident with type two diabetes and multiple pressure injuries refused wound care, and the facility failed to create a care plan addressing this non-compliance. Despite physician's orders for treatment, the resident's refusal was documented, but no care plan was developed to manage the situation. The DON confirmed that a care plan should have been created, as per facility policy, to communicate with the interdisciplinary team.
Failure to Follow Two‑Person Transfer Requirements Resulting in Fall and Bilateral Ankle Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required a two‑person assist with a full body lift for transfers was provided that level of assistance, resulting in an unassisted transfer attempt and a fall. The resident had multiple diagnoses including diabetes mellitus, morbid obesity, extrapyramidal movement disorder, hypotension, neuropathy, generalized weakness, and a history of falls. Her MDS dated 3/1/2026 showed intact cognition and a need for maximal assistance for sit‑to‑stand transfers, and a fall risk evaluation identified her as at moderate risk for falls. A care plan initiated on 6/2/2023, and confirmed as current by the MDS specialist, specified that due to obesity and poor lower extremity strength, the resident was at risk for falls and required safe handling with a full body lift and a two‑person assist for transfers. On the day of the incident, after the resident was showered, CNA 1 returned her to her room in a shower chair. CNA 1 reported that the resident stood up using a walker next to her bed, holding onto the bed rail, and that the resident would normally pivot to get onto the bed. Instead, the resident suddenly screamed for help and stated her legs felt weak. CNA 1 stated she got behind the resident, called for help, and eased her to the floor, where the resident landed on her bottom with her knees and feet bent. CNA 1 acknowledged that she had been working with this resident for four years and usually assisted her alone during transfers because the resident was often able to walk and help with transfers. CNA 1 also stated she was not aware that the resident’s care plan required a two‑person assist with transfers. Following the fall, an SBAR documented that after the transfer from chair to bed, both of the resident’s legs became weak and she was eased to the floor. Later that day, the resident complained of bilateral leg pain and had swelling and bluish discoloration of the right ankle. She was transferred to a general acute care hospital, where ED documentation indicated she reported falling when getting out of her shower chair that morning and was found to have significant swelling and ecchymosis of the right ankle and likely swelling of the left ankle. Radiology and orthopedic notes confirmed displaced distal fibular fractures and bilateral bimalleolar fractures of both ankles. The DON stated CNA 1 should have requested assistance for the transfer and that licensed nurses should have communicated the resident’s need for a two‑person assist during transfers. The facility’s falls and fall risk policy required staff to identify and implement resident‑centered interventions based on risk factors such as lower extremity weakness and functional impairments, which were present in this resident.
Failure to Report Alleged Theft of Resident Wallet and Unauthorized $800 Charge to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of suspected theft of a resident’s wallet and an associated unauthorized $800 credit card charge to the California Department of Public Health (CDPH) as required. The resident, who had diagnoses including metabolic encephalopathy, pneumonia, acute chronic respiratory failure with hypoxia, and diabetes mellitus, was initially admitted and later readmitted after a transfer to a general acute care hospital (GACH). The resident’s Minimum Data Set indicated intact cognition. The resident’s Inventory of Personal Effects documented a billfold/wallet, two credit cards, and four check booklets. On the date of readmission, the facility’s Theft and Loss Log recorded that the resident reported his wallet missing, and several days later the log showed the wallet was replaced. A Theft/Loss Report documented the missing brown leather wallet but left blank the sections for estimated value and whether the item was listed on the inventory form. During interviews, the resident stated that when he was transferred to the GACH he was too sick to remember to take his wallet, which he usually kept in the drawer next to his bed. While still hospitalized, he asked a family member to look for the wallet, and it could not be found in its usual place, leading him to believe it had been stolen. The resident reported that someone charged $800 to his credit card, that the bank detected the unauthorized charge, and that the bank reimbursed the money. He stated he informed a social services staff member about both the theft of his wallet and the unauthorized $800 withdrawal, and that his wallet was replaced but not the contents, which he said included his credit card, Medicare card, Medi-Cal card, social security card, family pictures, and the card used for the $800 charge. The Social Services Director stated that, after the resident returned from the GACH, the resident reported that $800 had been taken from his bank account but reimbursed by the bank, and acknowledged that the theft of the wallet and missing money should have been reported to the police because the amount exceeded $100. The Social Services Director also stated that the allegation of $800 missing after the report of the missing wallet suggested someone could have taken and used the resident’s credit card. Another social services staff member confirmed that the resident reported $800 missing from his bank account and that, because the bank was going to return the money, he did not think to report the missing money to CDPH, though he acknowledged the allegation could imply someone from the facility took the wallet. The Administrator stated he was not aware of the resident’s report of the missing $800 and that, if such a report had been made following the report of the lost wallet, it should have been reported to CDPH per regulations. Facility policies required notification of state licensing and certification and other agencies within specified time frames when alleged or suspected misappropriation of resident property is reported, and required staff to report suspected exploitation, theft, or misappropriation of resident property, which did not occur in this case with respect to CDPH notification.
Failure to Investigate Alleged Theft and Unauthorized Bank Charge
Penalty
Summary
The deficiency involves the facility’s failure to investigate a resident’s allegation that his wallet was missing and that an unauthorized $800.00 charge was made to his bank account after his wallet was reported lost. The resident, who had intact cognition per a recent MDS and diagnoses including metabolic encephalopathy, pneumonia, acute chronic respiratory failure with hypoxia, and diabetes mellitus, was initially admitted and then transferred to a general acute care hospital (GACH) for drowsiness and refusal to eat. His Inventory of Personal Effects documented a billfold/wallet, two credit cards, and four check booklets. While he was at the GACH, he realized his wallet was missing when a family member could not locate it in its usual drawer next to his bed. Upon readmission, the facility’s Theft and Loss Log recorded that he reported his wallet missing and that it was later replaced, but the Theft/Loss Report left blank the sections for estimated value and whether the item was on the inventory form. The resident reported to a social services staff member that $800.00 was missing from his bank account and that the bank would reimburse the money. He also stated that his wallet had contained his credit card, Medicare card, Medi-Cal card, social security card, family pictures, and cash, and that someone had charged $800.00 to his credit card before the bank reversed the charge. The resident reported that he informed a social services specialist of both the theft of his wallet and the unauthorized withdrawal, and that although the wallet itself was replaced, the contents were not. A family member later contacted another social services staff member to report that the wallet and its contents, including identification and financial cards, were still missing and expressed concern that no investigation had been conducted into the theft while the resident was at the GACH. Despite these reports, the facility did not initiate an investigation into the allegation of the unauthorized $800.00 charge until nearly two months after the wallet was reported missing, as reflected in the Five Day Report. The social services specialist acknowledged that the allegation of missing funds could imply that someone from the facility took the wallet but stated he did not report or investigate the matter because the bank was handling the reimbursement. The administrator reported he was unaware of the resident’s report of the missing $800.00 and stated that such an allegation should have been investigated. The facility’s policy on investigating incidents of theft and/or misappropriation of resident property requires that all reports of theft or misappropriation be promptly and thoroughly investigated and that the administrator appoint a staff member to investigate, which did not occur in this case.
Failure to Maintain Functional Suction Equipment on Crash Cart
Penalty
Summary
The facility failed to ensure that an oxygen nut and stem adaptor, commonly referred to as a 'Christmas tree' connector, was readily available and connected to the portable suction machine on the south station crash cart. This deficiency was identified when staff were unable to provide suctioning to a resident during an emergency situation because the necessary plastic connector piece was missing from the suction machine. Multiple staff interviews confirmed that, during the incident, the suction machine could not be used as intended due to the absence of this critical component, and staff were unaware of where to locate a replacement. The incident involved a resident with a history of heart failure and type 2 diabetes mellitus, who was found unresponsive, without a pulse, and not breathing while sitting on the toilet. Staff initiated CPR and attempted to clear the resident's airway, noting the presence of food and secretions in the mouth. Despite efforts to remove the obstruction manually, the inability to use the suction machine due to the missing connector impeded the staff's ability to clear the airway effectively during the emergency. Interviews with various staff members, including CNAs, respiratory therapists, and nursing leadership, revealed that it was the responsibility of the night shift to check and ensure the crash cart was fully stocked and that all equipment, including the suction machine, was operational. The facility's policy required that all critical supplies for basic life support be available and replaced promptly after use. However, the missing connector on the suction machine was not identified or replaced prior to the emergency, resulting in the equipment being nonfunctional when urgently needed.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who stated that his roommate pulled his right arm and touched his right leg multiple times. The resident, who expressed fear and discomfort during the incident, reported the event to his assigned CNA, who then informed the RN. The RN subsequently reported the incident to the abuse coordinator, and a meeting was held where the complaint was treated as a grievance rather than an abuse allegation. The administrator decided not to investigate the complaint as possible abuse and did not report it to the California Department of Public Health (CDPH), as he did not believe it constituted abuse. The resident accused of the touching had a history of Pick's disease and schizophrenia, with documented moderate cognitive impairment. Facility records, including the face sheet and MDS, confirmed these diagnoses. The facility's policy required timely reporting of suspected or identified abuse to appropriate agencies, but this protocol was not followed in this case. As a result, the incident was not reported to CDPH, preventing timely investigation and potentially leading to loss of information or recollection of the event.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess Resident Following Chest Pain Complaint
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic kidney disease (CKD) and diabetes mellitus (DM), reported experiencing chest pain on the left side that had persisted for several weeks. The resident's cognition was noted to be intact. Following the complaint, the physician ordered a 12-lead EKG to assess the resident's chest discomfort. However, there was no documentation or evidence that the resident was assessed for chest pain or discomfort by the registered nurse (RN) who received and carried out the EKG order. The RN acknowledged that an assessment should have been performed, especially since the EKG was ordered due to chest discomfort, which could be related to serious conditions such as a heart attack. Further review revealed that facility policy required nurses to make detailed observations and gather pertinent information prior to notifying the physician or healthcare provider about a change in a resident's condition. The RN supervisor's job description also included the responsibility to identify changes in residents' physical or psychological conditions. Despite these requirements, there was no documentation of an assessment or monitoring of the resident's status following the complaint of chest pain, resulting in a lack of knowledge regarding the resident's medical status at the time.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent and Address Severe Unplanned Weight Loss
Penalty
Summary
A resident experienced severe unplanned weight loss totaling 29 pounds (18.59% of body weight) over a six-month period. The facility failed to implement multiple recommendations made by the Registered Dietician (RD), including weekly weight monitoring, administration of protein supplements, provision of double portions at breakfast, initiation of an appetite stimulant, and completion of blood tests for a complete metabolic panel and prealbumin. The resident's care plan, which required monitoring and reporting of weight loss and poor oral intake to the physician, was not followed. Additionally, the facility did not conduct weekly interdisciplinary team (IDT) weight variance meetings or develop a comprehensive care plan with interventions to prevent further weight loss. The resident had a complex medical history, including diabetes mellitus, kidney transplant, legal blindness, and gastro-esophageal reflux. Despite documented weight losses of 10 lbs., 8 lbs., 9 lbs., and 2 lbs. across several months, the facility did not complete required Change of Condition (COC) assessments or notify the physician and family as outlined in facility policy. The RD and nursing staff did not communicate or act on significant weight changes in a timely manner, and the resident's declining food intake and refusal of meals were not adequately addressed. The resident's family reported concerns about the facility's food and the lack of communication regarding the resident's weight loss. Interviews with facility staff, including the Assistant Director of Nurses (ADON), RD, and Director of Nurses (DON), confirmed that there were missed opportunities to identify and intervene in the resident's weight loss. The RD was unaware of the resident's weight loss until several months after it began, and recommended interventions were not implemented. Facility policies required prompt notification and multidisciplinary care planning for significant weight changes, but these procedures were not followed, resulting in the resident's continued and preventable weight loss.
Inaccurate and Unclear Documentation of Restorative Nursing Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aide (RNA) services were accurately documented for three residents. For each of these residents, the RNA daily documentation did not clearly reflect whether services were provided, missed, or not applicable, due to the use of unclear notations such as 'n, n, n' or 'n, n' in the electronic medical record. Staff interviews revealed that these notations were used inconsistently to indicate either that prompts did not pertain to the RNA task or that the resident was not seen for RNA treatment, but there was no standardized understanding or guidance on their use. This led to confusion among staff, including the Assistant Director of Nursing (ADON), Medical Records Director (MRD), and Director of Nursing (DON), all of whom were unable to determine from the documentation whether RNA services had actually been provided on specific dates. For one resident with a history of left femur fracture and gout, the RNA flowsheets indicated scheduled walking exercises and range of motion (ROM) activities, but the documentation was unclear as to whether these services were performed. The resident was observed to have significant physical limitations and required substantial assistance with daily activities. Staff interviews confirmed that the documentation process was confusing, and it was not possible to determine from the records if the resident received or missed RNA sessions on several dates. Another resident with right-sided hemiplegia, legal blindness, and sepsis had RNA documentation for walking exercises that also used the unclear 'n, n, n' notation. The resident reported inconsistent assistance with exercises, and staff again could not confirm from the documentation whether services were provided on certain dates. A third resident, who required a splint applied to the right elbow, had RNA documentation prompts that did not match the actual RNA task, leading to further confusion. The facility's policy required that all services provided be documented objectively, completely, and accurately, but the observed documentation practices did not meet these standards.
Infection Control Lapses in Equipment Cleaning, Hand Hygiene, and Environmental Cleanliness
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were identified during the survey. Staff failed to ensure that shared resident-care equipment, specifically cloth gait belts used in therapy, were disinfected according to manufacturer instructions. The cloth gait belts, made of porous material, were wiped with Super Sani-Cloth disinfectant wipes, which are only effective on non-porous, hard surfaces. Both the Infection Preventionist Nurse and the Director of Nursing confirmed that the wipes were not appropriate for disinfecting cloth gait belts, and that laundering after each use was necessary to prevent cross contamination. Hand hygiene practices were not consistently followed by staff when entering and exiting resident rooms or after providing care. Observations showed that CNAs did not perform hand hygiene before assisting residents with meals or after touching high-contact surfaces in resident rooms, including those on Enhanced Barrier Precautions due to the presence of medical devices and risk of MDRO infection. Staff interviews confirmed awareness of the hand hygiene policy, but lapses in practice were observed, including failure to use hand sanitizer or wash hands as required by facility policy and CDC recommendations. Environmental cleanliness was also found lacking, as evidenced by stained and soiled curtains in a resident's room. The resident expressed discomfort with the unclean curtains, and both nursing and housekeeping staff acknowledged that curtains should be clean and free of stains for both infection control and resident dignity. Facility policy requires a clean, sanitary, and homelike environment, but observations and staff interviews confirmed that this standard was not met in this instance.
Failure to Maintain and Inspect Electrical Therapy Equipment
Penalty
Summary
The facility failed to maintain and perform preventative maintenance on three types of electrical therapy equipment used in the therapy gym: a motorized electrical bicycle for arms and legs, a recumbent cross trainer, and a recumbent stepper. Observations and interviews with the Director of Rehabilitation (DOR) revealed that no inspections or maintenance had been conducted on any of these devices, despite instructions in the user manuals requiring regular checks and maintenance. The Maintenance Director confirmed that the maintenance department did not perform any routine inspections or preventative maintenance on the therapy equipment, and acknowledged the importance of such actions to ensure proper functioning and safety. Review of the user manuals for each device indicated specific maintenance schedules and safety checks that were not being followed, such as tightening screws, cleaning components, checking batteries, and inspecting drive belts. The facility's own policy and procedure required maintenance services to be provided for all equipment and for maintenance personnel to follow manufacturer-recommended schedules. Interviews with the DOR and Director of Nursing (DON) further confirmed the lack of maintenance and the importance of keeping rehabilitation equipment safe and operable for resident use.
Failure to Document, Assess, and Notify Physician for Changes in Resident Condition
Penalty
Summary
Three residents experienced deficiencies in care and services due to failures in documentation, assessment, and timely physician notification. One resident, with a history of diabetes mellitus and hypertension, had a physician order for laboratory tests to be drawn every three months. Despite three consecutive unsuccessful blood draws, there was no documentation of a change in condition (COC) or physician notification, as confirmed by both the LVN and the Director of Nursing. The lack of documentation meant that staff were not formally alerted to the change in the resident's status or the need for monitoring. Another resident, with diagnoses including diabetes mellitus, hemiplegia, anxiety disorder, and hyperlipidemia, reported an incident involving a certified nursing assistant (CNA) during personal care. The resident alleged inappropriate handling and possible abuse. Despite this allegation, a full body skin assessment was not performed immediately after the incident. The Director of Staff Development and the Director of Nursing both acknowledged that the absence of a timely skin assessment delayed the identification and treatment of any potential injuries or changes in the resident's condition. A third resident, diagnosed with vascular dementia, anxiety disorder, depression, and diabetes mellitus, had persistently elevated blood sugar readings over several days, despite being on a sliding scale insulin regimen and the addition of long-acting insulin. Nursing staff did not notify the physician about the continued hyperglycemia, nor did they seek new orders or adjustments to the treatment plan. Both the LVNs and the Director of Nursing confirmed that the lack of physician notification and intervention meant the resident's blood sugar remained uncontrolled for an extended period.
Staff Failed to Feed Residents at Eye Level, Compromising Dignity
Penalty
Summary
Staff did not assist residents at eye level during feeding for two residents, contrary to facility policy and best practices for maintaining dignity. For one resident with dementia, anxiety, cirrhosis, and anemia, who required set up and moderate assistance with eating and other activities of daily living, staff were observed standing in front of the resident while feeding, rather than sitting at eye level. Similarly, another resident with metabolic encephalopathy, anemia, acute respiratory failure, and benign prostatic hyperplasia, who was severely cognitively impaired and required set up and maximal assistance with eating, was also assisted by staff standing over him during feeding. In both cases, staff did not follow the facility's policy, which specifies that residents should be fed with attention to safety, comfort, and dignity, including not standing over them. Interviews with a CNA and the DON confirmed that feeding residents at eye level is important for their comfort and dignity, and that standing over residents can make them feel inferior or babied. The facility's policies on dignity and meal assistance both emphasize the importance of treating residents with respect and providing assistance in a manner that promotes their well-being and self-esteem. The observed actions were inconsistent with these policies and had the potential to impact the residents' sense of dignity and respect.
Failure to Obtain Valid Informed Consent for Psychoactive Medications
Penalty
Summary
Licensed nursing staff failed to ensure that a resident and/or their responsible party were properly informed in advance about the risks and benefits of psychoactive medications. The resident in question was admitted with diagnoses including dementia, mood disorder, and anxiety, and was assessed as having severely impaired cognition, requiring moderate assistance with daily activities. Despite documentation indicating the resident could not make medical decisions, the resident was asked to sign consents for psychoactive medications, including Ativan, Buspirone, and Lamictal, which were prescribed for anxiety and mood disorder. Interviews with nursing staff, including an LVN, RN Supervisor, and the DON, confirmed that the resident was confused, unable to make medical decisions, and should not have been signing consents. The facility's policy required that the risks and benefits of psychotropic medications be reviewed with the resident or their representative prior to obtaining documented consent. However, the consents were signed by the resident, who did not have the capacity to understand or authorize such decisions, resulting in a violation of the resident's right to make an informed decision regarding psychoactive medication use.
Failure to Provide Appropriately Sized Mattress for Resident
Penalty
Summary
A deficiency occurred when the facility failed to accommodate the needs and preferences of a resident whose mattress was too small for his bedframe. The resident, who had diagnoses including paraplegia, obesity, and depression, was cognitively intact and dependent on staff for activities of daily living. He expressed a preference for a larger mattress and reported having previously had one, which was removed. During observation, it was noted that the mattress did not fit the bedframe, and the resident stated that a larger mattress would be more comfortable. Staff interviews confirmed awareness of the issue. The LVN acknowledged the mattress was too small and that this could affect the resident's comfort and sense of safety. The Social Services Director was aware of the resident's request and had spoken to maintenance but did not document or follow up on the request. The DON also confirmed that the resident should have the correct size mattress to ensure comfort and dignity. Facility policies reviewed indicated that residents should be provided with a comfortable, homelike environment and that their individual needs and preferences should be accommodated.
Failure to Notify Physician of Unsuccessful Lab Draws
Penalty
Summary
The facility failed to notify a resident's physician when laboratory tests ordered for the resident were not successfully drawn for three consecutive days. The resident, who had diagnoses including diabetes mellitus and hypertension, was admitted with intact cognition and required full assistance with activities such as toileting, showering, and dressing. An order for routine laboratory tests was placed, but the laboratory was unable to obtain the required blood samples over three attempts. Despite these unsuccessful attempts, the physician was not informed of the issue. The resident expressed frustration over the repeated failed blood draws, and both a Licensed Vocational Nurse and the Director of Nursing confirmed during interviews that the physician should have been notified after multiple unsuccessful attempts. The facility's policy requires prompt notification of the resident, physician, and representative regarding changes in the resident's condition or status, which was not followed in this instance. This lack of communication resulted in a delay in care and treatment for the resident.
Failure to Provide Privacy Curtains for Resident During Personal Care
Penalty
Summary
The facility failed to provide privacy curtains for one resident, resulting in a lack of privacy during personal care activities. The resident, who was admitted with a broken right leg, broken hip, and encephalopathy, required partial to moderate assistance from nursing staff for activities of daily living such as toileting, showering, dressing, and personal hygiene. Observations confirmed that the resident's bed did not have privacy curtains, and staff interviews revealed that the absence of curtains had been noticed but not promptly reported or documented in the maintenance log. Certified Nursing Assistant (CNA) 2 acknowledged assisting the resident with showering and lotion application, stating that privacy curtains are important to prevent exposure, but admitted not documenting the need for curtains. Licensed Vocational Nurse (LVN) 5 noticed the missing curtains and documented it in the maintenance log only after the deficiency was observed. The Registered Nurse (RN) and Maintenance Director were unaware of the missing curtains until the issue was brought to their attention. The facility's policy requires staff to promote and protect resident privacy, including bodily privacy during personal care, which was not upheld in this instance.
Failure to Limit and Monitor PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure that a resident was free from chemical restraints. Specifically, the facility did not provide non-pharmacological interventions before administering a prn (as needed) psychotropic medication, Ativan, to a resident with diagnoses including vascular dementia without behavioral disturbances, anxiety disorder, and depression. The resident had severely impaired cognitive skills and was dependent on staff for multiple activities of daily living. The care plan for the resident required non-pharmacological interventions prior to the use of Ativan, but this was not followed. Record reviews and staff interviews confirmed that the order for Ativan 1 mg every six hours as needed for restlessness was active and had been in place for more than 14 days, exceeding the facility's policy limit for prn psychotropic medications. Licensed nurses did not document the use of non-pharmacological interventions before administering Ativan, and the order was not reevaluated or renewed by a physician after 14 days as required. Staff acknowledged that Ativan was administered without first attempting less restrictive measures and without timely physician review. The facility's policy stated that prn orders for psychotropic medications are limited to 14 days and that non-pharmacological approaches should be used to minimize medication use. Despite this, the resident received Ativan beyond the policy limit and without documented attempts at alternative interventions, as confirmed by the Director of Nursing and other staff during interviews and record reviews.
Failure to Provide Alternative Communication Method for Non-English Speaking Resident
Penalty
Summary
Resident 96, who was diagnosed with vascular dementia, anxiety disorder, and depression, was identified as having severely impaired cognitive skills and was dependent on staff for multiple activities of daily living. The resident was noted to speak only Chinese and had a care plan in place that required the use of alternative communication tools, such as a communication board, writing pad, signs, and pictures, to facilitate communication. However, during observations and interviews, it was found that no communication board or signage was present at the resident's bedside, and staff primarily relied on hand gestures or contacting a family member to translate, which staff acknowledged was not a reliable or appropriate method for effective communication. Multiple staff members, including a CNA, RN, and Treatment Nurse, confirmed the absence of appropriate communication aids and expressed concerns that the resident's inability to communicate her needs due to the language barrier could impact her care and quality of life. The Director of Nursing also acknowledged that the resident's specific care needs were not being met because of the language barrier. The facility's policy required staff to accommodate residents' communication needs, but this was not implemented for Resident 96, resulting in a deficiency related to the failure to provide an alternative communication method in a language the resident could understand.
Failure to Provide Adequate Fingernail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate fingernail care for two residents who were dependent on staff for activities of daily living. Both residents were observed to have long fingernails with an accumulation of unknown substances underneath. One resident, with diagnoses including diabetes mellitus and hypertension, was seen feeding herself with her hands and expressed concern about the length of her nails and the risk of scratching her scalp. The other resident, who was legally blind and had a history of intracerebral hemorrhage, also had long fingernails and stated a preference for them to be shorter. Both residents were assessed as having intact cognition but required assistance with personal hygiene tasks. Staff interviews revealed that CNAs acknowledged the importance of keeping resident nails clean and trimmed for infection prevention and to avoid skin injury, but admitted that nail care was sometimes neglected due to time constraints. The Infection Prevention Nurse and the Director of Nursing both confirmed the significance of proper nail care for infection control and resident dignity. Review of the facility's policy indicated that daily cleaning and regular trimming of nails are required to prevent infections and skin problems, but these procedures were not consistently followed for the two residents involved.
Failure to Follow Up on Ophthalmology Referral for Resident with Glaucoma
Penalty
Summary
A deficiency occurred when the facility failed to follow up on an ophthalmology referral for one of two sampled residents with a diagnosis of glaucoma, muscle weakness, and anxiety. The resident was admitted with impaired vision, required medications for glaucoma, and had a care plan addressing impaired visual function. Despite a referral to an eye specialist for glaucoma and cataract removal, there was no evidence that the resident was seen by the specialist. The resident expressed difficulty seeing, a desire to read, and reported being blind in one eye and needing glasses for the other. During observation, the resident was found without eyeglasses and stated he needed assistance. Interviews with social services and the DON confirmed that the referral was not followed up, and the resident was not sent to the eye specialist as ordered. The facility's policy required social services to coordinate and arrange such referrals, including transportation and collaboration with nursing staff. The failure to ensure the resident's access to necessary vision services was acknowledged by staff and was not in accordance with facility policy.
Failure to Provide PROM Exercises as Recommended by PT
Penalty
Summary
A deficiency occurred when a resident with left-sided hemiplegia and hemiparesis, following an intracerebral hemorrhage, did not receive passive range of motion (PROM) exercises to the left leg as recommended by physical therapy. The resident's physical therapy evaluation documented no strength in the left hip, knee, and ankle, and the discharge summary specifically recommended a restorative nursing aide (RNA) program to provide PROM to the left leg and active assistive range of motion (AAROM) to the right leg. However, review of the RNA documentation for the relevant month showed that PROM exercises for the left leg were not included in the RNA task list, and staff confirmed this omission during interviews. The physical therapist acknowledged forgetting to input the PROM task for the left leg, despite its importance for the resident, who was unable to move the left leg independently. Observations of the resident revealed significant physical limitations, including inability to move the left arm and leg, and abnormal positioning of the left limbs. The resident was cognitively intact and required varying levels of assistance for activities of daily living, with documented functional range of motion limitations in one arm and one leg. The facility's policy required that residents with limited ROM receive appropriate treatment and services to prevent further decline, but this was not followed in this case, as the recommended PROM exercises were not implemented.
Failure to Label and Change Oxygen Equipment as Required
Penalty
Summary
The facility failed to ensure that oxygen nasal cannula tubing and oxygen humidifiers were properly labeled and changed according to policy for two residents receiving oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD), observations revealed that the nasal cannula tubing in use was not labeled with a date, despite the resident actively receiving oxygen therapy. Multiple staff members, including a Licensed Vocational Nurse, the Infection Prevention Nurse, and the Respiratory Therapist, confirmed that the tubing was not dated and acknowledged that it should have been labeled and changed weekly to prevent infection, as per facility policy and the resident's care plan. Another resident, with a history of pleural effusion and Covid-19, was also found to have an unlabeled and undated nasal cannula and oxygen humidifier during observation. The Registered Nurse and Respiratory Therapist both confirmed that these items were not labeled or dated, and stated that it was standard practice to change and label them weekly. The Director of Nursing further confirmed that the lack of labeling and dating could lead to uncertainty about when to change the equipment, increasing the risk of infection. A review of facility policy indicated that oxygen cannula and tubing should be changed every seven days or as needed, and that humidifier bottles should be marked with the date and initials upon opening and discarded after 24 hours. The failure to follow these procedures was directly observed and confirmed by staff interviews and record reviews, demonstrating noncompliance with established infection prevention protocols for residents receiving respiratory care.
Failure to Timely Reorder and Administer Pain Medication
Penalty
Summary
The facility failed to ensure timely reordering and administration of pain medication for a resident with a history of bilateral breast cancer, bilateral leg neuropathy, and hypertension. The resident was dependent on nursing staff for most activities of daily living and required Norco for severe pain related to her cancer. According to interviews and record reviews, the resident reported having to wait two days for her pain medication and was told by nursing staff that she needed to wait for the doctor's approval before receiving it. She ultimately contacted her power of attorney to obtain pain medication from the emergency kit. Documentation revealed that the process for reordering Norco was not followed as required. The facility's protocol was to reorder pain medication when the supply was down to three days, but this was not done. The DON confirmed that the medication ran out and the doctor did not receive the faxed authorization request, resulting in a delay. The resident's medication was not filled on time, and there was a gap in both pain medication administration and pain assessments, as shown in the Medication Administration Record and pain assessment documentation. Facility records indicated that Norco was administered from the emergency medication kit only after the regular supply had run out. The Controlled Drug Record and Order Audit Report confirmed lapses in documentation and delays in reordering. The facility's policies required ongoing communication and timely implementation of medication regimens, but these were not adhered to, resulting in the resident experiencing a delay in pain management.
Unauthorized Modification of Restorative Nursing Program by Unqualified Staff
Penalty
Summary
A deficiency occurred when a Restorative Nursing Assistant (RNA) independently modified a resident's Restorative Nursing Aide program without the appropriate qualifications or authorization. The resident in question had a history of left-sided hemiplegia and hemiparesis following an intracerebral hemorrhage, with additional diagnoses of abnormal posture and muscle weakness. Therapy discharge summaries from both Physical Therapy (PT) and Occupational Therapy (OT) specified a maintenance program involving passive range of motion (PROM) and active assistive range of motion (AAROM) exercises for specific limbs, with clear instructions on frequency and type of exercises to be performed. Despite these instructions, the RNA provided additional exercises and activities not included in the resident's RNA tasks, such as sit-to-stand transfers and use of a motorized exercise bicycle. These activities were not recommended by the PT or OT and were not listed in the resident's care plan or RNA documentation. The RNA acknowledged being aware that these tasks were not part of the assigned program but proceeded to implement them regardless, without notifying the therapy department or a licensed nurse for reassessment or modification of the care plan. Interviews with the RNA, PT, OT, and the Director of Nursing (DON) confirmed that only licensed therapists are qualified to create or modify RNA programs, and that RNAs are required to follow the care plan as written. The facility's policies and job descriptions also supported this requirement. The independent modification of the RNA program by the RNA was identified through observation, interview, and record review, and was determined to place residents at risk for harm and injury due to the potential for inaccurate and inappropriate care.
Failure to Provide Social Services and Decision-Making Support
Penalty
Summary
The facility failed to provide necessary social services for two residents, resulting in delays in care and services. For one resident with paraplegia, obesity, and depression, the individual requested a larger mattress for comfort and safety, as the current mattress was too small for the bed frame. The social services director acknowledged awareness of the issue and discussed it with the maintenance department but did not document the conversation or follow up to ensure the request was fulfilled. Both the LVN and DON confirmed the mattress was inadequate and that the resident had the right to a comfortable and safe environment, as outlined in facility policy. For another resident with dementia, mood disorder, and anxiety, the individual was found to have severely impaired cognition and was unable to make medical decisions. Despite this, the resident was allowed to sign consents for psychoactive medications, even though staff, including the LVN and RN supervisor, recognized that the resident did not understand what was being signed. The social services director admitted that a conservatorship should have been pursued for this resident but had not taken steps to initiate the process. Facility policies reviewed indicated the importance of providing a homelike environment and ensuring residents' rights, including proper consent for psychotropic medication use. The lack of follow-up and documentation by the social services director, as well as the failure to secure appropriate decision-making support for a resident unable to consent, directly contributed to the deficiencies identified by surveyors.
Failure to Establish and Follow Blood Pressure Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that blood pressure parameters were established and followed prior to administering blood pressure medications for one resident. The resident in question had multiple diagnoses, including diabetes mellitus, heart failure, hypertension, and bipolar disorder, and required varying levels of assistance with daily activities. The resident was prescribed amlodipine, furosemide, and lisinopril, all of which were administered as ordered throughout the month. During medication administration, the LVN reported that there were no specific parameters in place for holding blood pressure medications if the resident's blood pressure was below a certain threshold. The LVN stated that, in the absence of such parameters, she would have to administer the medication as ordered, even if the resident's blood pressure was low, unless she contacted the physician for clarification, which could delay administration. The Director of Nursing confirmed that staff should check blood pressure before administering such medications and that parameters are important to ensure safe administration. A review of facility policies indicated that medications should be administered according to prescriber orders, including any required vital sign checks, and that medication orders must include relevant clinical information and follow-up requirements. However, in this case, the orders for blood pressure medications did not include specific parameters for withholding the medication based on blood pressure readings, leading to the identified deficiency.
Failure to Communicate Pharmacist's Medication Recommendation to Physician
Penalty
Summary
The facility failed to inform the physician of the consultant pharmacist's recommendation regarding the administration of sertraline for a resident. The pharmacist's note, dated 4/30/2025, advised the attending physician to evaluate the need for discontinuation or gradual dose reduction of sertraline, in accordance with federal nursing facility regulations. However, the Assistant Director of Nursing (ADON) confirmed that this recommendation was not communicated to or reviewed by the physician. Additionally, there was no documentation found indicating that a gradual dose reduction had been implemented for the resident. The resident involved had a history of diabetes mellitus, schizophrenia, and chronic kidney disease, and had been receiving sertraline 50 mg daily for depression. The facility's policy required that residents on psychotropic medications receive gradual dose reductions unless clinically contraindicated. The Director of Nursing (DON) acknowledged that failure to provide the physician with the pharmacist's recommendations could result in the resident continuing to receive unnecessary medication.
Failure to Provide and Follow Up on Dental Services for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received necessary dental services as indicated by their medical and dental records. One resident, who had been re-admitted with severe protein-calorie malnutrition, diabetes, schizophrenia, and chronic kidney disease, had all teeth removed and had not received dentures for six weeks. Dental records showed that this resident required dental x-rays before denture impressions could be taken, and x-rays were completed, but there was no follow-up to provide dentures. The other resident, with diagnoses including diabetes and seizures, reported that her dentures did not fit properly, causing difficulty chewing, and had not seen a dentist in three weeks despite a recommendation for new dentures and a need for a full mouth dental x-ray. Interviews with staff revealed a lack of follow-up on dental recommendations for both residents. The Social Services Director admitted to not documenting missing teeth on the MDS and not understanding or following up on dental recommendations. A registered nurse confirmed that no follow-up occurred on the dental recommendations, and the Director of Nursing acknowledged the importance of following dental recommendations to prevent issues with chewing and nutrition. The facility's policy required prompt referral to a dentist for residents needing dental services, but this was not followed for the two residents.
Failure to Implement Effective QAPI Program for Resident Care Concerns
Penalty
Summary
The facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to identify and address multiple resident care concerns. Specifically, the facility did not monitor or identify weight loss in a resident, nor did it recognize weight loss as a problem in other residents. The Assistant Director of Nursing (ADON) confirmed during an interview that the facility did not review the comprehensive care plan for the affected resident or address the issue through an interdisciplinary team meeting. Additionally, the facility was focused on other areas such as falls and skin and wound management during the relevant period, and did not address the ongoing issue of weight loss. Further deficiencies included the failure to follow recommended Restorative Nursing Assistant Program exercises as prescribed by Physical Therapy, lack of accurate documentation by Restorative Nursing Assistant Services, and lapses in infection control practices. Staff were also observed not following proper feeding techniques, such as standing over a resident while feeding, and the facility did not follow up on a missed outpatient appointment. These actions and inactions were confirmed through interviews and record reviews, and were not addressed through the facility's QAPI processes as required by their policy.
Room Obstruction Creates Fire Hazard
Penalty
Summary
A deficiency was identified when a resident's bed was found obstructing the entrance to their room, creating a fire hazard by preventing the door from closing properly. The resident, who has multiple sclerosis, diabetes mellitus, and hypertension, is dependent on nursing staff for most activities of daily living and uses a wheelchair. The resident expressed concern that the bed's placement would impede access and egress in the event of a fire. Observations confirmed that the bed blocked the doorway, and interviews with staff, including a registered nurse and the maintenance director, acknowledged that this arrangement posed a fire hazard and violated safety protocols requiring doors to remain unobstructed. The maintenance director was aware of the issue and had discussed it with the administrator, who stated that beds are sometimes moved to accommodate residents' belongings. The administrator also confirmed that the resident's bed blocked the door and that the resident refused to move his items, citing limited space. Facility policy requires maintenance personnel to keep the building in good repair and free from hazards, but the obstruction remained at the time of the survey, resulting in a failure to maintain a safe environment.
Failure to Honor Resident's Choice for Shower Before Medical Appointment
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's expressed preference to have a shower before a scheduled medical appointment. The resident, who had diagnoses including diabetes mellitus, hemiplegia, and anxiety disorder, was cognitively intact and required partial to moderate assistance with bathing and other activities of daily living. On the morning of the appointment, the resident communicated to CNA 5 and RN 3 that he wished to shower before getting dressed, as it was his shower day. Despite this, CNA 5 attempted to dress the resident early and did not accommodate the request, citing other care responsibilities. The resident became frustrated and upset due to staff not listening to his preference. Multiple staff interviews confirmed that the resident's request for a shower was known and that honoring resident choice is recognized as important by facility policy and staff, including the LVN, DSD, and Administrator. CNA 7, who had previously promised to assist the resident with a shower before the appointment, later provided the shower, but only after the resident's initial request was disregarded. The facility's policy on resident rights supports self-determination and choice, which was not upheld in this instance.
Failure to Implement Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to implement individualized care plans for two residents, resulting in deficiencies related to the delivery of care and services. For one resident with diabetes mellitus and hypertension, the admission record and Minimum Data Set (MDS) indicated intact cognition and total dependence on staff for toileting, showering, and dressing. Despite a physician's order for quarterly lab draws, the resident reported that staff were unable to successfully draw her blood on three consecutive mornings. Interviews with nursing staff and the Director of Nursing (DON) confirmed that no care plan was developed to address the repeated unsuccessful lab draws or to guide staff in monitoring for potential infection related to these attempts. Another resident, with diagnoses including diabetes mellitus, hemiplegia following a stroke, anxiety disorder, and hyperlipidemia, required partial to moderate assistance with activities of daily living. The resident reported a concern regarding how a CNA turned and repositioned him, alleging inappropriate and abusive behavior during personal care. Review of the resident's Change in Condition (COC) evaluation and care plan revealed that the care plan did not address the alleged physical and sexual abuse. Nursing staff and the DON acknowledged that the care plan lacked specificity and did not include interventions or monitoring related to the abuse allegation. The facility's policy on comprehensive, person-centered care plans requires that care plans reflect current standards of practice and are revised as residents' conditions change. In both cases, the facility did not develop or update care plans to address the residents' specific needs and concerns, as confirmed by staff interviews and record reviews.
Resident Rooms Below Required Square Footage and Obstructed Egress
Penalty
Summary
The facility failed to provide resident rooms that met the required minimum size of 80 square feet per resident in multiple occupancy rooms, as determined through observation and record review. A review of the facility's room waiver request letter revealed that numerous rooms with two, three, or four beds did not meet the square footage requirement, with specific measurements for each room listed in the report. This deficiency was further supported by direct observation and documentation, confirming that the rooms in question were undersized for the number of residents assigned. During an interview, a resident reported that his bed was positioned in a way that blocked the door, raising concerns about the ability to close the door and potential hazards in the event of a fire. The facility administrator acknowledged that having a bed block the door could create a hazard and expressed a preference for keeping doors unobstructed to ensure prompt entry and exit at all times. The facility's policy and procedure on providing a safe, clean, comfortable, and homelike environment was also reviewed as part of the findings.
Failure to Notify Physician and Discontinue Blood Thinners After Resident Head Injury
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition following a head injury, despite the resident being on blood-thinning medications (Aspirin and Clopidogrel) for stroke prevention. After sustaining a head injury that resulted in an abrasion, laceration, a bump, and substantial bleeding, the resident's physician was not promptly informed. The resident continued to receive blood thinners for several days after the injury, as no order was obtained to discontinue these medications, and the care plan's instructions to monitor and report adverse reactions were not followed. Staff interviews and record reviews revealed that although a registered nurse attempted to contact the physician by voicemail and text message, there was no confirmation of a response or follow-up, and no further action was taken to ensure the physician was notified. Other nursing staff continued to administer the blood thinners, assuming the physician had been informed, and did not independently verify or escalate the situation. The resident subsequently exhibited noticeable changes in behavior, including decreased appetite, drowsiness, and reduced communication, which were not typical for him and were not reported to the physician as required by the care plan. The lack of timely physician notification and continued administration of blood thinners resulted in a delay in evaluation and treatment. The resident was eventually found lethargic and unarousable by a family member and was transferred to a hospital, where he was diagnosed with a subarachnoid hemorrhage and required a platelet transfusion. Facility policy required prompt physician notification in the event of accidents or significant changes in condition, but this was not adhered to in this case.
Delay in Authorization for Surgical Evaluation
Penalty
Summary
The facility failed to ensure timely authorization for a resident with an open cast to see a surgeon, as per the physician's order. The resident, who was admitted with a fracture of the right radius, had a physician's order dated 2/5/2025 to be evaluated by a surgeon. However, the authorization request was not faxed until 2/21/2025, resulting in a delay. The resident expressed concern about the prolonged duration of wearing the cast, indicating it had been on for four to five weeks without a follow-up appointment. Licensed Vocational Nurse 1 acknowledged the delay in requesting authorization, which should have been done earlier, as authorizations typically take 48 to 72 hours to process. The Social Services Director stated that authorizations should be completed within 24 hours of receiving the physician's order, with requests received within three to five business days. The facility's policy indicated that referrals for medical services must be based on physician evaluation and order, but this was not adhered to, leading to the deficiency.
Failure to Provide Adequate ROM and Mobility Services
Penalty
Summary
The facility failed to provide adequate treatment and services to maintain or prevent a decline in joint range of motion (ROM) and mobility for a resident. The resident, who was admitted with a fracture of the right radius, was moderately independent in decision-making but required substantial assistance for activities of daily living. Despite having orders for active assistive range of motion (AAROM) exercises for the left lower extremities, the resident did not receive services to maintain or improve ROM for the bilateral upper extremities or mobility. The resident expressed a desire to practice walking, but staff interviews revealed that the resident was not regularly transferred out of bed and was primarily seen in bed, increasing the risk of decline in ROM and mobility. The facility also failed to ensure that rehabilitation screenings were conducted upon the resident's readmission from a general acute care hospital. The Director of Rehabilitation acknowledged that a rehabilitation screen should have been completed when the resident returned from the hospital, but it was not done. The Director of Nursing confirmed that rehabilitation services should be provided to residents who require them to prevent a decline in functional mobility and ROM. The facility's policies indicated that residents with limited ROM should receive treatment to increase or prevent further decrease in ROM, but these were not followed in the case of the resident.
Failure to Provide Timely Rehabilitation Services
Penalty
Summary
The facility failed to provide necessary rehabilitation services for a resident who had a physician's order for a physical therapy evaluation dated 10/11/2024. The resident, who was admitted with a fracture of the right radius, was moderately independent in decision-making but required substantial assistance with activities of daily living. Despite the physician's order and a subsequent rehabilitation screen indicating the resident would benefit from physical therapy, no evaluation was completed. This oversight resulted in a delay in providing rehabilitation services. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that the rehabilitation screen conducted on 10/19/2024 showed the resident would benefit from physical therapy. However, the necessary evaluation was not performed, placing the resident at risk for a decline in ambulation and functional mobility. The facility's policy stated that therapeutic services should be provided upon the written order of the attending physician, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a severe incident between two residents. A Certified Nursing Assistant (CNA) left the room during a verbal argument between the residents, which escalated into a physical altercation. One resident punched the other in the head multiple times, leading to significant injuries. The injured resident was later diagnosed with a subdural hematoma and brain herniation at a hospital, where they subsequently passed away. The facility did not adequately investigate a grievance filed by another CNA regarding previous arguments between the two residents. The grievance highlighted ongoing tensions, but no preventative measures were developed to safeguard the residents from potential physical altercations. Additionally, the facility failed to create comprehensive care plans addressing the aggressive and dominating behaviors of the involved residents, which could have helped prevent the incident. Furthermore, the Social Service staff did not conduct necessary follow-up visits to assess the compatibility of the residents as roommates. This lack of oversight and documentation contributed to the failure to address the residents' incompatibility and escalating tensions, ultimately leading to the tragic outcome.
Failure to Administer Prescribed Depression Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident's prescribed escitalopram, a medication for depression, was not started as ordered by the physician on 5/1/2024. The resident, who had a history of major depressive disorder and was taking escitalopram 20 mg daily, was admitted and readmitted to the facility with multiple diagnoses, including COPD, type 2 diabetes mellitus, and heart failure. Despite having the capacity to understand and make decisions, the resident's medication was put on hold pending the signature of informed consent, which was already signed on 4/06/2024. The Assistant Director of Nurses (ADON) and the Director of Nurses (DON) acknowledged during interviews that the resident should not have been abruptly taken off the depression medication without a gradual dose reduction, as this could lead to clinical worsening and mood changes. The facility's policy on medication reconciliation, which aims to prevent unintended changes or omissions during transitions in care, was not followed, resulting in the omission of the resident's necessary medication.
Resident Rights Violation Due to Forcible Medication Retrieval
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity when the Social Services Director (SSD) forcibly took a sweater and a bottle of Norco medication from the resident without her permission. The incident occurred after the resident, who had been admitted with diagnoses including bipolar disorder, atrioventricular block, and type 2 diabetes, was observed self-administering a pill from the bottle. Despite being informed by the Licensed Vocational Nurse (LVN) and the SSD that self-administration of Norco was against facility policy, the resident refused to relinquish the medication, leading the SSD to forcibly take the sweater containing the medication. The resident, who was assessed to have intact cognition and the capacity to understand and make decisions, reported experiencing pain in both shoulders following the incident. The resident's Responsible Party (RP) confirmed that the resident did not give permission for the SSD to take the sweater or medication and reported the incident to the Director of Nurses (DON). However, the facility did not follow up on the report, and the resident expressed fear of interacting with the SSD. The facility's policy on self-administration of medications states that residents have the right to self-administer if deemed clinically appropriate and safe by the Interdisciplinary Team (IDT). Additionally, the facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity. Despite these policies, the incident was not reported as abuse by the facility, and the DON acknowledged that the incident should have been reported due to the resident's complaint of shoulder pain and feeling unsafe around the SSD.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged physical altercation between the Social Services Director (SSD) and a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved the SSD tugging a sweater from the resident without permission, which was witnessed by a Licensed Vocational Nurse (LVN). The resident's Responsible Party (RP) reported the incident, stating that the action caused the resident pain in both shoulders and fear of the SSD. Despite the report, the facility did not notify CDPH promptly, resulting in a delay in the investigation. The resident involved had a medical history including bipolar disorder, atrioventricular block, and type 2 diabetes. The resident was assessed to have the capacity to understand and make decisions, with intact cognition and functional limitations in the range of motion in one leg. On the day of the incident, the resident was found to be hiding narcotics in her sweater, which the SSD attempted to retrieve by taking the sweater, leading to the alleged physical altercation. Interviews with staff revealed that the incident was not reported as abuse because they did not perceive it as such, despite the resident's complaint of shoulder pain and feeling unsafe around the SSD. The Director of Nursing (DON) acknowledged that the incident should have been reported due to the resident's complaints and the violation of her rights. The facility's policy requires reporting of such incidents, but this was not adhered to, resulting in a deficiency in reporting suspected abuse or neglect.
Failure to Investigate Resident's Allegation of Rights Violation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an incident involving a resident and the Social Services Director (SSD). On 10/18/2024, the SSD removed a sweater from the resident's grasp without consent, intending to confiscate a medication bottle containing Norco, which the resident was self-administering. The resident, who had intact cognition and the capacity to make decisions, later reported shoulder pain allegedly resulting from the incident. Despite the resident's complaint and the report made by the resident's responsible party to the Director of Nurses (DON), the facility did not follow up or report the incident as required. The resident's medical history included bipolar disorder, atrioventricular block, and type 2 diabetes. The incident was documented in the resident's Nurse Progress Notes, and the Interdisciplinary Team (IDT) met to address the resident's concerns about shoulder pain. The resident expressed feeling unsafe around the SSD and did not wish to interact with her further. The responsible party reported the incident to the DON, but no follow-up was conducted, and the incident was not reported as abuse. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) witnessed the resident self-administering Norco and called the SSD for assistance. Both the LVN and SSD attempted to educate the resident on the risks of self-administration and the facility's policy against keeping narcotics. However, the SSD proceeded to remove the sweater to access the medication bottle, which was seen as a violation of the resident's rights. The DON acknowledged the failure to report the incident, recognizing that it should have been reported due to the resident's complaint of pain and feeling of unsafety.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services, as evidenced by the lack of psychiatric follow-up after the resident expressed feelings of sadness on multiple occasions. The resident, who was admitted with diagnoses including anemia, dementia, and polyneuropathy, had a care plan that included consulting psychiatric services due to psychosocial well-being problems. Despite referrals made on two separate occasions, the resident was not seen by a psychiatrist after the initial visit, which was documented in the psychiatric progress notes. Interviews with facility staff revealed that the Social Services Director (SSD) did not follow up to confirm whether the resident was seen by a psychiatrist after expressing sadness. The SSD acknowledged the oversight and stated that the facility failed to meet the resident's behavioral and psychosocial needs. The Quality Assurance (QA) nurse also confirmed that the facility did not ensure consistent psychiatric visits for the resident, despite the continued expression of sadness. The Director of Nursing (DON) admitted that the facility should have addressed the resident's ongoing sadness during care plan conferences and ensured psychiatric follow-up. The facility's policies and procedures indicated that behavioral health services should be provided to maintain residents' well-being, but these were not adhered to in this case, leading to the deficiency.
Failure to Implement Care Plan for Resident Removing Nasal Cannula
Penalty
Summary
The facility failed to develop and implement a care plan addressing specific interventions for a resident who frequently removes her nasal cannula, which is essential for providing supplemental oxygen. This deficiency resulted in the resident not receiving oxygen as ordered and staff being unaware of specific interventions to provide. The resident, who has diagnoses including sepsis, heart failure, and dementia, was observed without her nasal cannula, which was supposed to deliver continuous oxygen at two liters per minute to maintain oxygen saturation above 93%. Despite the care plan indicating the need for oxygen therapy, it lacked specific interventions for the resident's behavior of removing the nasal cannula. During observations and interviews, it was noted that the resident consistently removed her nasal cannula, and staff, including a CNA and an LVN, were aware of this behavior. However, there was no care plan in place to guide staff on how to address this issue. The CNA placed the nasal cannula back in the resident's nostrils without notifying a licensed nurse, which was against the facility's policy. The Director of Nursing acknowledged the absence of a care plan addressing the resident's behavior, which placed the resident at risk for desaturation and delayed services. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables, which was not met in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for Resident 2, who was admitted with diagnoses including diabetes mellitus type 2 and a stage 4 pressure ulcer. The resident required total assistance with activities of daily living, including toileting hygiene. Despite the care plan indicating the need for good peri care after each incontinence episode to prevent skin impairment, Resident 2 reported waiting for three hours to have his soiled brief changed. This delay resulted in a new onset of moisture-associated skin damage, as observed by the surveyors. During the investigation, it was revealed that CNA 1 did not change Resident 2's brief during her shift, citing the resident's refusal due to pain. However, LVN 1 stated that Resident 2 was not in pain when she administered his medications and had not been informed of any refusal of care. LVN 2 confirmed that the moisture-associated skin damage was a new development, likely due to prolonged exposure to urine and feces. The facility's policy required CNAs to notify a supervisor if a resident refused care, which was not followed in this instance.
Failure to Follow Physician's Orders for Wound Care and Oxygen Tubing
Penalty
Summary
The facility failed to adhere to physician's orders for a resident with severe cognitive impairment, who was admitted with a right ischium pressure injury and a Stage IV sacral coccyx pressure injury. The physician's orders required the resident's nasal cannula to be changed weekly and the wounds to be cleaned with normal saline daily. However, during an observation, it was noted that the nasal cannula lacked a date, indicating it had not been changed as per the order. Additionally, the wounds were cleansed with a wound cleanser spray instead of the prescribed normal saline, as the latter was unavailable. Interviews with the LVN and the DON confirmed the deviation from the physician's orders. The LVN acknowledged the absence of a date on the nasal cannula and the use of an alternative wound cleanser due to the unavailability of normal saline. The DON emphasized the importance of following physician's orders, noting that failure to do so could expose the resident to bacteria and germs, potentially affecting the healing process of the wounds. The facility's policies on oxygen and wound care were reviewed, highlighting the requirement to verify physician's orders during wound care preparation.
Failure to Create Care Plan for Non-Compliant Resident
Penalty
Summary
The facility failed to create a care plan for a resident who refused care and treatment for multiple pressure injuries and diabetic ulcers. The resident, who was admitted with type two diabetes and unstageable pressure ulcers, had a moderately impaired cognition as indicated by the Minimum Data Set. Despite having physician's orders for wound care, the resident consistently refused treatments, as noted in the Weekly Wound Note. The Licensed Vocational Nurse confirmed the absence of a care plan addressing the resident's non-compliance with wound treatments. The Director of Nursing acknowledged that a care plan should have been created when the resident refused care, and the physician should have been notified. The facility's policy requires the interdisciplinary team to review and update the care plan when there is a significant change in the resident's condition. The lack of a care plan for the resident's refusal of treatment had the potential to exacerbate the resident's pressure injuries and diabetic ulcers.
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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