Madera Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 11900 Ramona Boulevard, El Monte, California 91732
- CMS Provider Number
- 055141
- Inspections on file
- 52
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 38 (1 serious)
Citation history
Health deficiencies cited at Madera Post Acute Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not develop complete, person-centered care plans for two residents. One resident with an above-the-knee amputation, a right foot fracture, cognitive impairment, and documented PT orders for maximum, two-person assistance with transfers had a care plan that only stated transfers with staff participation and did not specify the required two-person assist. Another resident with cancer diagnoses and an abdominal biliary drain tube had physician orders for routine flushing of the drain, but there was no corresponding care plan addressing the biliary drain, including monitoring and management. The DON acknowledged that both the transfer assistance and biliary drain use should have been incorporated into the residents’ care plans in accordance with the facility’s comprehensive care planning policy.
Surveyors found a box of 5% lidocaine patches labeled for a discharged resident stored on a shelf in an unsecured nursing supply shed accessible to many people, rather than in designated medication storage areas. The Director of Maintenance reported no knowledge of the medication and confirmed it should not be in the shed, while the DON stated that medications are to be stored only in med carts and medication rooms and that this placement, likely by a staff member, violated facility policy and created a risk of medication diversion.
A resident with DM, heart failure, and documented decision-making capacity was allowed to smoke without the facility completing required smoking evaluations in accordance with its P&P. Two smoking evaluation forms were left incomplete, lacking documentation of smoking frequency, smoking safety, care plan updates, and resident education on safe smoking practices, smoking risks, and designated smoking areas. Despite a care plan problem for noncompliance with the smoking policy and a noted change in condition, no reassessment of the resident’s smoking ability was found in the medical record. The MDS nurse and DON confirmed that smoking evaluations must be completed quarterly, annually, and with changes in condition, that all sections must be filled out or refusals documented, and that failure to do so could create smoking safety issues.
Facility staff, including the administrator, conducted a search of a resident's room for cigarettes and a lighter without the resident's consent or prior notification, despite documentation that the resident had decision-making capacity and was independent in most ADLs. After the resident was seen smoking on the patio and refused to surrender a lighter, the administrator involved the police and entered the resident's room to search for the lighter. The DON later acknowledged that staff could not search a resident's room without permission and that residents have a right to privacy, consistent with the facility's Resident Rights policy.
A resident with cerebral palsy, quadriplegia, dysphagia, severe cognitive impairment, and total ADL dependence had a GT and a physician’s order for 60 ml of water every hour for 20 hours daily for hydration. There was no enteral feeding pump in the room to deliver the ordered water, and both an LVN and the ADON reported that the hydration order had been overlooked. Another LVN stated they were unaware of the order, had never seen a feeding pump in the room, and acknowledged that multiple MAR entries indicating hourly water administration were incorrect, meaning the resident did not receive the prescribed GT hydration in accordance with the facility’s hydration policy.
The facility failed to follow its abuse reporting policy by not reporting multiple allegations of staff abuse and inappropriate conduct to the State Agency within the required timeframes. Cognitively intact residents with significant medical conditions reported or were involved in incidents where CNAs allegedly made sexually inappropriate comments, engaged in sexually suggestive gestures, and spoke aggressively and rudely, including telling a resident to shut up. Staff who became aware of these allegations delayed reporting them to administration, and an LVN acknowledged not reporting the allegations to the State Agency. The Administrator conducted an internal investigation of at least one allegation and decided it was not abuse, and therefore did not report it externally, despite the written policy requiring immediate reporting of all alleged violations.
Two residents at high risk for falls did not receive care consistent with the facility’s Fall Management System policy. For one resident with dementia and severe cognitive impairment, who had an order and care plan for a bed pad alarm when in bed, surveyors observed the resident sitting at the bed’s edge while the alarm device was switched off on the nightstand. For another cognitively impaired resident with multiple comorbidities and high ADL assistance needs, the IDT did not add new fall-prevention interventions after multiple falls, and the resident’s care plan was not updated to reflect these events.
Surveyors found that kitchen staff failed to follow facility P&Ps for labeling and dating refrigerated cheese products. In the walk-in refrigerator, shredded cheese, Parmesan cheese, and blocks of orange cheese were labeled with dates that did not specify whether they were open, use by, or expiration dates, and some items lacked a use by or expiration date altogether. The Dietary Supervisor, a dietary aide, and the administrator all acknowledged that food items should be labeled with clear use by or expiration dates to prevent use of expired food, and facility policies required all stored foods, including commercially processed ready-to-eat items, to be properly labeled and dated according to defined time frames.
A cracked floor in a hallway, observed by surveyors and reported as unsafe by several residents and staff, was not repaired or marked with warning signs. Residents with mobility impairments and fall risks were seen traversing the area, and facility records showed no maintenance reports or actions taken, despite the facility's policy requiring safe and well-maintained flooring.
A resident with respiratory failure and COPD did not receive continuous oxygen therapy as ordered by the physician. Records showed the resident was frequently on room air instead of oxygen, and observations confirmed the oxygen flow was set below the prescribed rate. Facility staff acknowledged the physician's order was not followed, contrary to facility policy.
A resident with multiple medical conditions and a high risk for falls was found to have their call light placed under their pillow, making it inaccessible when assistance was needed. The care plan and facility policy required the call light to be within reach, but staff failed to ensure this, as confirmed by both DON and an LVN during interviews.
The facility did not have infection control (IC) policies and procedures available at any of the four nurse's stations. Staff, including an LVN, RN, IPN, and ADON, were unable to locate the IC policy and procedure binder at their stations and confirmed that the documents were kept in the IPN's office instead. The DON stated that these policies should be accessible at all nurse's stations for staff to reference during infection control situations.
Staff at all four nursing stations, including RNs, the infection prevention nurse, and the ADON, were unable to locate the required name, address, and telephone number of local health officers. The DON confirmed this information was not available at any nursing station, preventing easy access to local health officer contact details.
Surveyors found that insulin pens for three patients were labeled with incorrect storage instructions, stating they should be refrigerated after opening, contrary to standard practice. Additionally, two patients' monthly physician order recapitulation reports were not signed and dated, as required. These deficiencies were identified through observation, interview, and record review.
Two residents with diabetes and cognitive impairments had monthly physician order recapitulation reports that were not properly signed or dated by the approving physician, as required by facility policy. The DON confirmed that the necessary physician signatures and dates were missing from the Order Summary Reports for multiple months.
The facility failed to ensure that two residents' medication and IV therapy administrations were properly documented as ordered. One resident's required monitoring for depression while on Zoloft was not recorded on several shifts, and another resident's D5NaCl IV therapy was not documented as administered on multiple days. These omissions resulted in incomplete medical records, as confirmed by the DON.
Two residents with cognitive impairment and significant care needs were found without wristband identification or any other means of identification, despite facility policy requiring such identification at all times. Facility staff, including the DSD and DON, confirmed the absence of wristbands and acknowledged the importance of identification for safe care and medication administration.
A resident with diabetes did not receive insulin as ordered when an LVN held multiple doses of Tresiba without a physician's order and failed to notify the physician. Additionally, another LVN administered Tresiba but did not document it in the MAR as required by facility policy.
Several residents with a history of smoking, including those with cognitive impairment and complex medical conditions, were found to have unsupervised access to cigarettes and lighters, despite care plans and facility policy requiring secure storage and supervision. Staff were unaware that residents possessed these items, and some residents were able to access smoking areas independently, bypassing required supervision.
During meal service, 20 cups of thickened and boxed milk were left at room temperature, with temperatures measured above the required 41°F. The milk was removed from refrigeration and not placed on ice, contrary to facility policy, and staff did not monitor or maintain proper cold holding temperatures.
Staff failed to follow infection prevention and control policies by not labeling and properly storing a resident's urinal, not wearing required PPE during high-contact care for residents on Enhanced Barrier Precautions, not changing PPE between care of two residents, and not posting EBP signage or providing PPE carts for a resident with nephrostomy tubes. These actions were confirmed by staff interviews and policy review.
Multiple residents were not provided adequate privacy during care, including exposure during medical procedures and uncovered drainage bags, and one resident was left in a soiled brief for several hours without being offered timely toileting assistance, despite being able to communicate their needs. Staff and facility policies confirmed these actions did not meet required standards for dignity and respect.
The facility did not ensure that each resident received an accurate assessment, as required. Inaccurate assessments were identified, which could affect care planning and service delivery for residents.
Four residents did not have comprehensive care plans developed or implemented to address their specific needs, including management of Buspirone for anxiety, chronic abdominal pain, recurrent UTIs, and Hydrocodone use for pain. Staff interviews and record reviews confirmed the absence of required care plans, despite facility policy and physician orders, resulting in a lack of guidance for staff in providing appropriate care and monitoring.
A resident with a history of enterocolitis and irritable bowel syndrome experienced no bowel movement for four days and reported severe abdominal pain. Despite a clinical alert and facility policy requiring physician notification and documentation of a change in condition, staff did not assess or notify the physician. Nursing staff interviews revealed communication lapses and failure to act on alerts or reports from CNAs.
A resident's bedroom wall was found to be missing a baseboard, exposing drywall and peeling paint, which was confirmed by both the DON and Maintenance Supervisor. The resident, who had impaired cognition and required assistance with daily activities, was living in an environment that did not meet the facility's standards for cleanliness and homelike conditions as outlined in its policies.
A resident with mobility impairments and orders for sensor pads in bed and wheelchair did not have a functioning wheelchair alarm, as observed during an equipment check. While the bed alarm worked, the wheelchair alarm failed to sound until a different alarm was used. Facility leadership confirmed there was no monitoring or policy in place to ensure alarm functionality, despite general equipment maintenance policies.
A resident with hemiplegia and right-sided paralysis was found with bilateral upper side rails in use without documented physician order or informed consent. The DON confirmed that neither the required order nor consent was present in the medical record, despite facility policy mandating these steps before bed rail installation.
A resident with hemiplegia and hemiparesis, who had a physician's order for a plate guard to assist with eating, was observed eating without the adaptive equipment, resulting in food spilling onto their blanket and clothes. Both an LVN and the DON confirmed the plate guard should have been provided as per the order and facility policy.
Nurse staffing information was only posted on a consumer board in a hallway, rather than in a prominent and accessible location for residents and visitors. The DSD confirmed responsibility for the posting and acknowledged that the current location was not accessible to all, including those using wheelchairs, despite facility policy requiring prominent and accessible posting.
A resident with hemiplegia and other medical conditions experienced an incident during transfer from a shower chair when their paralyzed leg became caught, but the CNA did not report the event to nursing staff. The resident later complained of pain, and although an RN administered Tylenol, no further assessment was documented until more severe symptoms appeared, leading to the discovery of a tibial fracture. The facility did not follow its policy for reporting and assessing significant changes of condition.
A resident with multiple chronic conditions was found with purplish discoloration on the right great toe, but staff failed to document how the injury occurred. Interviews indicated the injury happened during a shower when the resident struck their foot, but this was not recorded in the clinical record as required by facility policy. Nursing staff and the DON confirmed that complete documentation was necessary but was not done in this instance.
A resident with a history of diabetes and chronic kidney disease experienced increased swelling in the left leg and foot, but the LVN failed to notify the physician or complete a Change of Condition form as required by facility policy. This delay in communication resulted in a lack of timely medical intervention, putting the resident at risk for further complications. The DON confirmed the importance of prompt notification and monitoring according to the facility's policy.
A resident with diabetes and chronic kidney disease experienced increased swelling in the left leg and foot, but the LVN failed to complete necessary documentation or notify the physician, delaying care. The resident's condition worsened, leading to open toe wounds. The DON confirmed the oversight in following the facility's protocol for change of condition.
A CNA improperly applied ointments to a resident without a physician's order, contrary to facility policy and professional standards. The resident, at risk of skin breakdown, had ointments applied at the request of a family member. Interviews with an LVN and the DON confirmed that only licensed nurses should apply such treatments and that a physician's order is required.
A facility failed to report a verbal abuse incident involving a resident and a family member to the appropriate authorities within the required timeframe. The incident, witnessed by staff, involved derogatory language directed at a resident by a family member of another resident. Despite being informed, the DON did not report the incident, violating the facility's policy on reporting abuse.
A resident was prescribed Seroquel for false accusations towards staff without a proper psychiatric diagnosis, contrary to the facility's policy requiring specific conditions for psychotropic medication use. The resident's Minimum Data Set showed intact cognition, but a Change in Condition Evaluation noted confusion and hallucinations. The primary care provider and DON expressed concerns about the medication order's appropriateness, emphasizing the need for a thorough medical work-up and proper behavior monitoring.
The facility failed to follow proper food sanitation and handling practices by placing raw meat next to ready-to-eat carrots in the refrigerator and storing used spoons with clean knives, risking contamination and foodborne illnesses.
The facility failed to provide communication devices for two residents with language barriers, leading to potential communication issues and delayed care. One resident, with dementia and a cognitive communication deficit, spoke Mandarin but lacked a communication board. Another resident, with osteoarthritis and a history of falling, spoke Taiwanese and also lacked a communication board. Staff acknowledged the absence of communication boards, which were required by the facility's policy.
The facility failed to attempt alternatives to bed rails for two residents, risking entrapment and injury. One resident, with diabetes and anxiety, had bed rails up despite being able to get out of bed independently. Another resident, with dementia and COPD, had bed rails installed without documented attempts of alternatives, despite behavioral issues. The facility's policy requiring alternatives before bed rail use was not followed.
The facility failed to ensure call lights were within reach for three residents at risk of falls. A resident with dementia had a tangled call light, another with severe cognitive impairment had a non-functional call light on the floor, and a third resident's call light was unreachable under the bed. These deficiencies were against the facility's policy and care plans, which required call lights to be accessible.
The facility failed to implement safety measures for two residents. One resident, with epilepsy and a high fall risk, did not have floor mats or padded side rails as required by their care plan. Another resident, with impaired cognition, was found with cigarettes despite a policy requiring smoking materials to be kept at the nurse's station. Staff confirmed these oversights, which were against the facility's policies.
Three residents with indwelling catheters were not properly monitored for UTI symptoms, as required by the facility's P&P. One resident had a catheter with white sediments and cloudy urine, another had a kinked catheter tubing with sediments, and a third also had sediments in the catheter tubing. These deficiencies in monitoring and reporting could lead to delayed care and treatment.
The facility failed to properly manage gastrostomy tubes for two residents, leading to deficiencies in care. A resident's GT formula bottle was not labeled with the start time, and another resident did not receive the prescribed water flush. Observations and interviews confirmed these oversights, with staff acknowledging the importance of proper labeling and adherence to physician orders to prevent dehydration and tube clogging.
A resident with COPD did not receive continuous oxygen therapy as ordered due to improper placement of nasal prongs. The resident's care plan required oxygen at two liters per minute to maintain saturation above 92%, but during an observation, the nasal prongs were found misplaced. A CNA confirmed the issue, noting that staff are responsible for ensuring proper placement. The facility's policy mandates correct administration of oxygen therapy, which was not followed, risking the resident's breathing.
A facility failed to provide Advance Directive (AD) information to a resident with dysphagia and dementia, as required by their policy. The resident's medical record lacked documentation of AD acknowledgment, and the Social Service Director confirmed that AD information was not offered to the resident or their representative.
A resident with joint contracture and dysphagia had an elbow splint applied incorrectly, contrary to physician orders, risking further decline in range of motion. The resident's care plan required a splint and hand roll application, but observations revealed improper application, confirmed by staff interviews. This failure contradicted the facility's policy to maintain mobility and prevent loss of function.
A resident in hospice care with a terminal diagnosis was not provided the prescribed puree diet with thin liquids, instead receiving a mechanical soft diet. This discrepancy arose due to a lack of communication between the hospice team and facility staff, as the hospice nurse did not inform the facility of the new diet order. The facility's policy required adherence to hospice physician orders, which was not followed in this instance.
The facility failed to post accurate nursing staff information at the beginning of each shift, with discrepancies noted on multiple days. Observations and interviews revealed that the Federal Posting (FP) forms were not updated to reflect the actual number of nursing staff working. The Director of Staff Development confirmed these inaccuracies, emphasizing the importance of posting actual staffing numbers to inform residents and their families. The facility's Policy and Procedure mandates daily posting for compliance, which was not followed.
A resident with end-stage renal disease experienced massive bleeding from a Permacath due to the facility's failure to follow IV and CVC care protocols. The nursing staff did not properly flush, clamp, or document the catheter's status after an IV infusion, resulting in the resident being found in a pool of blood and requiring emergency hospital transfer. Interviews revealed inconsistencies in catheter management, highlighting a significant deficiency in care.
Failure to Care Plan Transfer Assistance and Biliary Drain Management
Penalty
Summary
The facility failed to develop comprehensive care plans with measurable interventions for two residents. For the first resident, who had an above-the-knee left leg amputation and osteomyelitis of the right foot and ankle, the activities of daily living (ADL) care plan dated 1/5/2026 listed a goal to improve the current level of function in ADLs and an intervention to transfer the resident with staff participation, but did not specify that two-person assistance was required for transfers. The resident’s history and physical dated 1/8/2026 documented fluctuating capacity to understand and make decisions, and a Minimum Data Set (MDS) dated 2/25/2026 showed moderately impaired cognitive skills, need for varying levels of assistance with ADLs, and impairment of one lower extremity that interfered with daily function or placed the resident at risk of injury. Further record review for the first resident showed a physician progress note dated 3/11/2026 indicating a possible right 5th metatarsal head impaction fracture, with an expectation of healing in six months. A physical therapy (PT) evaluation and plan of treatment dated 3/13/2026 specified that the resident required maximum, two-person assistance with transfers. In interviews, a CNA stated the resident required maximum assistance for transfers from bed to wheelchair due to the left leg amputation and right foot fracture, and the Director of Physical Therapy confirmed the need for two-person assistance because of an unsteady gait, fluctuating mobility, and changing mental status. The DON acknowledged that the resident’s care plan should have indicated the need for two-person assistance during transfers. For the second resident, who was admitted with malignant neoplasms of the colon and axilla/upper limb lymph nodes, the history and physical dated 2/21/2026 documented intact decision-making capacity, and the MDS showed intact cognitive skills with varying levels of assistance required for ADLs. An order recap report dated 2/26/2026 documented an order to flush an abdominal biliary drain tube with 10 ml of sterile saline every day and evening shift. However, review of the electronic medical record revealed no care plan addressing the abdominal biliary drain tube. In interviews, the DON stated that care plans are developed to implement goals and interventions for residents’ health concerns and confirmed that the use of an abdominal biliary drain should have been included in the care plan with directions to monitor the drain, drainage amount, signs of infection, and changes in condition and pain. The facility’s policy on comprehensive person-centered care planning, dated 4/2025, required development of a comprehensive care plan with measurable objectives and timeframes to meet residents’ medical, nursing, mental, and psychosocial needs.
Improper Storage and Retention of Discharged Resident’s Medication in Unsecured Area
Penalty
Summary
Surveyors identified a deficiency related to improper storage and handling of medications when a box of 5% lidocaine patches was found in an unsecured nursing supply shed. During observation, the medication box was seen on a shelf on top of diaper boxes in the shed, which was an area accessible to many people. The box was labeled with a resident’s name. The Director of Maintenance stated they had never seen the box before, did not know why it was there, and confirmed that medications should not be stored in the shed because many people had access to it. In a subsequent interview, the DON stated that medications are only supposed to be stored in medication carts and medication storage rooms, and confirmed that medications should not be stored in the shed, particularly since the box still had a resident’s name on it. The DON stated the medication belonged to a resident who had already been discharged from the facility and did not know why the medication was in the shed, suggesting that a staff member most likely grabbed the medication box and took it there. The DON characterized this as an unacceptable practice with a risk of medication diversion. Review of the facility’s 2023 Medication Storage policy showed that medications and biologicals are to be stored properly per manufacturer or supplier recommendations, accessible only to licensed nursing, pharmacy personnel, or staff lawfully authorized to administer medications, and that medications labeled for individual residents are to be stored separately from floor stock medications and not in the medication cart.
Failure to Complete and Update Smoking Evaluations per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its smoking policy and procedure for a resident who smoked. The resident had diagnoses including diabetes mellitus and heart failure and was documented in a recent H&P as having the capacity to understand and make decisions. An MDS assessment indicated the resident was independent in cognitive skills for daily decision making and independent in most ADLs, with supervision needed only for showering/bathing and footwear. The facility’s smoking evaluations for this resident, dated 11/13/2025 and 2/12/2026, were incomplete and did not document smoking frequency, smoking safety, whether the care plan was updated, or whether the resident received education on safe smoking practices, risks of smoking, or locations of designated smoking areas. A care plan for noncompliance with the smoking policy, dated 3/10/2026, only indicated that the intervention was to explain smoking P&P. Record review and staff interviews showed that the facility’s policy required all residents to be assessed to determine if it was safe for them to smoke, with results placed in the medical record, and that residents’ ability to smoke safely would be reassessed quarterly and whenever there was a change in cognition. The MDS nurse stated that smoking evaluations are to be completed quarterly, annually, or with a change in condition, that the form must be completely filled out to be valid, and that she had not completed the smoking evaluation for this resident. The DON confirmed that smoking evaluations are used to determine if it is safe for a resident to smoke, are to be completed quarterly and annually, and that all sections of the form must be completed or a reason documented if the resident refuses. The resident’s medical record did not contain a reassessment of smoking ability after a change of condition on 3/10/2026, and staff acknowledged that incomplete or untimely smoking evaluations could create smoking safety issues and that failure to complete the form could mean the resident was not informed of the smoking P&P.
Unauthorized Room Search Violates Resident Privacy and Dignity
Penalty
Summary
Facility staff failed to honor a resident's right to privacy and dignity when the administrator searched the resident's room without the resident's consent. The resident, who had diabetes mellitus and heart failure, had an H&P indicating capacity to understand and make decisions, and an MDS showing independent cognitive skills for daily decision-making and independence in most ADLs. The resident reported that the administrator searched his room for cigarettes and lighters without informing him or obtaining his consent, and that staff should not walk into residents' rooms and search through their personal belongings without permission. The administrator stated that the resident was observed smoking on the patio and produced a lighter, and when staff asked the resident to surrender the lighter, the resident refused. The administrator reported that the police department was called, and the administrator and police entered the resident's room to search for a lighter without notifying the resident about the room search. The DON stated that facility staff could not search a resident's room without the resident's permission and that residents had the right to privacy. The facility's Resident Rights policy indicated that residents had the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Provide Ordered GT Hydration and Accurate MAR Documentation
Penalty
Summary
The facility failed to provide ordered hydration via gastrostomy tube (GT) for one resident, resulting in insufficient hydration. The resident had cerebral palsy, quadriplegia, dysphagia, severely impaired cognitive skills, and was dependent for all ADLs, and had a GT in place. A physician’s order dated 10/28/2025 directed that the resident receive 60 ml of water every hour for 20 hours per day via GT, totaling 1200 ml of water daily. On observation, there was no enteral feeding pump in the resident’s room to deliver the ordered hourly water. The Registered Dietician confirmed that the current hydration order was 60 ml of water every hour for 20 hours per day via GT. During interviews, LVN 1 stated they had never seen the physician’s order for hourly GT water and confirmed that such an order would normally be administered through a feeding pump, which had not been present in the resident’s room for a long time. The ADON acknowledged that the physician’s hydration order had been overlooked. LVN 2 also reported being unaware of the order and stated they had never seen a feeding pump in the resident’s room. Review of the MAR for the month showed that LVN 2 had documented administering 60 ml of water every hour on multiple dates and shifts, but LVN 2 stated that the resident did not actually receive water every hour and that the MAR entries were marked in error. The facility’s hydration policy required providing hydration based on the physician’s treatment plan and resident condition, which was not followed in this case.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report multiple allegations of abuse to the State Agency in accordance with its April 2025 policy on reporting alleged violations of abuse, neglect, exploitation, or mistreatment. The policy required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation is made, to the Administrator, State Survey Agency, and Adult Protective Services as appropriate. Despite this requirement, allegations involving three cognitively intact residents were not reported within the required timeframe. Resident 3, who had diagnoses including acute kidney failure, COPD, and UTI and was assessed as cognitively intact and independent in dressing, toileting, and personal hygiene, was the subject of an allegation that a CNA had spoken inappropriately about the size of the resident’s penis. This allegation was relayed to a CNA by another CNA but was not immediately reported to the DON or Administrator as required. Resident 4, who had acute kidney failure, type 2 diabetes mellitus, and muscle weakness, and required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, was involved in a separate incident in which a CNA allegedly grabbed her own breasts in front of the resident and asked if they looked good. The CNA who witnessed this behavior considered it sexual harassment but did not report it promptly to leadership, instead waiting several days before informing an LVN, who then informed the Administrator. Resident 9, who had atrial fibrillation, muscle wasting and atrophy, and hypertensive chronic kidney disease, and required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, reported that a CNA was aggressive, rude, told the resident to shut up, and argued with the resident. The resident reported this behavior to an LVN, who acknowledged receiving the allegation and stated that the LVN reported it to the Administrator in October 2025; however, the Administrator later stated being unaware of these allegations. The LVN also stated that neither the allegation involving Resident 4 nor the allegation involving Resident 9 was reported to the State Agency. The Administrator confirmed that an allegation involving inappropriate behavior toward a resident by a CNA was investigated internally and determined not to be abuse, and therefore was not reported to the State Agency, contrary to the facility’s policy requiring reporting of all alleged violations within the specified timeframes.
Failure to Implement Fall Management Interventions and Alarm Use
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Management System policy for two residents identified as being at risk for falls. For one resident with dementia, severe cognitive impairment, and a physician’s order to apply a bed pad alarm whenever the resident was in bed due to poor safety awareness, surveyors observed the resident sitting at the edge of the bed while the bed sensor pad alarm unit was hanging on the nightstand with the switch in the off position. The resident’s care plan also specified that a pad alarm was to be applied whenever the resident was in bed. During a concurrent observation and interview, the Infection Preventionist confirmed that the alarm was off and stated that the alarm needed to be on in order to sound when the resident attempted to get out of bed unassisted. For another resident with metabolic encephalopathy, Alzheimer’s disease, type 2 diabetes mellitus, severe cognitive impairment, and dependence or substantial/maximal assistance needs for multiple ADLs, the facility’s Interdisciplinary Team did not implement new interventions after the resident experienced multiple falls, including falls on two specific documented dates. Post-Event IDT Review forms for those falls did not show any new interventions, and the Director of Nursing confirmed that new interventions should have been implemented to prevent further falls. The Director of Nursing also confirmed that the resident’s care plan was not updated following the falls on those dates, despite the facility’s Fall Management System policy requiring investigation of falls, documentation of recommendations in the clinical record, and updating of the resident’s care plan.
Improper Labeling and Dating of Refrigerated Cheese Products
Penalty
Summary
Surveyors identified a deficiency in the facility’s food labeling and dating practices in the kitchen walk-in refrigerator, where multiple cheese products were not labeled in accordance with the facility’s policies and procedures. During an observation with the Dietary Supervisor, a plastic box of orange-colored shredded cheese was found labeled only with the date "12/30/25" and the word "cheese," without clarification of what the date represented (open, use by, or expiration) and without specifying the type of cheese. A plastic box of white, powdered cheese labeled as Parmesan was marked with the date "11/27/25" but again did not indicate whether this was an open date, use by date, or expiration date. Additionally, a plastic bag containing three blocks of orange-colored cheese was labeled with a delivered date of "12/24/25" and an opened date of "12/25/25" but lacked any use by or expiration date. In interviews, the Dietary Supervisor stated that foods in the kitchen should be labeled with a use by or expiration date to ensure expired foods are not used and that all expired food should be discarded immediately. The Dietary Aide similarly stated that it was important to label food with expiration and use by dates so staff would know when food could be used and that expired food should be discarded to prevent contamination. The Administrator stated that kitchen staff should ensure all food is labeled with a use by date to prevent using expired food. Review of the facility’s policies titled "Labeling and Dating of Foods" and "Refrigerated Storage Guide" showed that all food items in storage areas must be labeled and dated, that commercially processed ready-to-eat foods stored cold for more than 24 hours must be marked with a use by date, and that certain dairy and cheese products must be discarded by the manufacturer’s expiration date or within specified time frames after opening. The observed labeling practices for the cheese items did not comply with these written policies.
Failure to Repair Cracked Floor Creates Safety Hazard
Penalty
Summary
The facility failed to maintain the flooring in a safe and good repair, as evidenced by the presence of a cracked floor in the hallway from the entrance to nurse station 1, in front of the rehab service room and patio. Multiple residents, including those with mobility impairments and fall risks, were observed traversing this area. The cracked floor was directly observed by surveyors, and residents as well as staff acknowledged its unsafe condition, noting the potential for falls. Resident records reviewed showed that affected individuals had significant medical histories, including diabetes, COPD, osteoarthritis, cerebral infarction, hypertension, paraplegia, and rheumatoid arthritis. These residents required varying levels of assistance with mobility and activities of daily living, and their care plans specifically called for a safe, clutter-free environment to prevent falls. Despite these documented needs, the cracked floor remained unaddressed. Interviews with residents, a Licensed Vocational Nurse, the Maintenance Director, and the administrator confirmed that the cracked floor had not been reported or repaired. The Maintenance Log contained no entries regarding the issue, and no warning signs had been placed to alert residents or staff. The facility's own maintenance policy required regular upkeep of flooring to prevent injuries, but this was not followed in this instance.
Plan Of Correction
General Maintenance How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 10/09/25, the Maintenance Supervisor (MS) repaired the crack on the hallway floor near Station 1 and the Rehabilitation Room to eliminate any potential safety hazard for residents. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 10/21/25, the Safety Committee conducted a comprehensive walk through of the facility to identify any additional cracks or floor hazards throughout all resident and common areas. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/21/25 and 10/22/25, the Director of Staff Development (DSD) and Maintenance Supervisor (MS) provided in-service training to all staff regarding the use and importance of the Maintenance Log for timely reporting and follow-up on facility repairs. - Beginning 10/22/25, the Maintenance Supervisor will conduct floor inspections 2-3 times per week for three months to monitor for cracks or hazards and ensure prompt corrective action is taken as needed. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Maintenance Supervisor (MS) will be reporting the results of the monitoring to the QA committee and safety committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy as prescribed for one patient with significant respiratory conditions. The patient, who had diagnoses including respiratory failure, COPD, pleural effusion, and was receiving palliative care, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula or mask to maintain oxygen saturation above 90%. However, record reviews showed multiple instances where the patient was documented as being on room air instead of receiving continuous oxygen. Additionally, direct observations revealed the oxygen flow was set below the prescribed rate, at 1 to 1.5 liters per minute, rather than the ordered 2 liters per minute. Interviews with facility staff, including the ADON, LVN, IPN, and DON, confirmed that the physician's order for continuous oxygen was not followed. Staff acknowledged that the patient was not consistently provided with the ordered oxygen therapy and that the oxygen flow rate was not set as prescribed. The facility's policy and procedure on oxygen administration required adherence to physician orders, but this was not maintained in the care of this patient.
Plan Of Correction
Nursing Service--Administration of Medication How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, Patient 6's oxygen setting was corrected and adjusted to 2 L/min as ordered by the physician. - On 9/24/25, the Assistant Director of Nursing (ADON) provided a one-on-one in-service to LVN #2 regarding accurate oxygen administration in accordance with physician orders. - On 9/24/25, the ADON and Director of Staff Development (DSD) conducted an in-service for Licensed Nurses, CNAs, and staff on proper oxygen administration practices per physician orders and the facility's Oxygen Policy and Procedure. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 09/24/25, the Assistant Director of Nursing (ADON) conducted rounds on all residents receiving oxygen therapy to verify that oxygen settings were consistent with current physician orders. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - From 10/15/25-10/16/25, the ADON and DSD conducted in-service training for all Licensed Nurses, Certified Nursing Assistants (CNAs), and staff on accurate oxygen administration in accordance with physician orders and the facility's Policy and Procedure on Oxygen Use. - Starting 10/13/2025, the ADON and/or DSD will conduct random rounds 3x/week for 3 months to monitor compliance with proper oxygen administration per physician orders. Any findings identified during the rounds will be addressed promptly, and reeducation will be provided as necessary. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The ADON and/or DSD will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Call Light Not Accessible to High-Risk Resident
Penalty
Summary
The facility failed to ensure that a patient's call light was within reach, as required by both facility policy and the patient's care plan. During an observation, the call light for a patient with multiple medical conditions, including respiratory failure, COPD, pleural effusion, and a history of falls, was found under the patient's pillow and not accessible. The patient reported being unable to locate or reach the call light when needing to call for assistance. The patient's care plan specifically indicated that the call light should be within reach and that the patient should be encouraged to use it for assistance. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed that the call light should always be accessible to patients to ensure their safety and timely care. Both staff members acknowledged that failure to provide access to the call light could delay care and increase the risk of falls. Review of facility policies further supported the requirement for call lights to be within reach before staff leave a patient's room. The deficiency was identified for a patient assessed as high risk for falls, with documented cognitive impairment and dependence on staff for several activities of daily living.
Plan Of Correction
C1115 Nursing Service--Patient Care How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, patients 6's call light was immediately placed within reach. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/24/25, the Director of Staff Development (DSD) conducted facility-wide rounds to verify proper placement of call lights. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/24/25, and 10/14/25, the DSD conducted in-service training for all staff on the proper use and placement of call lights, emphasizing the importance of ensuring that call lights are always within the resident's reach. - Starting 10/10/25, the DSD will conduct random checks of call light placement 5x/week reviewing 5 residents each day, for a duration of three months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DSD will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Infection Control Policies and Procedures Not Accessible at Nurse's Stations
Penalty
Summary
The facility failed to ensure that infection control (IC) policies and procedures were available at all four nurse's stations as required. During observations and interviews, staff members at each nursing station, including an LVN, RN, Infection Preventionist Nurse (IPN), and Assistant Director of Nursing (ADON), were unable to locate the IC policy and procedure binder in their respective stations. The IPN confirmed that the IC policies and procedures were kept inside the IPN's office rather than being accessible at each nursing station. Staff reported that, in the absence of the binder, they would consult the Director of Nursing (DON) for guidance on infection control matters. The DON acknowledged that the facility's IC policies and procedures should be present at all nursing stations to provide staff with immediate access to guidelines for proper care and treatment, especially during an outbreak or infection control issue. The lack of readily available IC policies and procedures at the nurse's stations had the potential to deprive nursing staff of important information necessary for infection control practices.
Plan Of Correction
C1280 Nursing Service--Patients with Infectious Dis How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, copies of the current Facility Infection Control Policies and Procedures Manual were printed and placed at all four nursing stations by the Infection Preventionist. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/24/25, the Infection Preventionist (IP) verified that all four nursing stations contained the Infection Control Policies and Procedures Manual. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/24/25 and 10/10/25, the Infection Preventionist (IP) conducted an in-service training to educate staff on the location and accessibility of the facility's Infection Control Policies and Procedures Manual. - Starting 10/14/25, the Infection Preventionist will monitor the availability of the Infection Control Policies and Procedures manual at each nursing station 2x/week for three months to ensure accessibility for all staff. How the facility plans to monitor its performance to make sure that solutions are sustained: - The plan must be implemented, and the corrective action evaluated for its effectiveness. - The POC is integrated into the quality assurance system. - The Infection Preventionist will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Missing Local Health Officer Contact Information at Nursing Stations
Penalty
Summary
The facility failed to ensure that the name, address, and telephone number of local health officers were available in all four nursing stations, as required. During observations and interviews, staff members at Nursing Stations 1, 2, 3, and 4, including a registered nurse, the infection prevention nurse, and the assistant director of nursing, were unable to locate this information at their respective stations. The director of nursing confirmed that this contact information was not present in any of the nursing stations, which is necessary for staff to easily access local health officer contact details for guidance.
Plan Of Correction
C1285 Nursing Service--Patients with Infectious Dis How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, the Administrator Assistant posted updated information for the current Local Health Officers at all four nursing stations. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. - On 9/24/25, the Administrator Assistant verified that all four nursing stations had the current Local Health Officers information posted. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. - On 9/24/25 and 10/10/25, the Administrator Assistant conducted an in-service training to educate staff on the location and accessibility of the Local Health Officers' information. - Starting 10/14/25, the Administrator Assistant will monitor the posting of the Local Health Officers' information at each nursing station 2x/week for three months to ensure accessibility for all staff. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The Administrator Assistant will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Incorrect Insulin Storage Labeling and Unsigned Physician Order Recaps
Penalty
Summary
The facility failed to ensure accurate storage instructions on medication labels for insulin injection pens belonging to three patients with type 2 diabetes mellitus. During an observation of the medication cart, it was found that the labels on one Novolog and two Lantus Solostar insulin pens incorrectly instructed staff to keep the pens refrigerated after opening. Licensed staff acknowledged that insulin does not require refrigeration after opening and that the labeling should have been clarified with the pharmacist. The facility's policy required proper and safe storage of drugs, including correct labeling, but this was not followed for these medications. Additionally, the facility failed to ensure that monthly physician's order recapitulation reports were signed and dated for two patients. This omission was identified through interview and record review, and it was noted that the lack of proper documentation had the potential to result in patients not receiving accurate medication and treatment as ordered. The facility's policy required that physician orders be correctly recapitulated, signed, and dated, but this was not done for the affected patients.
Plan Of Correction
Pharmaceutical Service--General How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/25/25, the Novolog 100 U/ml and two Lantus Solostar 100 injection pens for patients 10, 11, and 12 were immediately discarded. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with insulin orders are considered at risk of being affected. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with insulin orders to identify any instances of improper insulin storage. - Following the audit, it was determined that no other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/26/25, the Director of Nursing (DON) conducted an in-service with LVN#1 regarding accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with an emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - On 10/10/25 and 10/16/25, the Director of Nursing (DON) conducted in-service training for all licensed nurses on the facility's policy and procedure for accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with particular emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - Starting 10/16/25, the DON and/or ADON will conduct random audits 2-3 times per week for 3 months to ensure proper insulin storage. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON and/or ADON will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and develop an action plan to prevent any further deficient practices. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with insulin orders are considered at risk. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with insulin orders to identify any instances of improper insulin storage. - Following the audit, it was determined that no other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/26/25, the Director of Nursing (DON) conducted an in-service with LVN#1 regarding accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with an emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - On 10/10/25 and 10/16/25, the Director of Nursing (DON) conducted in-service training for all licensed nurses on the facility's policy and procedure for accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with particular emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - Starting 10/16/25, the DON and/or ADON will conduct random audits 2-3 times per week for 3 months to ensure proper insulin storage. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON and/or ADON will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and develop an action plan to prevent any further deficient practices. Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 09/24/25, the monthly Physician's Order Recapitulation Reports for Patients #7 and #8 were reviewed, signed, and dated by the physician. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/26/25, the Medical Records Director conducted a facility-wide audit to verify all Physician's Order Recapitulation Reports were named, signed, and dated. - No other residents were affected by this finding.
Physician Order Recapitulation Reports Not Properly Signed and Dated
Penalty
Summary
The facility failed to ensure that monthly physician order recapitulation reports were properly signed and dated for two patients. For one patient, the Order Summary Reports (OSRs) for two consecutive months did not include the name of the physician who approved the orders, the physician's signature, or the date of approval. During a review with the Director of Nursing (DON), it was confirmed that the monthly recapitulated orders were either unsigned, missing the physician's name, or undated, and the DON acknowledged that the OSRs needed to be signed and dated by the approving physician each month. For the second patient, similar deficiencies were found. The OSRs for two months did not indicate the name of the physician who approved the orders or the date of approval. The DON confirmed during an interview that the monthly physician's recapitulated orders for these months did not include the approving physician's name or the date of approval. Both patients had significant medical conditions, including diabetes mellitus type 2 and cognitive impairments, with one requiring maximum assistance for daily activities and the other being dependent on staff for all care needs. The facility's policy required that monthly recaps be noted by a licensed nurse when the physician signs the recapitulation of orders, but this was not followed in these cases.
Plan Of Correction
Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 09/24/25, the monthly Physician's Order Recapitulation Reports for Patients #7 and #8 were reviewed, signed, and dated by the physician. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/26/25, the Medical Records Director conducted a facility-wide audit to verify all Physician's Order Recapitulation Reports were named, signed, and dated. - No other residents were affected by this finding. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/10/2025, the Director of Nursing (DON) provided an in-service to the Medical Records staff regarding proper completion of the Physician's Order Recapitulation Reports, with emphasis on ensuring all reports are accurately identified, signed, and dated by the physician. - Starting 10/10/25, the Medical Records Director will audit all Physician's Order Recapitulation Reports once a week for 3 months to ensure all reports are accurately identified, signed, and dated by the physician. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Medical Records Director will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/10/2025, the Director of Nursing (DON) provided an in-service to the Medical Records staff regarding proper completion of the Physician's Order Recapitulation Reports, with emphasis on ensuring all reports are accurately identified, signed, and dated by the physician. - Starting 10/10/25, the Medical Records Director will audit all Physician's Order Recapitulation Reports once a week for 3 months to ensure all reports are accurately identified, signed, and dated by the physician. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Medical Records Director will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Document Medication and IV Therapy Administration as Ordered
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two patients by not following physician orders and facility policy regarding medication and treatment administration records. For one patient with diagnoses including diabetes mellitus type 2 and chronic pain syndrome, the order summary required monitoring and documentation of episodes of depression, specifically unconsolable crying, while on Zoloft. However, the Medication Administration Record (MAR) for September 2025 showed that this monitoring was not documented, checked, or signed off as performed on multiple dates and shifts. The Director of Nursing confirmed that the required documentation was missing for these periods and acknowledged that such monitoring was necessary to determine the effectiveness of the medication. For another patient with dementia and protein-calorie malnutrition, the order summary required administration of Dextrose Sodium Chloride (D5NaCl) Solution 5-0.45% at a specified rate until the patient consumed more than 50% of food intake. The Intravenous Medication Administration Record (IV MAR) indicated that the administration and documentation of this IV therapy were not completed or signed off on three specific dates. The Director of Nursing confirmed the lack of documentation and stated that the fluids were not documented as administered as ordered. The facility's policies and procedures required adequate monitoring and documentation for both medication and IV therapy, including specifying the type of fluid, rate of infusion, and the signature and title of the person recording the data. The failures in documentation for both patients resulted in incomplete medical records, as confirmed by record review and staff interviews.
Plan Of Correction
Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/25/25, Patient 7 was reassessed following a reported episode of inconsolable crying possibly related to the current antidepressant medication. Upon assessment by the RN Supervisor, no further episodes of inconsolable crying were observed. The physician was notified and reviewed the resident's current medications and behavioral patterns for a 3-month look-back period. Gradual Dose Reduction (GDR) was initiated. - On 09/29/2025, a 1:1 in-service training was conducted with the RN responsible for Patient 9's IV therapy regarding accurate documentation practices, including type of IV fluid, rate of infusion per hour, additives, if and signature and title of the person recording the data. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with antidepressant medication are potentially at risk of being affected. - All residents with IV Hydration, IV medication, and Peripheral Lines are potentially at risk of being affected. - On 10/10/25, the Director of Nursing (DON) conducted a comprehensive audit of all residents with an order for antidepressant medication to ensure accuracy and completeness of behavior monitoring documentation. - No other residents were affected by this deficient practice. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with an order for IV Hydration, IV medication, and peripheral lines. The audit emphasized accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of recording nurse. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - From 10/10/25 to 10/16/25, the Director of Nursing (DON) conducted in-service training for licensed nurses on the facility's medication administration policy and procedure, emphasizing the importance of accuracy and completeness of behavior monitoring documentation. - From 10/10/2025 to 10/16/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted in-service training for licensed nurses regarding the facility's medication administration policy and procedure, emphasizing accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of recording nurse. - Starting 10/16/25, the DON and/or ADON will conduct a random audit 2-3 times per week for 3 months of residents with an order for antidepressant medication to ensure accuracy and completeness of behavior monitoring documentation. - Starting 10/16/25, the DON and/or ADON will conduct a random audit 2-3 times per week for 3 months of residents with IV Hydration, IV medication, and residents with peripheral lines. The audit will emphasize accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of the recording nurse. - Any findings identified during the audits will be addressed promptly, and reeducation will be provided as necessary. A summary of each audit will be submitted to the DON and ED for review and follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: - The DON and/or ADON will report the results of the monitoring to the QA committee monthly for 3 months for review and recommendations, ensuring substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root causes and develop an action plan to prevent any further deficient practices.
Failure to Provide Required Patient Identification Wristbands
Penalty
Summary
The facility failed to provide wristband identification tags or any other means of identification for two of three sampled patients, as required by regulation and the facility's own policy. Patient 7, who was admitted with diagnoses including diabetes mellitus type 2 and chronic pain syndrome, was found during observation to have no wristband or other identification while lying in bed. Patient 7's Minimum Data Set (MDS) indicated moderately impaired cognition and a need for maximum assistance with several activities of daily living. Both the patient and the Director of Staff and Development (DSD) confirmed the absence of an identification wristband, with the DSD acknowledging the necessity of such identification, especially during medication administration and emergencies. Patient 8, admitted with diabetes mellitus type 2 and cognitive impairment, was also observed without a wristband or any other form of identification. The MDS for Patient 8 showed severely impaired cognition and total dependence on staff for all activities of daily living. The DSD confirmed that Patient 8 did not have any identification wristband or alternative means of identification. The Director of Nursing (DON) further stated that all patients, particularly those who are nonverbal or confused, should have wristband identification at all times to ensure proper identification before care and treatment. A review of the facility's policy and procedure titled "Admission, Discharge and Transfer" indicated that wristbands or ankle bands must be worn by residents at all times to ensure proper identification prior to receiving medication, treatment, or special services. Despite this policy, the observations and interviews confirmed that both Patient 7 and Patient 8 were not provided with the required identification, constituting a failure to meet the licensure requirement.
Plan Of Correction
Patient Identification How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, patients 7 and 8 were immediately provided with wristbands after it was identified that they were without one. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. - All residents are at risk of being affected. - On 9/26/25, a facility-wide resident identification wristband audit was conducted by the Administrator Assistant. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. - On 9/24/25, the Admissions Department received in-service training on the proper placement of identification wristbands for all admitted residents, conducted by the Administrator Assistant. - From 10/13/25-10/15/25, all staff received in-service training on resident identification wristbands, conducted by the Administrator Assistant. - Starting 10/13/25, the Administrator Assistant will perform random weekly checks of five residents for 3 months using an audit form to ensure proper use of identification wristbands. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The Administrator Assistant will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Follow Physician Orders and Document Insulin Administration
Penalty
Summary
The facility failed to provide necessary care and services to a resident with type 2 diabetes mellitus by not following physician's orders for medication administration and by failing to accurately document medication administration. Specifically, a Licensed Vocational Nurse (LVN) held multiple doses of Tresiba, a once-daily insulin medication, without a physician's order to do so. The nurse based the decision to hold the medication on the resident's blood sugar level, despite the absence of any such instruction in the physician's order. The nurse notified the Registered Nurse Supervisor about holding the medication, but the physician was not informed, and the facility's policy required a doctor's order before holding any medication not specified in the original order. Additionally, there was a failure in documentation when another LVN administered Tresiba to the same resident but did not record the administration in the Medication Administration Record (MAR) as required by facility policy. The resident confirmed receiving the medication, and the nurse also stated it was given, but the MAR did not reflect this. The facility's policy mandates that medication administration be documented immediately after administration, which was not followed in this instance.
Plan Of Correction
F0684 Quality of Care How corrective action will be accomplished for those residents found to have been affected by the identified practice: • On 8/9/25, Resident 1 was transferred to the hospital for further evaluation. • On 09/08/2025, 1:1 Inservice with LVN 1 regarding obtaining physicians' orders prior to holding medication. • On 09/08/2025, 1:1 Inservice with LVN 2 regarding accurate medication administration documentation. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: • All residents in the facility with long-acting insulin are potentially at risk of being affected. • On 09/08/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted an audit of all residents with orders for long-acting insulin to identify any instances of medication being withheld without a physician's order. • No other residents are affected by this deficient practice. On 09/08/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) audited all medication administration records to ensure accurate documentation for residents with long-acting insulin orders: • No other residents are affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: • From 09/09/2025 to 09/12/2025, the Director of Nursing (DON) conducted in-service training for licensed nurses on the facility's medication administration policy and procedure, emphasizing the importance of obtaining a physician's order before withholding any medication. • From 09/09/2025 to 09/12/2025, the Director of Nursing (DON) conducted in-service training on accurate documentation practices for medication administration to ensure compliance with facility standards. • Starting on 09/10/2025, the DON and ADON will conduct random 3-5 times a week audits for any long-acting insulin withheld without a physician's order. • Starting 09/10/2025, the DON and ADON will conduct random 3-5 times a week audits for accurate documentation of all medication administration for all residents with long-acting insulin orders. • Any findings identified during the audits will be addressed promptly, and reeducation will be provided as necessary. A summary of each audit will be submitted to the DON and ED for review and follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • The DON and ADON will be reporting the results of the monitoring to the QA committee monthly for three months for review and recommendations and to ensure substantial compliance is sustained. • Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Failure to Secure Smoking Materials and Provide Supervision for Residents Who Smoke
Penalty
Summary
Multiple residents with a history of smoking were found to have unsupervised access to cigarettes and lighters, contrary to the facility’s smoking policy and individualized care plans. One resident, with diagnoses including anxiety and bipolar disorder, was observed to keep cigarettes and a lighter in their possession, despite documentation indicating the need for supervised smoking and that all smoking materials should be stored securely by staff. Staff members, including a CNA, LVN, AD, DON, and ADM, were unaware that this resident had these items, and the resident reported obtaining them from a family member during visitation. The facility’s policy required all smoking materials to be locked at the nurse’s station, but this was not followed. Another resident, with heart failure and a pacemaker, also kept cigarettes and a lighter at their bedside and smoked on the patio without supervision. The care plan and smoking evaluation for this resident specified the need for supervised smoking and secure storage of smoking materials. The DON and ADM were not aware that the resident had these items, and the items were only retrieved after the issue was discovered. The facility’s policy, as stated by the DON, did not allow residents to keep smoking materials in their possession due to fire risk. A third resident, with anxiety disorder, palliative care needs, and severely impaired cognition, was found to have a lighter and cigarettes in their pocket. This resident was able to access the smoking patio independently by using a pin code, which staff stated should only be known by designated personnel to ensure supervision. Staff interviews confirmed that the resident could go to the patio and smoke unsupervised, in violation of the care plan and facility policy. The facility’s written policy required all smoking materials to be retained by nursing staff and for residents to be supervised while smoking, but these procedures were not consistently implemented.
Milk Not Maintained at Safe Temperature During Meal Service
Penalty
Summary
The facility failed to ensure that 20 cups of milk, including thickened and boxed milk, were maintained at or below the required temperature of 41 degrees Fahrenheit during meal service. During a kitchen observation, the milk was found placed on top of plastic trays at room temperature, with measured temperatures of 57°F for thickened milk and 47.8°F for boxed milk. The milk had been removed from the chiller at 7:00 AM and left out on trays as the meal service began, without being placed on ice. The kitchen staff reported that milk was not placed on ice during breakfast because the kitchen was perceived as not being as hot during that time, despite the kitchen temperature being recorded at 81.5°F during the observation. A review of the facility's policy and procedure indicated that cold foods should be kept in the refrigerator or freezer and only pulled out in small quantities as close to serving time as possible to ensure temperatures remain below 41°F. The policy also required periodic monitoring of food temperatures throughout meal service. The observed practice of leaving milk out at room temperature and not monitoring or maintaining the required cold holding temperature was inconsistent with the facility's established procedures.
Failure to Implement Infection Prevention and Control Policies
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures for five sampled residents, resulting in multiple deficiencies. For one resident with dementia and osteoarthritis, the urinal was found hanging on a garbage can, unlabeled and filled with urine, rather than being labeled and stored in a designated basket as required. Staff interviews confirmed that urinals should be labeled with the resident's name or room number and stored properly to prevent cross-contamination, but this was not done in this instance. Another resident with end stage renal disease and a dialysis catheter, who was on Enhanced Barrier Precautions (EBP), did not have staff wearing the required personal protective equipment (PPE) during high-contact care activities such as range of motion exercises. The staff member acknowledged that gowns and gloves should have been worn to prevent cross-contamination, and facility policy confirmed this requirement for residents with indwelling medical devices or a history of multidrug-resistant organisms (MDROs). Additionally, a staff member failed to change PPE between providing care to two different residents, both of whom were on EBP due to wounds or indwelling devices. The staff member wore the same gown and gloves while assisting both residents with personal care and did not perform hand hygiene or don new PPE between residents, contrary to facility policy and staff training. In another case, a resident with bilateral nephrostomy tubes did not have EBP signage or a PPE cart outside the room, and staff were unaware of the need for EBP, resulting in care being provided without the required gown and gloves. These failures were observed and confirmed through staff interviews and review of facility policies.
Failure to Ensure Resident Dignity, Privacy, and Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure the dignity, privacy, and respect of four residents during the provision of care, as evidenced by multiple observed incidents. In one case, the Director of Staff and Development (DSD) checked a resident's gastrostomy tube site without closing the privacy curtain, exposing the resident's abdominal area to the roommate and hallway. Both the DSD and the Director of Nursing (DON) acknowledged that privacy curtains should be closed to maintain resident dignity during care, and facility policy confirmed this requirement. Another incident involved a resident with bilateral nephrostomy bags, where the drainage bags were left uncovered and visible, exposing the contents to view. The DSD and DON confirmed that the facility's policy required the use of privacy covers for such devices to maintain resident dignity. The DON stated that this policy applied to all body fluid collection devices, including nephrostomy bags, and that the lack of a privacy cover was not in accordance with facility procedures. Additional deficiencies were observed when two nursing assistants provided care to a resident without being able to fully close the privacy curtain due to missing hooks, resulting in potential exposure when the door was opened. Furthermore, another resident was not offered the opportunity to use the bathroom for several hours and was left sitting in a urine-soaked brief, despite being able to communicate the need for toileting assistance. Staff interviews confirmed that the resident was not always incontinent and could request help, but was not consistently offered the chance to use the restroom, contrary to the resident's care plan and facility policy.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning process and the delivery of appropriate services to residents. Specific details about the residents involved or the nature of the inaccuracies in the assessments are not provided in the report.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents with specific medical needs, as identified through observation, interviews, and record reviews. For one resident with anxiety disorder and insomnia, there was no care plan initiated or implemented for the use of Buspirone, despite physician orders and staff acknowledgment that such a plan was necessary to ensure proper and effective interventions. The facility's own policy required a comprehensive, person-centered care plan to be developed within seven days of the Minimum Data Set (MDS) assessment, but this was not done. Another resident with diagnoses including enterocolitis due to Clostridium difficile and irritable bowel syndrome experienced severe abdominal pain, but no care plan was developed to address this symptom. The resident repeatedly reported pain, and pain medication was administered, but documentation did not consistently indicate the location of the pain. The care plan for pain did not address abdominal pain specifically, nor did the care plan for Clostridium difficile include monitoring for abdominal symptoms, contrary to CDC recommendations. A third resident with a history of recurrent urinary tract infections (UTIs) and multiple hospitalizations for UTIs did not have a comprehensive care plan addressing this issue. The only care plan found was a short-term plan following hospitalizations, which did not include interventions to prevent further UTIs. Additionally, a fourth resident receiving Hydrocodone-Acetaminophen for pain management did not have a care plan in place to address the use of this opioid medication, despite its black box warning and the need for monitoring for adverse effects. In each case, staff interviews confirmed the absence of appropriate care plans and acknowledged the importance of such plans for guiding care and monitoring resident conditions.
Failure to Notify Physician and Document Change of Condition for Resident with No Bowel Movement
Penalty
Summary
The facility failed to ensure that a change in condition was identified and that the physician was notified for a resident who had not had a bowel movement for four days. The resident, who had diagnoses including enterocolitis due to clostridium difficile and irritable bowel syndrome, was dependent on staff for toileting and mobility. Documentation showed no bowel movement for several consecutive days, and the resident reported severe abdominal pain rated at 10/10. Despite a clinical alert for no bowel movement being generated, there was no evidence in the records that a change of condition was documented or that the physician was notified during this period. Interviews with nursing staff revealed gaps in communication and follow-through regarding the resident's condition. The Assistant Director of Nursing acknowledged that the absence of a bowel movement for more than three days should have triggered a change of condition and physician notification, as per facility policy. However, neither the required assessment nor the notification occurred. Licensed nursing staff indicated reliance on hand-off communication and did not receive or act upon alerts or reports from certified nursing assistants regarding the resident's status.
Failure to Maintain Safe and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified when a resident's bedroom wall was found to be missing part of the baseboard, exposing drywall and peeling paint. This condition was observed during a survey in the resident's room, specifically behind the bed. The resident had a history of sepsis, lack of coordination, and dysphagia, and was assessed as having moderately impaired cognition. The resident used a walker and required setup or clean-up assistance with toileting hygiene. The missing baseboard and exposed wall were confirmed by both the Director of Nursing (DON) and the Maintenance Supervisor (MS) during interviews and observations, with both acknowledging that the area should not be left in that condition. The facility's policies and procedures for housekeeping and maintenance were reviewed and indicated that the environment should be kept clean, comfortable, homelike, and sanitary, and that the building and equipment should remain safe, clean, and functional for residents, staff, and visitors. The failure to maintain the resident's room in accordance with these policies resulted in a living area that was not safe, clean, or homelike, as required.
Failure to Ensure Functioning Bed and Wheelchair Alarms
Penalty
Summary
The facility failed to ensure that essential equipment, specifically bed and wheelchair alarms, were functioning properly for a resident with diagnoses including Parkinson's disease, encephalopathy, and abnormal gait and mobility. The resident required moderate assistance with mobility and had orders for sensor pads in both bed and wheelchair to alert staff when attempting to get up unassisted. During observation, the bed alarm functioned as expected, but the wheelchair alarm did not sound when the resident was assisted to stand. The Assistant Director of Nursing attempted to fix the pad and switch alarms, and only after switching to a different alarm did the device function correctly. Interviews with facility leadership revealed there was no monitoring system in place to check the functionality of bed and wheelchair alarms, and no policy or procedure regarding the use of tab alarms. Review of facility policies indicated a general requirement to maintain equipment in good working order, but there was no specific guidance or monitoring process for the alarms in question. This lack of oversight and procedure led to the failure to ensure the resident's safety equipment was consistently operational.
Failure to Obtain Physician Order and Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain a physician order and informed consent prior to the installation of bilateral upper side rails for a resident. The resident, who was admitted with hemiplegia, hemiparesis, and dysarthria, was observed lying in bed with both upper side rails raised. The resident was noted to have right-sided paralysis and was dependent on staff for several activities of daily living. During interviews and record reviews, it was confirmed by the DON that there was no documentation in the resident's chart or electronic medical record indicating that a physician order or informed consent had been obtained before the side rails were installed. The facility's policy required that alternatives to bed rails be attempted and, if unsuccessful, that the interdisciplinary team assess the resident for risk of entrapment, review risks and benefits, and obtain informed consent prior to bed rail use. Despite these requirements, the necessary documentation and consent process were not completed for this resident, as confirmed by both observation and staff interviews.
Failure to Provide Ordered Plate Guard During Meals
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis, dysarthria, and adult failure to thrive was admitted to the facility and had a physician's order to use a plate guard during all meals. The resident's Minimum Data Set indicated intact cognition but dependence on staff for several activities of daily living. Despite the order, during an observation at mealtime, the resident was found eating without a plate guard, resulting in food spilling onto their blanket and clothes. The resident was observed picking up spilled food from their blanket and clothes while eating with their left hand. Interviews with a Licensed Vocational Nurse and the Director of Nursing confirmed that the resident should have been provided with a plate guard as ordered, to assist with scooping food and to prevent spillage. Review of the facility's policy indicated that residents recommended to use a plate guard should have it available and in place during meals. The failure to provide the ordered adaptive equipment constituted a deficiency in care.
Nurse Staffing Information Not Posted in Prominent, Accessible Location
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place that was readily accessible to residents and visitors. Observations on multiple days revealed that the staffing sheet was only posted on the consumer board in a hallway, with no postings at the facility entrance or at any of the nursing stations. During interviews, the Director of Staff Development (DSD) confirmed that she was responsible for the nurse staffing postings and acknowledged that the information was only displayed on the consumer board in the hallway. The DSD also stated that the facility was large and that some residents, particularly those using wheelchairs, could not view the posting. Review of the facility's Shift Hours Form indicated that nurse staffing information was supposed to be posted daily in a prominent place at the beginning of each shift and be accessible to residents and visitors.
Failure to Report and Assess Resident Injury Following Transfer Incident
Penalty
Summary
The facility failed to follow its policy and procedure regarding significant changes of condition for a resident with a history of hemiplegia, hemiparesis, diabetes, and muscle atrophy. During a morning shift, a Certified Nursing Assistant (CNA) transferred the resident from a shower chair to bed, during which the resident's left leg, which was paralyzed, became caught on the shower chair. The CNA did not report this incident to a charge nurse or supervisor, stating that the resident did not complain of pain at the time. However, another CNA later heard the resident complain of left foot pain and informed a Registered Nurse (RN), who administered Tylenol and documented its effectiveness, but did not further assess or document the incident involving the leg. Later that day, the resident complained of pelvic and left knee pain, and bruising was observed on the left lateral leg. The physician was notified, and an x-ray was ordered, which revealed a depressed lateral tibial plateau fracture. Interviews with facility leadership confirmed that the incident should have been reported and assessed as a significant change of condition, with appropriate documentation and physician notification. The facility's policy requires that any change in a resident's condition, such as a decline in physical function or an incident, be reported to a licensed nurse or supervisor, who must then assess, document, and communicate with the provider as needed. In this case, the failure to report and assess the incident involving the resident's leg delayed necessary care and services, as the injury was not promptly identified or addressed according to policy.
Incomplete Documentation of Resident Injury
Penalty
Summary
The facility failed to follow its own policy and procedure regarding charting and documentation by not providing complete documentation for a resident who was found with purplish discoloration on the right great toe. The resident, who had a history of chronic obstructive pulmonary disease, acute kidney failure, and chronic systolic heart failure, was dependent on staff for several activities of daily living, including toileting, bathing, dressing, and footwear. The eINTERACT Change in Condition Evaluation noted the discoloration but did not document how the injury occurred. Progress notes for the relevant month also lacked any explanation for the discoloration. Interviews with staff revealed that the resident had struck their right foot during a shower, either by hitting something unknown or by kicking a doorway while attempting to kick a CNA. Both the LVN and RN interviewed acknowledged that details of the incident should have been documented, and the DON emphasized the importance of complete documentation to understand what happened and to prevent recurrence. The facility's policy required concise and continuous documentation of treatment, care, and changes in resident condition, but this was not followed in this case.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician of a change in condition for a resident who experienced increased swelling in the left leg and foot. The Licensed Vocational Nurse (LVN) observed the swelling on multiple occasions but did not complete a Change of Condition (COC) form or notify the resident's physician as required by the facility's policy. This delay in communication resulted in a lack of timely medical intervention for the resident's condition. The resident, who had a history of type 2 diabetes mellitus with diabetic neuropathy and chronic kidney disease, was admitted with existing venous and arterial ulcers. Despite the resident's complex medical history and the presence of severe pitting edema, the LVN only visually monitored the condition without notifying the physician or completing the necessary documentation. The swelling was noted to be an indication of circulation problems, which could lead to complications such as ulcers and wounds. The Director of Nursing (DON) confirmed that the facility's policy required licensed nurses to notify the physician and monitor the condition for 72 hours if a change in condition was observed. The DON acknowledged that the failure to notify the physician in a timely manner put the resident at risk for further skin breakdown and complications. The facility's policy emphasized the importance of prompt communication and documentation to ensure residents receive appropriate care and treatment.
Failure to Document and Address Change of Condition
Penalty
Summary
The facility failed to monitor and document a change of condition for a resident, identified as Resident 8, as per the facility's policy and procedure on Significant Change of Condition. The Licensed Vocational Nurse (LVN) 3 did not complete a Situation-Background-Assessment-Recommendation (SBAR) or Change of Condition (COC) form when an increase in swelling was observed in Resident 8's left leg and foot. This oversight occurred on two occasions, first when the swelling was initially noted and again when the condition did not improve after 72 hours. Resident 8, who had a medical history including type 2 diabetes mellitus with diabetic neuropathy and chronic kidney disease, was admitted with existing venous and arterial ulcers. The resident required assistance with daily activities and used a wheelchair. Despite the care plan interventions that required monitoring and reporting of signs of infection or changes in condition, LVN 3 only visually monitored the swelling without completing the necessary documentation or notifying the physician. This lack of action potentially delayed the care and treatment needed for Resident 8's condition. The Director of Nursing (DON) confirmed that the facility's protocol required licensed nurses to notify the physician and complete a COC form when a resident's condition changed. The DON acknowledged that the failure to notify the physician and complete the necessary documentation could have contributed to the worsening of Resident 8's condition, including the development and deterioration of toe wounds. The facility's policy emphasized the importance of timely assessment and intervention to maintain residents' well-being.
Improper Application of Ointments by CNA Without Physician's Order
Penalty
Summary
The facility failed to adhere to professional standards of practice by allowing a Certified Nursing Assistant (CNA) to apply ointments to a resident, instead of a Licensed Vocational Nurse (LVN). This occurred for a resident who was at risk of skin breakdown due to conditions such as hemiplegia, hemiparesis, type 2 diabetes mellitus, and epilepsy. The resident required substantial assistance with personal care and was at risk of developing pressure ulcers. During an observation, the CNA was seen applying calmoseptine and vitamin A&D ointments to the resident's skin, which was requested by the resident's family member. The facility also failed to ensure there was a physician's order for the ointments being applied. Interviews with the LVN and the Director of Nursing (DON) confirmed that CNAs were not permitted to apply these ointments and that a physician's order was necessary to ensure there were no contraindications and to monitor the treatment's effectiveness. The facility's policy required that medications be administered only upon a written order from a licensed prescriber, which was not followed in this instance.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a family member to the California Department of Public Health, local law enforcement, and the Ombudsman within the required two-hour timeframe as per the facility's policy. The incident involved a verbal altercation between Resident 1 and a family member of Resident 2, which was witnessed by a registered nurse. Despite being informed of the incident, the Director of Nursing did not report it to the appropriate authorities, violating the facility's policy on reporting alleged violations of abuse. Resident 1, who was cognitively intact and capable of making decisions, reported feeling verbally abused after being called derogatory names by the family member of Resident 2. The altercation occurred when Resident 1 was requesting pain medication from a nurse, and the family member intervened, leading to a confrontation. The incident was witnessed by other residents and staff, who confirmed the use of offensive language by the family member. The Director of Nursing acknowledged the incident as a form of abuse and recognized the need to report it to ensure the safety of the residents. However, the failure to document and report the incident in a timely manner as required by the facility's policy resulted in a deficiency. The facility's policy mandates immediate reporting of such incidents to prevent further abuse and ensure resident protection.
Inappropriate Use of Psychotropic Medication for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically Seroquel, which was ordered without a proper diagnosis. The resident, who was admitted with diagnoses including malignant neoplasms and unspecified psychosis, was prescribed Seroquel for false accusations towards staff, despite not being diagnosed with unspecified psychosis by a psychiatrist or medical doctor. The facility's policy requires that psychotropic medications be used only when necessary to treat a specific condition, and non-pharmacological interventions should be attempted first. The resident's Minimum Data Set indicated intact cognition and no evidence of acute mental status changes, delusions, or hallucinations. However, a Change in Condition Evaluation noted increased confusion and hallucinations, leading to a recommendation for a psychiatric consultation. The psychiatric evaluation diagnosed the resident with unspecified schizophrenia spectrum disorder and generalized anxiety disorder, recommending Seroquel. Despite this, the physician's order for Seroquel was based on false accusations, not a specific psychiatric diagnosis, and lacked appropriate behavior monitoring instructions. Interviews with the primary care provider and the Director of Nursing revealed concerns about the appropriateness of the Seroquel order. The primary care provider emphasized the need for a thorough medical work-up and consultation with specialists before diagnosing schizophrenia or psychosis in an elderly resident. The Director of Nursing stated that the order did not target an appropriate behavior and highlighted the risk of sedation and potential abuse. The facility's policy mandates that psychotropic medications should not be used for discipline or convenience and should only be administered when required to treat medical symptoms after non-pharmacological interventions have failed.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food sanitation and safe handling practices, as observed during a survey. In the facility's kitchen, a container of raw ground turkey was placed on the lowest shelf of the walk-in refrigerator next to a container of ready-to-eat chopped carrots. This arrangement was contrary to the facility's policy and procedure, which mandates that ready-to-eat foods should be stored above raw meats to prevent contamination from raw-product juices. The Certified Dietary Manager (CDM) acknowledged that this practice could lead to food contamination and potential foodborne illnesses among residents. Additionally, the facility's kitchen staff placed used spoons with food particles in the same rack as clean knives, which was observed during the survey. This practice was also against the facility's sanitation policy, which requires all utensils to be kept clean to prevent cross-contamination. The CDM confirmed that placing used utensils with clean ones could cause cross-contamination, posing a risk of foodborne illness to the residents.
Failure to Provide Communication Devices for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate communication devices for two residents, leading to potential communication barriers and delayed care. Resident 50, who was admitted with dementia and a cognitive communication deficit, had a care plan indicating a risk for communication problems due to a language barrier. The care plan included interventions such as writing, using a communication board, gestures, and a translator. However, during an observation, it was noted that the resident spoke Mandarin, and the staff member was communicating through gestures without a communication board available. The staff member acknowledged that Mandarin-speaking staff were not always available, and a communication board was not present in the resident's room. Similarly, Resident 80, who had osteoarthritis and a history of falling, was identified as having a communication problem related to a language barrier. The care plan included assistance with word finding and providing a translator. The resident's preferred language was Taiwanese, and they required an interpreter. During an observation, it was found that the resident did not have a communication board at the bedside, although the staff used an in-person translator and language line. Interviews with the Activity Director and Director of Nursing confirmed that non-English speaking residents should have communication boards to facilitate communication and meet their needs. The facility's policy indicated that communication boards should be provided and kept at the resident's bedside.
Failure to Attempt Alternatives Before Bed Rail Installation
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives to bed rails before their installation for two residents, placing them at risk for entrapment and injury. Resident 99 was readmitted with diagnoses including diabetes mellitus and anxiety disorder. Observations revealed that bed rails were up on both sides of her bed since readmission, despite her ability to get out of bed independently. The Director of Nursing (DON) confirmed that the medical record lacked documentation of attempted alternatives to bed rails, such as low beds or foam bumpers, before their use. Similarly, Resident 26, who was readmitted with dementia and chronic obstructive pulmonary disease, had bed rails installed without documented attempts of alternatives. The resident was on antipsychotic medication for psychosis and exhibited behaviors like striking out at staff. The DON acknowledged the absence of documented evidence of alternatives being tried and noted the potential hazards of bed rails, especially for residents with behavioral issues. The facility's policy required alternatives to be attempted before bed rail installation, which was not followed in these cases.
Failure to Ensure Call Lights Within Reach for Residents at Risk of Falls
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of three residents, all of whom were at risk for falls, by not ensuring their call lights were within reach. Resident 89, who was admitted with gait abnormalities, mobility issues, and dementia, was observed sitting in a wheelchair with the call light placed on top of the bed and tangled on the side rail, making it inaccessible. The resident's care plan required the call light to be within reach, but this was not adhered to, as confirmed by a Certified Nurse Assistant who had to untangle the cord. Resident 32, who had severe cognitive impairment and was totally dependent on staff for daily activities, was found with a call light on the floor, which was not functioning. The resident's care plan specified that the call light should be attached to the bed within easy access. A Registered Nurse Supervisor confirmed the call light was not working and should have been clipped to prevent displacement. The Maintenance Supervisor stated that call lights were checked weekly, but this did not prevent the issue from occurring. Resident 84, who required substantial assistance and was dependent on staff for transfers, was observed with the call light on the floor under the bed, making it unreachable. The resident expressed difficulty in finding and reaching the call light, and a Certified Nursing Assistant confirmed it was not within reach. The facility's policy required call lights to be placed within reach before staff left the room, but this was not followed, leading to the deficiency.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to ensure a safe environment for Resident 12 by not implementing the prescribed safety measures. Resident 12, who was admitted with epilepsy and a high risk for falls, had a care plan that included placing floor mats at the bedside and padding the bed side rails for seizure precautions. However, during observations, it was noted that these safety measures were not in place. Licensed Vocational Nurse 1 confirmed the absence of floor mats and padded side rails, acknowledging the risk of serious injury if Resident 12 were to fall or have a seizure. Additionally, the facility did not adhere to its smoking policy for Resident 339, who had moderately impaired cognition and required maximal assistance with daily activities. The care plan for Resident 339 specified that smoking materials should be kept at the nurse's station to prevent injury. However, during an observation, Resident 339 was found in possession of cigarettes, contrary to the facility's policy. Certified Nurse Assistant 1 confirmed that the cigarettes should have been kept with the charge nurse and only provided to the resident during supervised smoking times. Interviews with the Director of Nursing and other staff members further highlighted the facility's failure to follow established policies and procedures for both residents. The facility's policies on fall management and smoking were not implemented as required, posing potential risks to the safety and well-being of Residents 12 and 339.
Failure to Monitor Indwelling Catheters for UTI Symptoms
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the care and monitoring of residents with indwelling catheters, leading to potential risks of urinary tract infections (UTIs) for three residents. Resident 30, who was admitted with a diagnosis of UTI and obstructive uropathy, had an indwelling catheter that was observed to contain white sediments and cloudy urine. Despite the care plan's directive to monitor for signs of UTI, such as sediment presence and urine cloudiness, these symptoms were not adequately assessed or reported by the nursing staff. Resident 106, admitted with neuromuscular dysfunction of the bladder and paraplegia, also had an indwelling catheter with white sediments observed in the tubing. Additionally, the catheter tubing was kinked, which could obstruct urine flow and increase the risk of infection. The care plan for Resident 106 required monitoring for UTI symptoms, but the presence of sediments and the kinked tubing were not addressed in a timely manner. Similarly, Resident 128, who was admitted with dysphagia and urinary retention, had an indwelling catheter with white sediments observed in the tubing. The care plan indicated the need for regular monitoring for UTI symptoms, yet the presence of sediments was not adequately monitored or reported. The facility's P&P required licensed nurses to assess for UTI signs every shift and ensure unobstructed urine drainage, but these protocols were not followed, leading to potential delays in care and treatment for the residents involved.
Deficiencies in Gastrostomy Tube Management for Two Residents
Penalty
Summary
The facility failed to ensure proper management and care for two residents with gastrostomy tubes (GTs), leading to deficiencies in their treatment. Resident 30, who was admitted with a urinary tract infection and required GT feeding due to swallowing difficulties, had their GT formula bottle unlabeled with the start time. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the need for labeling. The Director of Nursing (DON) also confirmed that the GT feeding bottle should be labeled with the date and time it was started. Resident 128, admitted with dysphagia and urine retention, did not receive the prescribed water flush through their GT. The care plan required a 100 ml water flush every four hours, but an observation revealed that the GT pump was not set accordingly. An LVN confirmed the discrepancy and emphasized the importance of following the physician's order to prevent dehydration and electrolyte imbalance. The DON reiterated the necessity of accurate water flushes to prevent dehydration, electrolyte imbalance, and tube clogging. The facility's policies and procedures also outlined the need for proper labeling and routine flushing to prevent tube clogging.
Failure to Ensure Proper Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD) received continuous oxygen therapy as ordered by the physician. The resident, who was readmitted to the facility with diagnoses including COPD and diabetes mellitus, had a care plan indicating the need for continuous oxygen at two liters per minute through a nasal cannula to maintain oxygen saturation above 92 percent. However, during an observation, it was noted that the nasal prongs were not properly positioned in the resident's nostrils, which could impede the delivery of oxygen. A Certified Nursing Assistant (CNA) present during the observation confirmed that the nasal prongs were misplaced and acknowledged that both CNAs and licensed staff are responsible for monitoring the proper placement of the oxygen cannula every shift. The facility's policy on oxygen administration, dated January 2024, requires that oxygen therapy be administered as ordered by the physician, with nasal prongs placed correctly in the nostrils and secured to prevent displacement. The failure to adhere to these procedures placed the resident at risk for severe difficulty in breathing.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information on Advance Directives (AD) for one of the sampled residents, identified as Resident 48. This deficiency was identified during a review of Resident 48's Admission Record and Medical Record, which showed no documentation of AD acknowledgment. Resident 48 was readmitted to the facility with diagnoses including dysphagia and dementia, and the Minimum Data Set indicated that the resident had unclear speech, rarely understood others, and was dependent on assistance for daily activities. Despite these conditions, there was no evidence that AD information was offered to Resident 48 or their responsible party. During an interview, the Social Service Director confirmed the absence of documentation regarding AD information being provided to Resident 48 or their representative. The facility's policy, revised in December 2023, requires that residents or their representatives be given written information about their rights to accept or refuse treatment and to formulate ADs upon admission. The lack of documentation in Resident 48's medical record suggests a failure to adhere to this policy, potentially leading to treatment being administered against the resident's will.
Failure to Apply Elbow Splint Correctly
Penalty
Summary
The facility failed to apply an elbow splint as ordered by the physician for a resident, which had the potential to result in a decline in the resident's range of motion. The resident, who was readmitted to the facility with diagnoses including joint contracture and dysphagia, was dependent on assistance for personal hygiene, dressing, and movement. The resident's care plan included the application of a right elbow splint and hand roll for up to five hours per day, five times a week. However, during an observation, it was noted that the splint was incorrectly applied, not covering the elbow as required. Interviews with the Restorative Nurse Assistant and the Director of Rehabilitation confirmed that the splint was applied incorrectly, which would not help prevent further contracture or maintain joint extension. The facility's policy emphasized the importance of a restorative program to maintain mobility and prevent loss of function, but the incorrect application of the splint contradicted this policy, potentially compromising the resident's joint health and skin integrity.
Failure to Implement Hospice Diet Order
Penalty
Summary
The facility failed to implement a hospice diet order for a resident who was near the end of life and had been admitted to hospice care. The resident, who had a terminal diagnosis of leukemia and suffered from Alzheimer's disease and dysphagia, was supposed to receive a puree diet with thin liquids as per the hospice physician's order. However, the resident was receiving a mechanical soft diet with thin liquids instead. This discrepancy was identified during a review of the resident's records, which showed conflicting diet orders between the hospice plan of care and the facility's order summary report. Interviews with facility staff, including the Social Services Director, Registered Dietician Consultant, Speech Language Pathologist, and Director of Nursing, revealed a lack of communication and coordination between the hospice team and the facility staff. The hospice nurse did not notify the facility staff of the new hospice diet order, and the Speech Language Pathologist team was unaware of the change in diet order. The facility's policy indicated that hospice services should be offered and followed as ordered by the physician, but this was not adhered to in the case of the resident.
Inaccurate Nursing Staff Posting
Penalty
Summary
The facility failed to post accurate nursing staff information at the beginning of each shift on multiple days, specifically on 7/17/2024 and 7/18/2024. Observations and interviews revealed that the Federal Posting (FP) forms were not updated to reflect the actual number of nursing staff working on those days. For instance, on 7/17/2024, the FP form was dated 7/16/2024, and on 7/18/2024, the form did not list the actual number of nursing staff for the morning shift. This discrepancy was confirmed during interviews with the Human Resources (HR) and the Director of Nursing (DON), who acknowledged the importance of posting accurate staffing numbers to ensure adequate care for residents. Further review of the FP forms and staff sign-in sheets from 7/15/2024 to 7/18/2024 showed inconsistencies in the reported and actual staffing levels. On 7/15/2024, fewer Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs) worked than were posted. Similar discrepancies were noted on 7/16/2024 and 7/18/2024, with fewer Registered Nurses (RNs) and CNAs working than indicated. The Director of Staff Development (DSD) confirmed these inaccuracies and emphasized the purpose of posting actual staffing numbers to inform residents and their families about the staffing levels available to provide care. The facility's Policy and Procedure (P&P) on Nursing Services, revised in 2/2024, mandates that a per patient day (PPD) will be kept and posted daily for compliance, which was not adhered to in this case.
Failure to Properly Manage IV and CVC Leads to Resident Bleeding
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the administration and care of intravenous (IV) lines and central venous catheters (CVC) for a resident, leading to a significant health event. The deficiency involved the improper handling of a resident's Permacath, a type of CVC used for hemodialysis. The Registered Nurse Supervisor (RNS) did not flush the resident's Permacath with saline after completing an IV infusion, nor did they document the procedure in the resident's clinical record. Additionally, the Permacath was not clamped and capped when not in use, which is a critical step to prevent bleeding. The resident, who had a history of end-stage renal disease and was dependent on hemodialysis, experienced massive bleeding from the Permacath site. This occurred after the IV infusion was completed, and the necessary steps to secure the catheter were not followed. The resident was found in a pool of blood, with blood-soaked sheets and approximately 300 ml of blood on the floor. The paramedics were called, and the resident was transferred to a hospital's intensive care unit for further evaluation and treatment. Interviews with the nursing staff revealed inconsistencies in the handling of the Permacath. RNS 3 claimed to have flushed and clamped the catheter, but there was no documentation to support this. The Director of Nursing emphasized the importance of clamping and capping the CVC to prevent complications such as bleeding, hypotension, and shock. The facility's policies and the manufacturer's instructions clearly stated the need for these precautions, which were not followed, leading to the resident's critical condition.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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