Los Palos Post-acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Pedro, California.
- Location
- 1430 West 6th Street, San Pedro, California 90732
- CMS Provider Number
- 055527
- Inspections on file
- 40
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Los Palos Post-acute Care Center during CMS and state inspections, most recent first.
The facility failed to follow its own policy requiring use of a Resident Council Response Form to document and track concerns raised in resident council meetings. In two meetings, residents reported problems with timely toileting assistance and delayed call light response, but these issues were only noted in the council minutes and were not entered on the required response form. The Activities Director was unaware of prior council concerns, and the DON acknowledged knowing about the issues and providing staff in-services but not using the mandated tracking tool, preventing formal follow-up and QAPI review of these resident-reported problems.
A resident with complex medical needs experienced low blood pressure prior to dialysis, but nursing staff failed to reassess vital signs or notify the physician before transport. Additionally, staff did not inform the physician when a foul-smelling odor was observed from the resident's diabetic foot wound, which had worsened. These failures delayed necessary care and increased the risk of hospitalization.
Two residents, both requiring supervision while smoking due to cognitive and physical impairments, were left unsupervised on the smoking patio after the scheduled smoking period. The patio door was not secured, and staff did not monitor or redirect the residents as required by facility policy. During this time, one resident became verbally aggressive and threw a plastic mug at another, causing a head injury and escalating pain. Staff interviews confirmed lapses in supervision and failure to follow established safety protocols.
Three residents with significant medical needs tested positive for COVID-19 on the same day, constituting an outbreak. The facility's Infection Prevention Nurse reported the outbreak to the local health department but failed to notify CDPH, despite facility policy and regulatory requirements. This deficiency was confirmed through record review and staff interviews.
A resident with a Stage 4 pressure ulcer, who was nonverbal and fully dependent, experienced unmanaged pain during wound care and repositioning. Staff observed facial grimacing and moaning but continued treatment without stopping to assess or address pain. Pain medication was not administered as ordered prior to wound care, and staff did not verify or coordinate the timing of medication and treatment, resulting in the resident undergoing procedures without adequate pain relief.
Surveyors identified multiple deficiencies in medication administration and documentation, including late administration of antihypertensive medication, unclarified duplicate topical orders, inaccurate MAR entries, improper handling and administration of ophthalmic and otic medications, and discrepancies in controlled substance documentation. These issues involved several residents with complex medical needs and were confirmed through observation, interviews, and record reviews.
Two residents experienced medication administration errors, including late administration of antihypertensive medication, failure to administer prescribed ophthalmic solutions, and preparation of an incorrect vitamin supplement. In one case, a nurse documented administration of eye drops that were not given, and allowed a resident assessed as unable to self-administer to keep medications at bedside. In another case, a nurse prepared vitamin B complex instead of the ordered thiamin. These actions resulted in a medication error rate above the acceptable 5% threshold.
Surveyors found that staff failed to ensure medication labels matched physician orders, did not label opened insulin pens with the date, left discontinued insulin in the medication refrigerator, allowed eye drops to remain at a resident's bedside despite lack of self-administration assessment, and stored expired naloxone in a medication cart. These actions were not in accordance with facility policy or manufacturer guidelines.
Three residents with complex medical conditions, including DM, HTN, CKD, and dysphagia, reported that the food served was consistently cold, bland, and unappetizing. Observations confirmed that meals were unseasoned, visually unappealing, and sometimes inedible. Food was prepared offsite and delivered in hot carts, but staff only checked for accuracy, not quality or palatability, resulting in dissatisfaction and some residents relying on outside food or personal seasonings.
The facility's QAA and QAPI committees did not implement corrective actions for systemic issues, including untimely call light response, inadequate ADL implementation, medication errors, improper storage and labeling of medications and food, and incomplete clinical records. Leadership acknowledged ongoing problems and the need for improvement, but deficiencies persisted, potentially impacting resident care.
A resident's MDS assessment was incorrectly coded to indicate incontinence, despite documentation and staff interviews confirming the resident was continent and able to communicate needs. The error was identified through review of records and interviews with the resident, CNA, LVN, and MDS nurse, revealing that the resident only used diapers at night due to delayed assistance, not incontinence.
A resident with diabetes, hypertension, and severe cognitive impairment developed a toe infection, but staff did not update or implement a care plan to address the new condition. Despite facility policy and staff acknowledgment that care plans should be revised with significant changes, no care plan interventions or monitoring were documented for the infection.
A resident with impaired cognition and multiple health conditions did not receive Ciprodex otic drops according to professional standards or facility policy. An LVN failed to shake the suspension and administered one drop at a time with five-minute intervals, causing the resident discomfort. Facility policy required all drops to be given at once, followed by a five-minute wait, but incorrect in-service instructions led to the deficiency.
A resident with a Stage 4 pressure ulcer did not receive wound care as ordered, as a nurse applied Santyl ointment instead of the prescribed Medi Honey. The nurse admitted to not verifying the current physician orders before treatment, and records confirmed the deviation from the care plan. This failure to follow the prescribed wound care regimen was confirmed by observation, interview, and record review.
A resident with hypertension and other chronic conditions did not receive their prescribed metoprolol succinate ER within the facility's required 60-minute window on multiple occasions. The medication, scheduled for administration with meals, was repeatedly given late, as confirmed by direct observation, record review, and staff interviews. Facility policy requiring timely medication administration was not followed.
A resident with severe cognitive impairment and limited English proficiency did not have his food preferences, including cultural preferences, identified or honored. The dietary staff supervisor failed to consult the resident's family or representative, resulting in the resident not receiving culturally appropriate meals, despite facility policy requiring such efforts.
A nurse documented the administration of several prescribed eye medications for a resident with glaucoma and other conditions, despite not actually administering them and not having the medications available. The resident was assessed as unable to self-administer medications, and facility policy required accurate documentation by the administering nurse. The DON confirmed that the resident was not reassessed for self-administration and that documentation practices were not followed, resulting in inaccurate medical records.
A LVN did not perform hand hygiene between resident care and when entering or exiting a resident room. The LVN acknowledged this lapse, and the DON confirmed that hand hygiene is required in these situations according to facility policy.
A resident with multiple chronic conditions and severe cognitive impairment was prescribed Doxycycline for toe cellulitis without first obtaining a wound culture or confirming infection criteria, contrary to the facility's Antibiotic Stewardship protocol. Staff interviews and record review confirmed that required steps were not followed before initiating antibiotic therapy.
A resident with multiple chronic conditions was found to have a large hole in the sliding screen door of their room, which had been present for several months without being addressed. The issue was known to the resident and observed by staff, but was not reported or documented for repair in a timely manner, resulting in a failure to provide a safe and home-like environment as required by facility policy.
A resident experienced discomfort due to excessively high room temperatures, reaching 90°F, which violated the facility's policy of maintaining temperatures between 71-81°F. Staff interviews revealed that room temperatures were only checked upon complaints, not daily as required, leading to this deficiency.
A resident with a history of aggressive behavior and severe cognitive impairment physically abused another resident after expressing a preference for solitude and a dislike for noise. The facility failed to provide a private room or adequate monitoring, resulting in the victim sustaining facial injuries and emotional distress.
A resident with dementia and a history of wandering behavior entered her previous room after an alleged altercation with her former roommate, due to the facility's failure to implement care plan interventions. Despite the care plan requiring constant visual checks and hourly monitoring, staff did not document these actions, leading to the resident's unsupervised movement. Surveillance footage confirmed the resident's entry into the previous room, highlighting a lapse in care plan implementation.
A facility failed to provide a resident's medical records to their legal representative within the required 48-hour timeframe. The resident, with severe cognitive impairment and multiple diagnoses, had their records requested on 8/14/2024, but the facility delayed the release until 9/24/2024. The delay was due to the facility's process of routing requests through their legal team, violating the policy of timely record release.
A facility failed to provide a resident's medical records within the required two working days after a request from the legal representative. The resident, with severe cognitive impairment and multiple diagnoses, had their records requested on August 30, 2024, but the facility did not submit them until September 6, 2024. The Medical Records Director and Administrator misunderstood the policy, leading to a violation of the resident's rights.
A resident at high risk for skin breakdown did not receive proper pressure ulcer care and prevention. The facility failed to measure existing wounds upon admission and delayed ordering a low air mattress, leading to the development of new ulcers and worsening of existing ones. Staff interviews confirmed non-compliance with facility policies on wound assessment and intervention.
A resident with bone cancer and congestive heart failure experienced a change in condition, requiring a breathing treatment that delayed an infusion appointment. The facility failed to notify the resident's representative of this change, violating the resident's rights. Staff interviews and facility policy confirmed the requirement for notifying and involving the representative in care planning.
A resident with bone cancer did not receive proper pain management as the facility failed to document the administration of Norco, assess pain using a rating scale, and evaluate the medication's effectiveness. The Controlled Medication Count Sheet showed Norco was given, but it was not recorded in the MAR. Nursing notes inaccurately documented the effectiveness of the medication at the time of administration. Staff interviews confirmed these documentation lapses, which did not comply with the facility's pain management policy.
A resident with severe cognitive impairment and a history of falls did not have floor mats at the bedside as required by their care plan. The absence of these mats was confirmed during an observation and interview with the Charge Nurse, who acknowledged the oversight. The facility's policy mandates comprehensive care plans to maintain residents' well-being, which was not followed in this case.
A resident with severe cognitive impairment refused podiatry and optometry services, and the facility failed to update the care plan or notify the family, as required by policy. This led to a delay in necessary services, potentially impacting the resident's health.
A resident with severe cognitive impairment and high fall risk did not have floor mats placed by their bed as ordered by the physician and indicated in the care plan. Despite the resident's history of falls and a high Morse Fall Scale score, the necessary safety measures were not implemented, posing a risk of severe injury.
The facility failed to maintain the dignity and privacy of two residents. One resident was left in a urine-soaked diaper without a privacy curtain, and another had an exposed urinary catheter without a privacy bag. Staff confirmed these were dignity issues.
The facility failed to ensure that the call light was within reach for two residents, leading to frustration, feelings of helplessness, and increased risk of falls and injuries. Both residents had significant medical conditions and required assistance with daily activities, but their call lights were not accessible, contrary to facility policy.
The facility failed to provide two residents with their preferred activities, negatively impacting their quality of life. One resident with cerebral infarction was observed multiple times without engagement in her preferred activities, while another resident with dysphagia and hemiplegia was mostly found sleeping without any activity personnel engaging her. Staff interviews confirmed the inconsistency in providing activities due to staffing issues.
The facility failed to ensure proper respiratory care for two residents. One resident's suction machine tubing and yankauer were not dated, and another resident's oxygen tubing was undated, with humidifying water not changed since 4/7/2024. Staff confirmed these items should be changed weekly to ensure patency and prevent germ growth.
The facility failed to provide accurate and safe pharmaceutical services by not disposing of discontinued medications for two residents, not transcribing physician's orders for fentanyl patches into the MAR for a resident, and not checking blood pressure parameters before administering antihypertensive medication to another resident. These failures were confirmed through observations, interviews, and record reviews.
The facility failed to maintain the medication storage refrigerator within the required temperature range of 36 to 46 degrees Fahrenheit, as observed during a survey. The refrigerator was found to be at 54 degrees Fahrenheit, containing several unopened and unexpired medications. Both the Registered Nurse Supervisor and the Director of Nursing acknowledged the importance of maintaining the correct temperature to ensure medication efficacy and potency.
The facility failed to store food in a sanitary manner, affecting 93 out of 95 residents. Food items were not dated or labeled, room temperatures were not documented, and frozen ham was improperly thawed and stored, leading to potential cross-contamination.
The facility failed to submit a resident's MDS discharge assessment to CMS within the required 14-day timeframe. The resident, who had moderate cognitive impairment and required assistance for daily activities, had their assessment submitted late, affecting the quality measures and accuracy of the assessment.
The facility failed to ensure a resident's fingernails were clean and trimmed, resulting in irregular edges and dark brown substance accumulation. Despite the resident's dependence on staff for ADLs, observations and staff interviews confirmed that proper nail care was not provided, contrary to the facility's policy.
The facility failed to ensure that a resident with hemiplegia received consistent range of motion (ROM) exercises during activities of daily living (ADLs). Medical records showed significant gaps in the provision and documentation of ROM exercises, and staff interviews revealed a lack of consistent implementation, contrary to the facility's policies on resident mobility and ADLs.
A resident was prescribed an antibiotic for a wound infection without proper assessment or testing to confirm the infection. The facility's IP and RN confirmed that no wound culture or blood work was done before starting the medication, contrary to the facility's Antibiotic Stewardship policy.
The facility failed to administer fentanyl transdermal patches as ordered by the physician for a resident with multiple diagnoses, including severe pain. The MAR indicated patches were applied every 48 hours instead of the prescribed 72 hours, leading to potential overdose and respiratory failure risks. Interviews revealed that nursing staff did not reconcile physician orders with the MAR and medication labels.
The facility failed to maintain accurate Controlled Drug Records for a resident's fentanyl patch administration and removal, missing the required two nurse signatures for several periods. Interviews with the Dispensing Pharmacist and DON confirmed the policy requirement for dual signatures to verify removal and destruction of patches.
A resident was prescribed an antibiotic without meeting the necessary criteria and without prior assessment for a wound infection. The facility's policy requires screening and lab tests before initiating antibiotic therapy, which was not followed, putting the resident at risk for adverse reactions and antibiotic resistance.
Failure to Document and Track Resident Council Concerns on Required Response Form
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy for documenting and tracking concerns raised during resident council meetings. Review of resident council minutes from two meetings showed that residents reported problems with timely toileting assistance, specifically requesting that nurses regularly check on residents who use the restroom often at least every two hours, and concerns that call lights were not being answered in a timely manner. These concerns were recorded in the council minutes but were not transferred to or documented on the facility’s Resident Council Response Form, which is the tool designated by policy to formally record issues and track their resolution. The Activities Director, who had been in the role for about a month, reported being unaware of prior resident council concerns and stated that council minutes should be shared with department heads so they can investigate and address issues. The DON acknowledged that the facility was aware of the residents’ concerns about delayed call light response and the need for assistance with toileting and hygiene at least every two hours, and stated that staff in-services were provided. However, the DON confirmed that the Resident Council Response Form was not used as required by the facility’s Resident Council policy. The policy specifies that the Response Form will be used to track issues and their resolution, that the responsible department will address the concerns, and that the QAPI committee will review resident council information as part of its quality review. Because the form was not used, the issues raised in the two council meetings were not formally tracked or integrated into the QAPI review process.
Failure to Reassess and Notify Physician for Low Blood Pressure and Wound Infection
Penalty
Summary
The facility failed to provide necessary care and services for a resident with multiple complex medical conditions, including end stage renal disease, diabetes with a foot ulcer, dependence on dialysis, peripheral vascular disease, and acute osteomyelitis. On the morning of the incident, the resident was found to have a low blood pressure reading of 90/42 mmHg. The assigned nurse administered midodrine as ordered but did not reassess the resident's vital signs after administration or prior to sending the resident to dialysis. The nurse also did not notify the physician of the low blood pressure, despite being aware that dialysis can further lower blood pressure and that the resident was at risk for clinical instability. The RN Supervisor was informed of the low blood pressure and administration of midodrine but also did not reassess the resident or notify the physician. The resident was subsequently transferred to the hospital from the dialysis center due to hypotension. Additionally, the facility failed to notify the physician when a foul-smelling odor was observed from the resident's right Achilles wound during wound care treatment the previous day. The wound had worsened, with increased swelling, maceration, and slough tissue, and the presence of a foul odor, which may indicate infection. The treatment nurse did not document a change in condition or notify the physician to obtain updated treatment orders. The wound care consultant, who assessed the resident the following day, noted signs of infection and significant pain but was not informed by staff of the foul odor observed earlier. Interviews with facility staff, including the DON, confirmed that the nurses were responsible for ensuring residents were stable before being sent to dialysis and for notifying the physician of significant changes in condition, such as low blood pressure or signs of wound infection. The facility's policies and job descriptions also required prompt notification and documentation of changes in condition. The failures to reassess the resident, notify the physician, and document changes in condition had the potential to delay necessary care and treatment.
Failure to Supervise Residents and Secure Smoking Patio Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for two residents who were left unsupervised on the smoking patio after the last scheduled smoking time. Both residents had documented needs for supervision while smoking, as indicated by their Smoking Safety Screens and care plans. Despite these requirements, staff did not supervise the residents on the patio at approximately 7:00 p.m., and the door to the smoking patio was not secured after the designated smoking period ended at 6:00 p.m. One resident, who had diagnoses including anxiety disorder, repeated falls, major depressive disorder, and a recent fracture, was assessed as having intact cognition but required substantial assistance with activities of daily living and was only permitted to smoke with supervision and a protective apron. The other resident had severe cognitive impairment and also required supervision while smoking. On the evening in question, the two residents remained on the patio unsupervised, during which time one resident became verbally aggressive and threw a plastic coffee mug at the other, resulting in a bump on the head and escalating pain over the following days. Interviews with staff revealed that CNAs and LVNs were unaware of the residents' whereabouts and did not monitor or redirect them as required. Staff acknowledged that residents sometimes remained on the patio unsupervised after smoking times, and that the patio door was not consistently locked. The facility's policy required supervision and securing of the patio after smoking times, but these procedures were not followed, directly leading to the incident of resident-to-resident aggression and injury.
Failure to Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) after three residents tested positive for COVID-19 on the same day. Resident 6, who had arthrogryposis multiplex congenita and required substantial assistance with activities of daily living (ADLs), tested positive for COVID-19. Resident 7, with a diagnosis of diabetes mellitus and moderate cognitive impairment, also tested positive, as did Resident 8, who had similar diagnoses and care needs. The positive test results for all three residents were documented on the same date, indicating an outbreak within the facility. Despite the facility's policy requiring the reporting of communicable disease outbreaks to appropriate agencies, including CDPH, the Infection Prevention Nurse reported the outbreak only to the local health department and not to CDPH. This omission was confirmed during interviews with both the Infection Prevention Nurse and the Director of Nursing, who acknowledged that such outbreaks should be reported to CDPH to ensure proper measures are taken. The facility's policy, dated December 2007, specifically mandates reporting of unusual occurrences, including communicable disease outbreaks, as required by federal or state regulations.
Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
A resident with a Stage 4 pressure ulcer to the left buttock, who was nonverbal and dependent on staff for all activities of daily living, experienced unrelieved and uncontrolled pain during wound care and repositioning. The resident had a history of anoxic brain injury and functional quadriplegia, rendering her unable to express needs or communicate verbally. Staff observed and reported that the resident exhibited facial grimacing and moaning—recognized nonverbal indicators of pain—during pressure ulcer treatments and repositioning. Despite these clear signs of pain, the treatment nurse continued with wound care procedures without stopping to assess or address the resident's discomfort. The facility failed to ensure that pain management protocols were followed as ordered by the physician and outlined in the resident's care plan. Specifically, Tylenol 500 mg was not administered one hour prior to wound treatment as required, and wound care was not consistently performed within one hour after pain medication administration. Multiple instances were documented where the timing of pain medication and wound care did not align, resulting in the resident undergoing painful procedures without adequate pain relief. Additionally, nurses did not verify whether pain medication had been given before starting wound care, and staff did not consistently assess or document the resident's pain before, during, and after treatment. Interviews with nursing staff and review of records confirmed that the facility's pain assessment and management policy was not followed. Staff acknowledged that they recognized the resident's nonverbal cues as indicators of pain but failed to intervene appropriately, such as stopping treatment, reassessing pain, or notifying the physician. The care plan specifically stated that the resident should not experience pain or facial grimacing during care, yet these interventions were not implemented. The deficiency resulted in the resident experiencing unnecessary pain and suffering during routine wound care and repositioning.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration for several residents, as evidenced by multiple deficiencies observed during survey. One resident with a history of hypertension, osteoarthritis, and glaucoma did not receive metoprolol succinate ER within 60 minutes of the scheduled time on multiple occasions, contrary to facility policy. Additionally, this resident had duplicate orders for diclofenac (Voltaren) topical gel that were not clarified or discontinued, and there was inaccurate documentation of medication administration, including instances where medications were documented as given when they were not administered. The same resident was found to have eye drops at bedside despite being assessed as unable to self-administer, and some prescribed eye medications were unavailable or not administered as ordered. Another resident with severe cognitive impairment was prepared to receive vitamin B complex instead of the ordered thiamin (vitamin B-1), and the error was only identified after the medication was refused. The facility staff prepared the incorrect medication, and there was no physician order for vitamin B complex. In a separate incident, a resident with diabetes and neuropathy received Ciprodex otic suspension incorrectly, as the nurse did not shake the suspension before administration and instilled the drops with a five-minute interval between each drop, causing discomfort and deviating from professional standards and facility policy, which required all drops to be instilled at once followed by a five-minute wait. Controlled medication documentation was also found to be inaccurate for two residents. For one resident, the count of pregabalin capsules did not match the controlled drug record (CDR) or the electronic medication administration record (eMAR), as the nurse failed to document administration in the CDR immediately after giving the medication. Similarly, for another resident prescribed lacosamide for seizures, the medication count and documentation were inconsistent, with the nurse admitting to forgetting to document on the controlled count sheet. These documentation lapses were confirmed by the DON, who acknowledged the importance of accurate and timely documentation for controlled substances.
Medication Administration Errors Exceeding Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration, resulting in an error rate of 18.75%. For one resident with diagnoses including hypertension, osteoarthritis, and glaucoma, a nurse administered metoprolol succinate ER more than 60 minutes after its scheduled time on multiple occasions, contrary to facility policy. Additionally, the same resident did not receive prescribed ophthalmic medications (timolol, Alphagan P, dorzolamide, and artificial tears) as ordered. The nurse documented these medications as administered, but later admitted the resident self-administered them, despite an assessment indicating the resident was unable to self-administer medications. The medications were found at the resident's bedside, and the nurse did not have all required eye drops in stock at the time of administration. Another resident with severe cognitive impairment and multiple diagnoses was prepared to receive vitamin B complex by a nurse, although the physician's order specified thiamin (vitamin B-1) only. The nurse realized the error after preparing the medication and acknowledged that administering vitamin B complex instead of thiamin would not be in accordance with the physician's order. The resident refused all medications except one, so the incorrect medication was not administered, but the preparation of the wrong medication was still identified as a deficiency. Facility policy required medications to be administered as prescribed and within 60 minutes of the scheduled time, and only by staff authorized to do so. The policy also specified that residents assessed as unable to self-administer medications should have all medications administered by nursing staff, and unauthorized medications found at bedside should be removed. These policies were not followed in the cases described, leading to the cited deficiencies.
Medication Storage, Labeling, and Removal Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and management of medications and biologicals. In one instance, a nurse administered insulin glargine to a resident using a pen whose pharmacy label did not match the current physician order in the electronic medical record. The nurse also failed to label the insulin pen with the date it was opened, contrary to manufacturer specifications and facility policy. The Director of Nursing confirmed that the discrepancy between the pharmacy label and the physician order posed a risk for medication errors, and that the open date was necessary to determine the insulin's expiration and potency. Another deficiency was observed when a discontinued vial of insulin lispro for a resident was found in the medication room refrigerator. The Registered Nurse Supervisor acknowledged that the medication should have been removed after discontinuation to prevent accidental administration. Review of the resident's records confirmed that the insulin had been discontinued and replaced with an oral medication, but the vial remained accessible in the refrigerator. Additional issues included the discovery of multiple eye drop medications at a resident's bedside, despite documentation that the resident was not assessed as capable of self-administering medications. The nurse present removed the medications, recognizing the risk of incorrect administration. Furthermore, expired naloxone nasal spray containers were found in a medication cart, and staff confirmed these should have been discarded as they would not be safe or effective for use. Facility policies reviewed by surveyors required proper labeling, timely removal of discontinued or expired medications, and assessment of residents' ability to self-administer medications, all of which were not followed in these instances.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to ensure that three sampled residents received food that was appetizing, palatable, and served at a safe and appealing temperature. Resident 82, who had diagnoses including diabetes mellitus, hypertension, and hyperlipidemia, was noted to have variable food intake possibly due to intolerance to the prescribed diet. His wife brought in outside food because he did not like the meals provided. Resident 48, with dysphagia, diabetes mellitus, and hyperlipidemia, and Resident 41, with diabetes mellitus, chronic kidney disease, and spinal stenosis, also expressed dissatisfaction with the food, describing it as awful, tasteless, and cold. Resident 41 reported keeping her own salt and pepper at bedside and described the breakfast as repetitive and the eggs as inedible and cold. During an observation and interview, a test tray consisting of pork, carrots, and polenta was found to be unseasoned, greasy, tasteless, and not visually appealing. The carrots appeared pale and grayish, and the polenta lacked flavor. The cook confirmed that food was prepared offsite and delivered in hot carts, with her responsibility limited to checking the food before distribution. The facility's policy required the dietary service supervisor to ensure residents received proper food items at appropriate temperatures for safety and palatability, but this standard was not met for the sampled residents.
Failure to Implement Corrective Actions for Systemic Quality Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to implement corrective actions for several identified systemic problems. These deficiencies included the lack of systems to ensure timely response to call lights, proper implementation of activities of daily living, accurate pharmaceutical services and procedures, prevention of significant medication errors, correct storage and labeling of biologicals and medications, sanitary food storage, and maintenance of clinical records according to professional standards. The report notes that these failures had the potential to result in residents not receiving necessary services and care. Interviews with the Administrator and Director of Nursing (DON) confirmed ongoing issues in areas such as pressure ulcers, medication management, and call light response. The DON acknowledged that all staff are responsible for identifying skin issues and answering call lights, and recognized the need for improvement in the deficient practices identified. Review of the facility's QAPI policy indicated objectives for monitoring and correcting negative indicators, but the report documents that these objectives were not met in practice.
Inaccurate MDS Coding of Continence Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's continence status. Specifically, the MDS for one resident was incorrectly coded to indicate incontinence, despite multiple sources confirming the resident was continent. The resident's admission record listed several diagnoses, including diabetes mellitus, myocardial infarction, a broken left arm, and hypertension. Interdisciplinary team meeting notes and the MDS itself documented that the resident was able to make decisions and communicate needs. Interviews with both a CNA and an LVN confirmed the resident was not incontinent and did not require assistance with toileting, instead using a urinal independently. Further interviews revealed that the MDS nurse, responsible for completing the MDS assessments, had relied on information from the initial care plan meeting and family input. However, during a joint interview with the resident and the MDS nurse, the resident stated he was not incontinent and only used diapers at night due to delayed assistance, not due to actual incontinence. The facility's policy required staff to assess and document continence status accurately, referencing MDS criteria. The inaccurate coding on the MDS was identified as a discrepancy that could affect the resident's care.
Failure to Update Care Plan for Resident's Toe Infection
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's toe infection. The resident, who had a history of hypertension and diabetes mellitus and was admitted with severely impaired cognition, was identified as having left second toe cellulitis, for which an antibiotic was ordered. Despite the identification of the infection and the initiation of treatment, the care plan was not updated or revised to reflect the new condition. Interviews with facility staff, including the Infection Prevention Nurse, an LVN, and the Director of Nursing, confirmed that the care plan should have been implemented or revised at the time the infection was identified. The facility's policy also indicated that care plan goals and objectives should be reviewed and revised when there is a significant change in a resident's condition. However, no care plan addressing the toe infection was created or updated, resulting in a lack of documented interventions and monitoring for the resident's new infection.
Improper Administration of Otic Medication
Penalty
Summary
The facility failed to ensure that a resident's Ciprodex otic (ciprofloxacin and dexamethasone) ear drops were administered according to professional standards of practice and the facility's own policy. During a medication pass, an LVN did not shake the ear suspension prior to administration and instilled one drop at a time into the resident's right ear, waiting five minutes between each drop, resulting in a total administration time of 20 minutes. The resident, who had moderately impaired cognition and required significant assistance with activities of daily living, complained of neck pain during the process due to prolonged tilting of the head. The facility's policy specified that the prescribed number of drops should be instilled into the ear canal, followed by instructing the resident to remain in the same position for approximately five minutes. The LVN, however, was following incorrect instructions received during an in-service, which led to the deviation from policy. The DON confirmed that the medication should have been administered as four drops at once, not with intervals, and acknowledged that the resident could experience discomfort and potentially refuse future doses as a result of the improper administration.
Failure to Follow Physician Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for a resident with a Stage 4 pressure ulcer on the left buttock. The resident, who was dependent on staff for all activities of daily living due to anoxic brain injury and functional quadriplegia, had physician orders specifying that the wound should be cleansed with normal saline, Medi Honey applied to the wound bed, and barrier cream to the peri-wound area daily. However, during an observation, the treatment nurse was seen applying Santyl ointment instead of Medi Honey as ordered. The nurse admitted to using Santyl based on previous experience rather than current physician orders and acknowledged that the correct treatment should have been verified prior to administration. Record reviews confirmed that the physician's orders and the treatment administration record both specified Medi Honey for the wound care regimen. The facility's policy required staff to verify the five rights of medication administration before providing care, which was not followed in this instance. Interviews with the treatment nurse and the Director of Nursing confirmed that the deviation from the prescribed treatment could directly impact the resident's well-being and healing process. The deficiency was identified through observation, interview, and record review, and was limited to this resident.
Failure to Administer Medication Within Required Timeframe
Penalty
Summary
A deficiency occurred when a resident with a history of hypertension, osteoarthritis, pain syndrome, retinal edema, and glaucoma did not receive their prescribed metoprolol succinate ER 25 mg within the facility's required timeframe. The medication, ordered to be administered twice daily with meals and held for low systolic blood pressure or pulse, was scheduled for 7:15 a.m. but was not given until 9:00 a.m. on the observed date. Facility policy requires medications to be administered within 60 minutes of the scheduled time, and this late administration was confirmed by both the RN Supervisor and the Director of Nursing. Review of the resident's medication administration history revealed that this medication was administered late on ten occasions within a two-week period. The late administration was observed directly by surveyors and confirmed through interviews and record reviews. The facility's policy on medication administration, which mandates adherence to prescriber orders and a 60-minute window for administration, was not followed in these instances.
Failure to Honor Resident's Cultural Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences, including cultural preferences, were identified and honored. The resident, who was admitted with diagnoses including Parkinson's disease, muscle weakness, and dementia, had a severe cognitive impairment and was unable to express his preferences verbally. The resident primarily spoke Japanese and had limited English proficiency, and no staff at the facility spoke Japanese. Despite this, the dietary staff supervisor only interviewed the resident, who was unable to communicate effectively, and did not consult the resident's family or representative to determine food likes, dislikes, or cultural preferences. The care plan indicated a goal to include the resident's food preferences in his therapeutic diet, but this was not achieved. Interviews with staff confirmed that the resident never received Japanese food and that the dietary staff supervisor was unaware of the resident's language or cultural background. The supervisor acknowledged that, given the resident's severe cognitive impairment, the family should have been interviewed to obtain this information. The facility's policy required the dietary service supervisor to participate in food preference updates and resident visits, but these steps were not followed. As a result, the resident did not receive food items consistent with his cultural preferences and choices.
Falsification of Medication Administration Records for Ophthalmic Medications
Penalty
Summary
Licensed staff failed to accurately document medication administration for a resident with multiple diagnoses, including glaucoma, hypertension, and pain syndrome. The resident had physician orders for several ophthalmic solutions and artificial tears to be administered at specific times daily. During medication administration observation, the nurse prepared and administered oral medications but did not include any of the prescribed eye drops. Despite this, the Medication Administration Record (MAR) reflected that the eye drops were administered at the scheduled times. Further review revealed that the resident was assessed as unable to self-administer medications, with a physician order specifying that all medications were to be given by a licensed nurse. The nurse initially claimed to have administered the eye drops, then stated the resident self-administered them, and finally acknowledged that the medications were not administered and that documentation indicating otherwise was incorrect. The nurse also admitted that some of the prescribed eye drops were not available in the medication cart and would need to be reordered from the pharmacy. The Director of Nursing confirmed that the facility had not reassessed the resident for self-administration and that nurses were not permitted to document medications as given when they were not administered. Facility policy required that only the individual who administers the medication should document it on the MAR immediately after administration, and that unadministered doses should be documented as such. The failure to follow these procedures resulted in inaccurate medical records for the resident.
Failure to Perform Hand Hygiene Between Resident Care
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to perform hand hygiene between providing care to residents and when entering and exiting a resident room, as observed by surveyors. During interviews, the LVN acknowledged the lapse in hand hygiene, and the Director of Nursing (DON) confirmed that hand hygiene is the primary method to prevent the spread of infection and is required between resident care and when moving in and out of resident rooms. Review of the facility's hand hygiene policy indicated that all personnel are required to follow handwashing procedures to prevent the spread of infections to staff, residents, and visitors.
Failure to Follow Antibiotic Stewardship Protocol Prior to Prescribing Antibiotics
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol for one of three sampled residents by prescribing an antibiotic without meeting established criteria. Specifically, a resident with a history of hypertension and diabetes mellitus, who was admitted with severe cognitive impairment and required supervision for daily activities, was prescribed Doxycycline for left toe cellulitis. The order for the antibiotic was placed without first obtaining a wound culture or confirming that the resident met McGreer's Criteria for infection, as required by facility policy. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that a wound culture should have been collected prior to starting the antibiotic to ensure appropriate treatment and adherence to the facility's protocol. The facility's policy states that antibiotics should only be prescribed when clinical criteria for infection are met and pathogen susceptibility is determined. The failure to follow these procedures was confirmed through record review and staff interviews.
Failure to Maintain Home-Like Environment Due to Damaged Screen Door
Penalty
Summary
A deficiency was identified when a resident was not provided with a home-like environment, as evidenced by a large hole in the sliding screen door of the resident's room. The resident, who was admitted with diagnoses including diabetes mellitus, hypertension, and hyperlipidemia, reported that the hole had been present since admission and had remained unaddressed for approximately four months. The resident was able to communicate and expressed awareness of the issue during an interview. Staff interviews revealed that a CNA noticed the hole but had not reported it, and the maintenance supervisor confirmed that monthly room checks were conducted, but could not provide documentation of repairs for the resident's room prior to the recent replacement of the screen door. The facility's policy required a safe, clean, and comfortable environment, but this was not maintained for the resident, as the hole in the screen door persisted for an extended period.
Failure to Maintain Safe Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe room temperature for a resident, which is a violation of the resident's right to a homelike environment. The resident, who was cognitively intact and required substantial assistance with personal hygiene, toileting, and transferring, reported that their room temperature was excessively hot, reaching 90 degrees Fahrenheit. This discomfort was confirmed by a family member who checked the room temperature. The facility's policy requires room temperatures to be maintained between 71 and 81 degrees Fahrenheit, but this standard was not met. Interviews with facility staff revealed that room temperatures were only checked upon receiving complaints, rather than being monitored daily as required by the facility's policy. The Maintenance Supervisor acknowledged that room temperatures should be logged daily to ensure compliance, especially for residents unable to communicate their discomfort. The Administrator also recognized the importance of daily monitoring to prevent risks such as dehydration and temperature-related health issues. Despite these acknowledgments, the facility's practice did not align with its policies, leading to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of aggressive behavior, slapped and punched him repeatedly. The incident occurred after the aggressive resident expressed a preference for not having roommates and a dislike for noise, yet was not provided a private room or transferred to a higher level of care. The aggressive resident had severe cognitive impairment and a history of mood fluctuations, which were documented in his care plan but not adequately addressed. The aggressive resident's care plan included goals to interact peacefully and prevent behavioral episodes, but the facility did not develop a plan of care that considered his need for a private room. Staff interviews revealed that the aggressive resident was known to become suddenly angry and had previously been involved in altercations. Despite this, the facility did not take appropriate measures to prevent the incident, such as providing a private room or closer monitoring. The incident resulted in the victim sustaining facial redness and pain, as well as emotional and psychological distress. The facility's policy on identifying types of abuse and monitoring resident interactions was not followed, contributing to the failure to prevent the altercation. Interviews with staff indicated that the incident could have been avoided with better planning and monitoring of the aggressive resident's behavior.
Failure to Implement Care Plan for Resident with Wandering Behavior
Penalty
Summary
The facility failed to implement the care plan interventions for a resident with wandering behavior, which resulted in the resident entering her previous room after an alleged physical altercation with her former roommate. The resident, who has dementia and major depressive disorder, was admitted to the facility with a history of repeated falls and required moderate assistance for mobility. Despite the care plan indicating the need for constant visual checks and hourly monitoring of the resident's whereabouts, staff did not document these checks, leading to the resident's unsupervised entry into her previous room. Observations and interviews revealed that the resident was seen wheeling herself around the activity room and into the hallway without staff assistance. A Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN) acknowledged the need for regular monitoring due to the resident's involvement in a recent altercation, but admitted that documentation of hourly rounding was not maintained. The Social Service Director (SSD) and the facility Administrator confirmed the importance of monitoring the resident to prevent further incidents and ensure safety, as outlined in the care plan. The care plan, revised after the altercation, emphasized the need to maintain a safe distance from other residents and to separate the resident from the alleged victim. However, surveillance footage confirmed that the resident entered her previous room, indicating a lapse in the implementation of the care plan. The facility's policies on care plans and resident-to-resident altercations stress the importance of documenting interventions and their effectiveness, which was not adhered to in this case.
Failure to Timely Provide Medical Records
Penalty
Summary
The facility failed to provide a copy of medical records upon written request from an authorized legal representative for a resident within the required timeframe. The resident, who was admitted with severe sepsis, septic shock, and vascular dementia, had severe cognitive impairment as indicated by the Minimum Data Set. The legal representative submitted a request for the resident's medical records on 8/14/2024, but the facility did not provide the records until 9/24/2024, which was beyond the facility's policy of providing records within 48 hours of the request. The delay in providing the requested medical records was attributed to the facility's process of routing requests from law offices through their legal team, as stated by the Administrator. The facility's policy, revised in 9/2024, required that medical records be released within 48 hours of the request, excluding weekends and holidays. However, the facility did not adhere to this policy, resulting in a violation of the resident and the legal representative's rights to access the medical records in a timely manner.
Failure to Timely Provide Medical Records
Penalty
Summary
The facility failed to provide a copy of medical records upon written request from an authorized legal representative for a resident within the required two working days as per the facility's policy. The resident, who was admitted with severe sepsis, septic shock, acute pyelonephritis, and Alzheimer's disease, had severely impaired cognition. The legal representative submitted a request for the resident's complete medical record via fax, which was received by the facility on August 30, 2024. The Medical Records Director acknowledged the request and stated that the facility's process allowed 15 calendar days to submit records for discharged residents, but only two days for in-house residents. Despite this, the records were not submitted until September 6, 2024, via email, which exceeded the two-day requirement. The Administrator also incorrectly stated that the facility had 15 days to submit the records, misunderstanding the policy for in-house residents. This resulted in a violation of the resident and legal representative's rights to timely access the medical records.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident at high risk for skin breakdown. The resident, who had a history of diabetes mellitus type 2, hemiplegia, and was bed-confined, was admitted with existing pressure ulcers that were not properly measured upon admission. The facility's policy required wound measurements to be documented within eight hours of admission, but this was not done until several weeks later, leading to a lack of baseline data to monitor the progression of the wounds. Observations revealed that the resident developed new pressure ulcers and existing ones worsened under the facility's care. A stage 1 pressure ulcer on the sacrococcyx developed into a stage 2 ulcer, and a new diabetic wound appeared on the left malleolus. The facility did not implement timely interventions such as providing a low air mattress, which was only ordered months after admission, despite the resident's high risk for pressure sores as indicated by the Braden Scale. Interviews with nursing staff confirmed that the facility did not adhere to its own policies regarding wound assessment and intervention. The admitting nurse failed to measure the resident's wounds upon admission, and the treatment nurse did not ensure the resident had an air mattress until much later. The facility's policy emphasized the importance of evaluating the resident's condition, implementing appropriate interventions, and monitoring their effectiveness, all of which were not adequately followed, leading to the deterioration of the resident's skin condition.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to include a resident's representative in the care planning process, which resulted in a deficiency. The resident, who was admitted with diagnoses of malignant neoplasm of the bone and congestive heart failure, experienced a change in condition during a transfer to an infusion appointment. The resident had shortness of breath and a low blood oxygen level, requiring a breathing treatment that delayed the appointment. However, there was no documentation indicating that the resident's representative was informed of this change in condition or the delay. Interviews with facility staff, including the Minimum Data Set Nurse and the Registered Nurse Supervisor, confirmed that the resident's representative should have been notified of the change in condition and involved in the decision-making process. The facility's policy on resident rights, revised in February 2021, also supports the requirement for resident representatives to be informed and participate in care planning and treatment. The lack of communication with the resident's representative was identified as a violation of the resident's rights.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 1, who was admitted with a diagnosis of malignant neoplasm of the bone and articular cartilage. The resident was prescribed Norco for moderate pain, but the administration of seven doses from September 1 to September 3 was not documented on the Medication Administration Record (MAR). Additionally, the facility did not assess and document the resident's pain using the pain rating scale, nor did they evaluate and document the effectiveness of the pain medication as per the facility's policy. The Controlled Medication Count Sheet indicated that Norco was administered to the resident on specific dates and times, yet these administrations were not recorded in the MAR. Nursing progress notes on September 2 and September 3 documented the administration of Norco for severe pain, but the effectiveness of the medication was noted at the same time as its administration, which is inconsistent with proper assessment procedures. The Minimum Data Set Nurse (MDSN) confirmed the lack of documentation and the failure to reassess the resident's pain after medication administration. Interviews with facility staff, including the Registered Nurse Supervisor, revealed that the licensed nurses did not follow the facility's Pain Assessment and Management policy. This policy requires a thorough pain assessment, documentation of medication administration, and evaluation of the medication's effectiveness after one hour. The failure to adhere to these procedures resulted in the potential for unrecognized and unrelieved pain for the resident, as well as the risk of medication errors due to inaccurate documentation.
Failure to Implement Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident had floor mats at the bedside as indicated in the resident's care plan. This deficiency was identified during a review of the resident's records and an observation in the resident's room. The resident, who was admitted with Alzheimer's disease, unspecified psychosis, unilateral primary osteoarthritis, muscle weakness, and unspecified abnormalities of gait and mobility, was assessed to have severe cognitive impairment and required substantial assistance with various movements and transfers. The resident's care plan, initiated due to a history of falls and generalized weakness, specified the need for floor mats at the bedside to reduce fall-related trauma. During an observation and interview with the Charge Nurse, it was noted that there were no rubber floor mats on either side of the resident's bed, contrary to the care plan's requirements. The Charge Nurse acknowledged that floor mats should have been present as per the care plan. The facility's policy on comprehensive person-centered care plans emphasizes the need to furnish services to maintain the resident's highest practicable well-being, which was not adhered to in this instance.
Failure to Address Resident's Refusal of Care
Penalty
Summary
The facility failed to develop an individualized care plan and conduct an interdisciplinary team conference involving the family member to address a resident's refusal of examination and treatment by a podiatrist and optometrist. This deficiency was identified during a review of the resident's records and interviews with family and staff. The resident, who had severe cognitive impairment and required substantial assistance with mobility and dressing, had active physician orders for podiatry and optometry consults as needed. The resident's care plans for cognitive deficit and vision impairment included interventions to involve the family in decision-making. However, the family was not informed of the resident's refusal to attend appointments with the podiatrist and optometrist on multiple occasions. Interviews with the charge nurse and registered nurse supervisor revealed that the refusals were not documented in the care plan, and the family was not notified, which could have potentially allowed them to persuade the resident to receive necessary care. The facility's policy and procedure for handling refusals of care required that an interdisciplinary team member meet with the resident or representative to address concerns and discuss alternative options. Additionally, the policy mandated prompt notification of the resident's representative and physician regarding changes in the resident's condition or status. The failure to adhere to these policies resulted in a delay of needed services for the resident, which could have contributed to further medical problems.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to adhere to a physician's order and the care plan for a resident, which required the placement of floor mats on both sides of the resident's bed to prevent fall-related injuries. The resident, who had severe cognitive impairment, dementia, bipolar disorder, and difficulty walking, was identified as high risk for falls with a Morse Fall Scale score of 75. Despite these risks and the active physician order dating back to 9/30/2022, the floor mats were not placed as required. During an observation, it was noted that the resident's bed lacked the necessary floor mats, which was confirmed by the Charge Nurse, who was unaware of the reason for their absence. The Director of Nursing acknowledged that the nurses should follow physician orders to ensure resident safety. The facility's policy on fall risk management emphasized the importance of implementing resident-centered fall prevention plans, yet this was not followed in this instance, leading to a potential risk of severe injury for the resident.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, Resident 82 and Resident 59. Resident 82, who has moderate cognitive impairment and requires dependent assistance for activities of daily living, was observed lying in bed wearing a urine-soaked diaper without a privacy curtain drawn, exposing him to the hallway. Despite multiple observations over a period of time, the resident remained in this undignified state. Interviews with staff confirmed that this exposure and lack of timely care were dignity issues and posed risks for skin breakdown and pressure ulcers. Resident 59, who has an indwelling urinary catheter, was observed with her privacy curtain open and her catheter exposed to passersby. The resident expressed discomfort and a desire to get out of bed. Staff interviews confirmed that the lack of a privacy bag for the catheter was a dignity issue, and the facility's policy emphasized the importance of maintaining resident privacy and dignity. The Director of Nursing also acknowledged the necessity of a privacy bag to ensure the resident feels respected and valued.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, Resident 82 and Resident 67. Resident 82, who has diagnoses including dysphagia, hemiplegia, hemiparesis, and essential hypertension, was observed with the call light on the floor and placed on the side where the resident has paralysis. This made it impossible for Resident 82 to reach the call light, leading to frustration and a feeling of helplessness, especially when needing assistance with incontinence care. Interviews with the resident and staff confirmed the negative impact on the resident's well-being and the increased risk of falls and injuries due to the inability to reach the call light. Similarly, Resident 67, who has severe cognitive impairment and requires assistance with daily activities, was observed with the call light hanging down the side of the bed, out of reach. Staff acknowledged the importance of having the call light within reach to prevent falls and ensure timely assistance. The Director of Nursing Service (DON) emphasized that the call light is a crucial communication tool for residents to call for help and should always be within easy reach. The facility's policy also mandates that call lights be accessible to residents, but this was not adhered to in these cases.
Failure to Provide Preferred Activities to Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 20 and Resident 145, were provided with their preferred activities, which could negatively impact their quality of life. Resident 20, who was admitted with cerebral infarction and hemiplegia, was observed multiple times lying in bed without any engagement in her preferred activities such as reading books, listening to music, or participating in group activities. Despite being able to communicate her preferences, Resident 20 was found staring at the window, napping, or sitting with a bored expression, with no activity personnel present to offer her the activities she enjoys. Similarly, Resident 145, who has diagnoses including dysphagia, hemiplegia, and hypertension, was also not provided with her preferred activities. Her care plan indicated a preference for staying in her room and enjoying activities like reading mystery and romantic books and listening to romantic music. However, observations revealed that Resident 145 was mostly found sleeping, with no evidence of activity personnel engaging her in her preferred activities. Interviews with staff confirmed that the activity personnel had not been consistently visiting Resident 145, and there was no documentation of activities being provided for the month of April 2024. Interviews with various staff members, including a CNA, LVN, and the Activity Director, highlighted the importance of providing residents with their preferred activities to support their mental and emotional well-being. The Activity Director admitted that activities were not consistently provided due to staffing issues, and the Director of Nursing Services emphasized the necessity of offering activities to support residents' psychological and social well-being. The facility's policy on activity evaluation also underscored the importance of promoting residents' physical, mental, and psychosocial well-being through activities tailored to their interests and preferences.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, Resident 17 and Resident 47. Resident 17, who was admitted with acute and chronic respiratory failure, had an order for suctioning as needed for increased mucus production. However, during an observation, it was found that Resident 17's suction machine tubing and yankauer were not dated. Similarly, Resident 47, who was admitted with chronic obstructive pulmonary disease and had an order for oxygen inhalation at 2 liters per minute, was observed using undated oxygen tubing and humidifying water that had not been changed since 4/7/2024. Resident 47 was unsure when the oxygen tubing and water were last changed, and Licensed Vocational Nurse 1 confirmed the oversight, stating that these items should be changed weekly to ensure patency and prevent germ growth. Registered Nurse Supervisor 1 and the Director of Nursing Services both confirmed that the suction machine tubing, yankauer, oxygen tubing, and humidifying water should be dated and changed weekly to maintain their effectiveness and prevent clogging and patency issues. The facility's policy on oxygen administration, revised in 2010, also mandates the regular checking and discarding of used or outdated respiratory supplies. The failure to adhere to these protocols has the potential to compromise the delivery of care and services to the residents involved.
Failure to Provide Accurate and Safe Pharmaceutical Services
Penalty
Summary
The facility failed to provide accurate and safe pharmaceutical services and procedures in several instances. Medications for two residents were not disposed of from the medication cart after being discontinued. Specifically, medications for Resident 39 and Resident 16 were found in the medication cart despite being discontinued. This oversight was confirmed during an observation with LVN 5 and interviews with the DON and LVN 5, who acknowledged that discontinued medications should be removed immediately to prevent accidental administration. The facility's policy on medication storage was not followed, as evidenced by the presence of these discontinued medications in the cart. Additionally, the facility failed to properly transcribe physician's orders for fentanyl transdermal patches into the Medication Administration Record (MAR) for Resident 14. The MAR did not reflect the updated physician's orders, leading to discrepancies in the administration of the fentanyl patches. Interviews with the Consultant Pharmacist, Primary Physician, and LVN 6 revealed that the nursing staff did not update the MAR as required, and the correct order to remove and re-apply the fentanyl patch every 72 hours was not followed. This failure was further compounded by missing signatures on the Controlled Drug Record, indicating that the patches were not properly destroyed as per the facility's policy. The facility also failed to check blood pressure parameters for Resident 148 before administering antihypertensive medication as ordered. During an observation, LVN 3 attempted to administer amlodipine Besylate to Resident 148 without realizing that the resident's systolic blood pressure was below the threshold specified in the physician's order. The DON confirmed that nurses should always check the doctor's orders, including parameters, before administering medication. The facility's policy on administering medications was not adhered to, putting the resident at risk for potential adverse effects such as hypotension and bradycardia.
Medication Storage Temperature Deficiency
Penalty
Summary
The facility failed to ensure the refrigerator in the medication storage room was operating within the normal temperature range of 36 to 46 degrees Fahrenheit, as per the facility's policy. During an observation on 5/1/2024 at 9:55 a.m., the refrigerator was found to be at 54 degrees Fahrenheit. This refrigerator contained several unopened and unexpired medications, including Lantus Solostar, Insulin glargine, Aplisol, Afluria Quad, Insulin Lispro, and various emergency kit medications such as Lorazepam, Humulin N, Humulin R, Humalog, Promethazine, Glucagon, Narcan, and epinephrine auto-injectors. The Registered Nurse Supervisor (RNS 1) confirmed that she had checked the temperature at the start of her shift at 7:00 a.m., and it was 46 degrees Fahrenheit. She acknowledged that the normal temperature range should be between 36 to 46 degrees Fahrenheit and that medications stored outside this range could lose their efficacy and potency, potentially affecting resident care and services. The Director of Nursing (DON) also confirmed that the facility and its nursing staff are responsible for ensuring the medication refrigerator's temperature remains within the specified range to maintain the medications' potency and efficacy. A review of the facility's policy on Medication Storage, revised in January 2018, indicated that medications and biologicals should be stored safely, securely, and properly, with the refrigerator temperature maintained between 36 to 46 degrees Fahrenheit. The failure to adhere to this policy could negatively impact the delivery of care and services to the residents.
Failure to Store Food in a Sanitary Manner
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to foodborne illnesses for 93 out of 95 residents. During an observation and interview, it was found that several food items in the refrigerator, freezer, and storage room were not dated or labeled, including three frozen packs of ham, Swiss cheese, a pack of frozen patties, and three packs of opened sliced bread. The Kitchen Aid (KA) confirmed that all food items should be labeled and dated upon delivery and that any food items without a label and date should be discarded. Additionally, the facility did not document the room temperature in the dry storage room on two specific days, which is essential to ensure food does not spoil. The KA acknowledged that someone must have forgotten to document the temperature on those days. Furthermore, three frozen packs of ham were improperly thawed in the refrigerator and stored next to cups of vanilla pudding, leading to potential cross-contamination. The Dietary Supervisor (DS) confirmed that the facility follows the First In, First Out (FIFO) method and that all food items in the refrigerator should be labeled with an opened date and a use-by date. The DS also stated that thawing of frozen ham should include labeling the entry date in the refrigerator and storing the food separately from cooked or ready-to-eat items to prevent cross-contamination. The facility's policies and procedures for labeling and dating foods and thawing meats were reviewed and found to be consistent with these practices, but they were not followed in this instance.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure that the discharge Minimum Data Set (MDS) Assessment for one of the sampled residents was transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required 14-day timeframe. Specifically, Resident 82's MDS discharge assessment was submitted late, more than fourteen days beyond the required submission period. This deficiency was identified during a review of Resident 82's records, which showed that the resident had moderate cognitive impairment and required dependent assistance for activities of daily living. The MDS Coordinator confirmed the late submission during an interview, acknowledging that the delay affected the quality measures and the accuracy of the resident's assessment. Resident 82 was initially admitted to the facility with diagnoses including dysphagia, hemiplegia, hemiparesis following cerebral infarction, and essential hypertension. The resident's MDS dated 3/29/24 indicated moderate cognitive impairment and dependency on assistance for daily activities. The facility's policy and procedure on MDS Completion and Submission Timeframes, revised in 07/2017, mandates that resident assessments be conducted and submitted in accordance with federal and state timeframes. However, the review of the MDS submission form dated 3/21/2024 revealed that the assessment completion was late, leading to the identified deficiency.
Failure to Maintain Resident's Fingernail Hygiene
Penalty
Summary
The facility failed to ensure that Resident 20's fingernails were clean and trimmed, which resulted in the resident having irregular edges and an accumulation of dark brown substance under the fingernails. This deficiency was observed on multiple occasions, including during a review of the resident's Minimum Data Set (MDS) and care plan, which indicated that Resident 20 was totally dependent on a 2-person assist for activities of daily living (ADLs) such as bathing, toileting, dressing, and personal hygiene. Despite these documented needs, the resident's fingernails were found to be untrimmed and unclean during observations on two separate days. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), confirmed that nail care should have been provided during the resident's shower and that the licensed nurses were responsible for trimming the fingernails due to diabetes precautions. The Director of Nursing Services (DON) also stated that personal grooming, including trimming and cleaning fingernails, is essential to prevent skin impairment and bacterial growth that could lead to infection. The facility's policy and procedure on fingernail care, revised in 2018, indicated that residents' nailbeds must be trimmed and cleaned daily to prevent skin problems and infection, which was not adhered to in this case.
Failure to Provide Consistent ROM Exercises
Penalty
Summary
The facility failed to ensure that Resident 20 was provided with range of motion (ROM) exercises by the certified nursing assistant (CNA) staff during activities of daily living (ADLs). Resident 20, who was admitted with a diagnosis of cerebral infarction resulting in hemiplegia on the left side of the body, had impairments in both upper and lower extremities that interfered with daily functions. The care plan for Resident 20 indicated a goal to develop some physical function and achieve some areas of independence. However, a review of the medical records for April and May 2024 showed significant gaps in the documentation and provision of both active and passive ROM exercises. Specifically, out of 30 days in April, ROM exercises were provided only twice, with multiple instances of documentation marked as 'Not Applicable,' 'Refused,' or left blank. Similarly, there was no documentation of ROM exercises from May 1 to May 3, 2024. Interviews with various staff members, including a CNA, Licensed Vocational Nurse, Registered Nurse Supervisor, Rehabilitation Coordinator, and Director of Nursing Services, revealed a lack of consistent implementation of ROM exercises for Resident 20. The CNA admitted to not knowing what to do to prevent further decline in Resident 20's mobility and function. The Licensed Vocational Nurse and Registered Nurse Supervisor confirmed that ROM exercises were supposed to be provided daily to prevent decline and worsening of contractures. The Director of Nursing Services stated that ROM exercises were incorporated into ADLs but acknowledged the importance of consistent provision to prevent overall decline. The facility's policies on resident mobility and ADLs emphasized the need for appropriate treatment and services to maintain or improve mobility, which were not adhered to in this case.
Failure to Assess for Infection Before Administering Antibiotics
Penalty
Summary
The facility failed to ensure that Resident 39 was free from unnecessary drugs by not assessing for infection before starting an oral antibiotic medication. Resident 39, who was admitted with diagnoses including dysphagia, a stage 4 pressure ulcer, and acute cystitis without hematuria, was prescribed Doxycycline Hyclate 100 mg daily for four days for a wound infection. However, there was no documentation of a wound culture or blood work being done to confirm the infection before starting the antibiotic treatment. During interviews, the Infection Preventionist (IP) and Registered Nurse (RN) confirmed that no tests were conducted to determine the presence of a wound infection before administering the antibiotic. The IP acknowledged that starting an antibiotic without proper assessment could lead to adverse reactions, medication resistance, and other complications. The Director of Nursing (DON) stated that the IP should have questioned the antibiotic order and recommended laboratory tests to prevent unnecessary use of antibiotics. The facility's policy on Antibiotic Stewardship also indicated that antibiotics should be prescribed and administered under the guidance of the stewardship program, which includes conducting necessary tests before starting antibiotic therapy.
Failure to Administer Fentanyl Patches as Ordered
Penalty
Summary
The facility failed to ensure that Resident 14 was free from significant medication errors by not administering fentanyl transdermal patches as ordered by the physician. Resident 14, who was admitted with multiple diagnoses including arthrogryposis multiplex congenita, pain due to an internal orthopedic prosthetic, peripheral vascular disease, gout, difficulty walking, and muscle weakness, had physician orders for fentanyl patches to be applied every 72 hours. However, the Medication Administration Records (MAR) for February, March, and April indicated that the patches were applied every 48 hours instead, without any changes reflecting the physician's orders dated 2/27/2024, 3/23/2024, and 4/23/2024. Interviews with the Consultant Pharmacist, Primary Physician, and Director of Nursing revealed that the nursing staff failed to reconcile the physician's orders with the MAR and the medication labels. The Consultant Pharmacist stated that discrepancies should be reported to the pharmacy, and the Primary Physician confirmed that the correct order was to apply the patch every 72 hours. The Director of Nursing acknowledged that improper monitoring of fentanyl patches could lead to overdose and respiratory failure. The manufacturer's medication insert also highlighted the risks of opioid addiction, abuse, misuse, and respiratory depression associated with improper dosing of fentanyl transdermal systems.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for documenting a resident's fentanyl patch administration and removal. Specifically, the Controlled Drug Records for the resident were missing the required two nurse signatures under the witness signature column for several periods. During interviews, the Dispensing Pharmacist and the Director of Nursing confirmed that the facility's policy requires two licensed staff signatures to verify the removal and destruction of fentanyl patches. The absence of these signatures was observed in records dated from late February to mid-April 2024. The facility's policy and procedure on charting and documentation, revised in July 2017, mandates that all medical records be complete and accurate, including the documentation of procedures and treatments with specific details such as date and time. This deficiency had the potential for non-accountability of medication and drug diversion.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement their protocol for Antibiotic Stewardship for Resident 39, who was prescribed an antibiotic without meeting the necessary criteria and without prior assessment for a wound infection. Resident 39, who had diagnoses including dysphagia, a stage 4 pressure ulcer, and acute cystitis, was given Doxycycline Hyclate without documentation of a wound culture or blood work to confirm the infection. This action was not in line with the facility's policy, which requires screening and lab tests before initiating antibiotic therapy. During interviews, the Infection Preventionist and the Director of Nursing acknowledged that the antibiotic should not have been prescribed without proper testing. The facility's policy on Antibiotic Stewardship, revised in December 2016, mandates that antibiotics be prescribed and administered under the guidance of the stewardship program, which includes conducting culture and sensitivity tests to determine the necessity and appropriateness of the antibiotic. The failure to follow this protocol put Resident 39 at risk for adverse reactions and antibiotic resistance.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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