Madera Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madera, California.
- Location
- 517 South A Street, Madera, California 93638
- CMS Provider Number
- 055147
- Inspections on file
- 33
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Madera Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain its boiler system in safe operating condition, resulting in a prolonged loss of hot water throughout multiple stations. After a staff report that hot water was not working on two stations, the Maintenance Supervisor identified a frozen boiler igniter motor and contacted a vendor, but the part was not immediately available. The Maintenance Supervisor informed the Administrator only about two affected stations, despite later acknowledging that additional stations also lacked hot water, and he assessed water temperatures by touch rather than using a thermometer as expected by facility policy. Over several days, CNAs and an RN reported no hot water in resident rooms, shower rooms, or nurses’ station sinks, and residents reported missed showers and being cleaned with cool water. Facility policies required routine maintenance of heating and plumbing systems and documented water temperature checks, which were not followed, leading to residents being without hot water for hygiene and staff without hot water for handwashing.
The facility failed to maintain complete and accurate EMRs when the IP performed influenza A testing on multiple residents with conditions such as dementia, cancer, Parkinsonism, stroke-related hemiplegia, respiratory failure, and chronic diseases, but did not document several of these tests or their results. Some residents had documented changes in condition, including cough, low O2 saturation, and positive influenza A findings, while others with similar respiratory symptoms were tested according to the IP but had no corresponding EMR entries. The DON and ADON confirmed that undocumented tests are considered not done and that it was the IP’s responsibility to chart all influenza tests in accordance with the facility’s documentation policy.
Surveyors found that 12 of 65 alcohol-based hand rub (ABHR) dispensers in hallways and at nurses’ stations were not dispensing product, including units near multiple resident rooms, a shower room, and the maintenance office. The IP stated housekeeping was responsible for refilling or replacing dispensers and confirmed staff were expected to perform hand hygiene when entering and exiting rooms, before and after glove use, and in other routine care situations. An LVN reported keeping ABHR gel on a med cart because some dispensers did not work, and CNAs described encountering non-functioning dispensers and needing to walk down the hall to find working ones. The DON and ADON emphasized the importance of functioning dispensers and frequent hand hygiene, while the facility’s hand hygiene policy required that hand hygiene products be readily accessible and that ABHR dispensers be placed in visible areas with hand hygiene performed before and after resident contact and after contact with the resident environment.
A slide barrel lock was installed out of reach on an exit door in the memory care unit without a hazard assessment, leaving residents and staff potentially unable to exit in an emergency. Additionally, a resident was struck by a vehicle while crossing a busy parking lot in a wheelchair to access the smoking area, resulting in multiple fractures and increased dependence on staff. Staff and policy reviews confirmed the lack of safe pathways and insufficient supervision for residents traveling to the smoking area.
Two residents' wheelchairs were found covered with black and brown substances, visible to passersby, due to a lapse in scheduled cleaning by housekeeping staff. Facility leadership and staff confirmed that wheelchairs were not cleaned as required, citing staffing issues, and acknowledged that this failure compromised the cleanliness and comfort of the environment, as well as potentially exposing residents to sources of infection.
Two residents' wheelchairs were found covered with black and brown unknown substances due to missed scheduled cleaning by housekeeping staff. Despite facility policies requiring regular cleaning and staff expectations for reporting and follow-up, the wheelchairs remained soiled, and the environment was not maintained as clean or homelike, as confirmed by the ADON, DON, and Administrator.
Two residents at high risk for falls, one with right-sided paralysis and another with dementia and impaired mobility, were not provided with adequate supervision or individualized interventions despite staff awareness of their specific risks and behaviors. Both experienced unwitnessed falls resulting in injuries, including fractures and lacerations, after care plans failed to address their needs for supervision and positioning. Staff interviews and record reviews confirmed that known hazards were not incorporated into care planning or daily practices, leading to avoidable accidents.
The facility did not ensure that the IP provided ongoing in-service training and education to all staff during Norovirus and Influenza outbreaks. Many staff members, including dietary, nursing, and CNAs, did not recall receiving refresher or make-up infection control training after the outbreaks began, and there was no evidence of reminders or posted schedules. The IP did not communicate low attendance or coordinate with leadership to ensure all staff were trained, resulting in inadequate preparation to manage and prevent the spread of infection.
The facility did not report allegations of abuse involving two residents to CDPH and the Ombudsman within the required two-hour timeframe. In one case, a CNA delayed reporting an observed incident of alleged physical abuse, and in another, staff failed to report abuse allegations made by a family member to the police. Both residents had severe cognitive impairment and required significant care. Staff interviews and policy reviews confirmed knowledge of mandated reporting requirements, but these were not followed, resulting in delayed investigations and notifications.
Multiple high-risk residents with cognitive and physical impairments experienced unwitnessed falls resulting in serious injuries due to the facility's failure to provide adequate supervision and implement individualized fall prevention interventions. Staff did not follow care plan instructions or address known behaviors, leading to repeated incidents and harm.
The administrator did not provide adequate oversight or resources to address a high number of resident falls, resulting in several unwitnessed falls with injuries requiring hospitalization. Despite being aware of the issue, the administrator did not participate in fall prevention efforts, leaving clinical staff to address the problem without effective leadership or follow-up on interventions.
Two residents with significant fall risks and complex medical histories experienced multiple falls and injuries due to the facility's failure to develop and implement individualized, person-centered care plans. Despite assessments indicating the need for substantial assistance and supervision, care plans included only generic interventions and did not address specific behaviors or needs, resulting in falls, injuries, and hospitalizations.
Nursing staff did not have their fall prevention competencies checked within the past year, despite a high number of falls. A resident with mobility issues suffered an unwitnessed bathroom fall, resulting in a hip fracture and hospitalization. Not all staff attended a recent fall prevention in-service, and there was no evidence of competency testing or a policy for staff competency assessment.
Two residents received hospice services without a valid, signed agreement between the facility and the hospice agencies, as required by facility policy. The Administrator acknowledged that hospice agreements must be signed by both parties before starting care, but this was not done for either resident, both of whom had significant medical conditions and were under hospice care.
The facility did not implement an effective QAPI program to address a high number of resident falls, resulting in multiple falls with significant injuries requiring hospital care. Despite awareness of the issue, leadership failed to systematically track, analyze, or document interventions, and there was no integrated approach to performance improvement or staff competency assessment.
A resident with severe cognitive impairment and physical disabilities was moved to a new room and experienced a fall without the required notification to his responsible party (RP). Facility staff and documentation confirmed that the RP was not informed of these significant events, and the new room's bathroom setup was not suitable for the resident's needs, making safe transfers difficult. The facility's policies requiring advance notice and documentation of such changes were not followed.
A resident with severe cognitive impairment and multiple medical conditions was found with a hospital bed footboard that was loose and detached, creating an environmental hazard. CNAs were aware of the issue but did not report it through proper channels, and the maintenance log did not reflect the problem. Facility leadership confirmed the hazard and noted that required maintenance and reporting procedures were not followed.
A resident with severe cognitive impairment and a history of repeated falls experienced two unwitnessed falls from bed, resulting in head injuries that required emergency room treatment. The facility documented the incidents and notified the physician but failed to report the falls to CDPH as required by policy. Staff interviews confirmed the events were not reported, and the administrator was unaware of the multiple falls during the period.
A resident with a history of pressure ulcers was provided a low air loss (LAL) mattress that was incorrectly set at 320 lbs instead of the resident's actual weight of 72 lbs, contrary to physician orders and manufacturer guidelines. The MDSC and DON confirmed the improper setting, which was not in line with facility policy or the user manual, and linked it to the resident's discomfort and a recent fall.
A resident with multiple chronic conditions was found to have an oxygen concentrator filter covered in dust and lint. The ADON and DON confirmed this was unacceptable and not in line with facility policy, which requires licensed nurses to maintain equipment cleanliness. Facility policies and the manufacturer's manual both specify regular inspection and cleaning of such equipment, but this was not followed in this instance.
Two residents with severe cognitive and physical impairments experienced multiple falls, including one unwitnessed fall resulting in injury, due to lack of adequate supervision and failure to update care plans or conduct fall risk assessments. Another resident with known exit-seeking behavior eloped from the facility when a malfunctioning wander guard device was not properly tested, and staff did not provide direct supervision, resulting in the resident being found outside by police.
A CNA assisted a resident on contact precautions for norovirus without wearing the required gown and gloves, despite facility policy and posted instructions. Additionally, 11 rooms under isolation precautions lacked biohazard receptacles, leading staff to remove and dispose of contaminated PPE outside resident rooms or in hallways. These actions were observed and confirmed by interviews with staff and leadership, and were not in compliance with facility procedures or CDC guidelines.
Two residents with severe cognitive and functional impairments experienced repeated falls and injuries due to the facility's failure to develop and implement individualized, person-centered care plans. Despite staff awareness of each resident's decline and specific fall risks, care plans were not updated with effective interventions or appropriate supervision levels, resulting in preventable falls and injuries.
Nursing staff did not conduct required fall risk assessments for several residents with severe cognitive impairment and a history of falls, relying only on post-fall summaries that did not evaluate risk factors or provide scores. Additionally, staff failed to follow manufacturer guidelines for testing wander guard devices, using improper methods instead of the recommended handheld tester. These failures led to multiple falls, injuries, and an elopement event, placing residents at increased risk.
A resident with dementia, muscle weakness, and an unsteady gait was inaccurately assessed as independent in ambulation on the MDS, despite staff and care plan documentation indicating a need for supervision. The resident was left unsupervised on a patio, resulting in a fall and injury. Staff interviews and record reviews confirmed the MDS did not reflect the resident's true functional status.
A resident with COPD, CHF, Major Depressive Disorder, and Anxiety Disorder was left in her room during a loud verbal altercation between visitors, causing her emotional distress. The staff failed to assess her emotional status or offer relocation for safety, violating her rights to be free from abuse.
The facility failed to implement its water management plan, crucial for preventing Legionella growth. Testing revealed Legionella in the kitchen sink, and the Maintenance Supervisor did not assess or monitor for it. Additionally, a leaking pipe in the laundry room caused wet, stained, and warped floor tiles, with staff mopping frequently to prevent standing water.
The facility failed to inform and provide six residents with written information to formulate an advance directive upon admission. A review of EMRs showed no evidence of such information being offered, indicating a systemic issue. Interviews with the SSD and DON revealed discrepancies in the process for handling advance directives, contrary to the facility's policy.
The facility failed to provide written notifications of transfers to residents, their representatives, and the Ombudsman for several residents. Despite the policy requiring written notices, the facility did not adhere to this, as evidenced by the lack of written notices for multiple transfers. Interviews with staff revealed a lack of awareness regarding the requirement for written notifications, indicating a systemic issue in the facility's transfer processes.
The facility failed to provide written bed hold notices to residents or their representatives during hospital transfers, as required by policy. This deficiency was identified for four residents, where the facility's electronic medical records and interviews revealed that written notices were not provided, and staff were unaware of the requirement to include reserve bed payment information. The facility administrator confirmed that written notices were not issued.
The facility failed to develop comprehensive care plans for 10 residents, omitting critical information such as code status and sex offender registry status. This oversight left staff uninformed about essential aspects of residents' care needs and histories, including DNR orders and legal statuses.
The facility failed to maintain the required minimum square footage per resident in 32 rooms, with some rooms having insufficient space for the number of beds present. The Administrator noted that a room waiver had expired, and it was usually renewed upon receiving a deficiency.
The facility failed to have a dialysis contract for two residents with end-stage renal disease (ESRD) who were receiving dialysis treatments. Despite having a policy requiring agreements with contracted ESRD facilities, the facility did not have a contract with the dialysis center used by these residents, as confirmed by the Administrator. This deficiency could impact the residents' overall care management.
A resident with CHF and other significant medical conditions experienced a deterioration in health due to the facility's failure to monitor and manage her weight gain and edema. The interdisciplinary team did not collaborate effectively, leading to the resident's transfer to the hospital for a right foot infection and sepsis, which contributed to her death.
The facility failed to notify physicians and implement timely interventions for two residents experiencing significant changes in their conditions. One resident experienced severe weight loss without timely physician notification or dietary intervention, leading to hospitalization for hepatic encephalopathy. Another resident had blood in the urine, but the delay in notifying the physician and collecting a urine sample resulted in a prolonged start of UTI treatment.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with COPD and ESRD, placing them at risk for complications. The facility's policy requiring timely care plans was not followed, as confirmed by the ADON and an LVN.
The facility failed to meet professional standards of quality by not administering the correct oxygen rates as per physician's orders for two residents with COPD. One resident received 3 LPM instead of the ordered 4 LPM, and another received 3.5 LPM instead of the ordered 2 LPM, as confirmed by LVNs and the ADON.
Failure to Maintain Boiler System Resulting in Prolonged Loss of Hot Water
Penalty
Summary
The deficiency involves the facility’s failure to maintain essential equipment, specifically one of two boiler systems responsible for heating water, in safe operating condition. According to the Administrator, the Maintenance Supervisor reported on the morning of 2/21/26 that the boiler supplying hot water to stations 1 and 2 was not working. The Maintenance Supervisor identified that the fan motor to the boiler igniter was frozen and contacted the outside vendor, who came that day but did not have the necessary replacement part. The Maintenance Supervisor stated he informed the Administrator that stations 1 and 2 had no hot water but did not report that other stations were also affected, despite later acknowledging that stations 3, 4, 5, and 6 did not have hot water in their shower rooms, resident rooms, or nurses’ station sinks. The boiler did not receive routine service from an outside vendor and was only serviced when issues arose. Multiple staff interviews confirmed that there was no hot water throughout the facility from 2/21/26 until 2/24/26. Certified Nursing Assistants reported that there was no hot water in resident rooms, shower rooms, or nurses’ station sinks on several stations over the weekend and into Monday, and that residents were offered cold showers or bed baths with cold water. A Registered Nurse also stated that there had been no hot water on her station since 2/21/26. The Director of Nursing reported receiving a text on 2/21/26 that stations 1 and 2 did not have hot water and stated that staff were told the laundry room, which was on a separate boiler, had hot water that could be used for bed baths. The Director of Nursing and Administrator both stated that their expectation was that water temperatures be checked with a thermometer for accurate readings, but the Maintenance Supervisor reported he only used his hand to assess water temperature and did not use a thermometer. Residents confirmed the impact of the lack of hot water. One resident stated that there had been no hot water since Saturday and that she did not receive her scheduled shower on 2/23/26 because of this. Another resident stated he was told there had been no hot water since Saturday and that a CNA used cool water to clean him over the weekend. Facility policies and procedures for Maintenance Service and Water Temperatures, Safety of, required the maintenance department to maintain equipment in safe and operable condition, maintain heating and plumbing systems in good working order, and conduct and record periodic tap water temperature checks using thermostats and temperature controls. The Maintenance Supervisor acknowledged that the boiler did not receive routine service and that he did not follow the policy expectation of using a thermometer to check water temperatures, contributing to the prolonged period without hot water throughout the facility. The facility’s failure to maintain the boiler system in safe operating condition resulted in a non-functioning boiler from 2/21/26 to 2/24/26, during which residents were unable to shower and nursing staff were unable to wash their hands in hot water, placing residents at risk for poor hygiene, infectious disease, and discomfort.
Failure to Document Influenza Testing in Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records when the Infection Preventionist (IP) performed influenza testing on several residents and did not document these tests in the electronic medical record (EMR). The facility’s policy on Charting and Documentation requires that all services provided to residents, including treatments or services performed, be documented in the medical record with complete and accurate details such as date, time, provider, and how the resident tolerated the procedure. The IP’s job description states that the IP is accountable for surveillance of healthcare-acquired and community-acquired infections. Despite these requirements, the IP acknowledged that multiple influenza tests she performed were not documented in the EMR, resulting in incomplete medical records. Record reviews showed that several residents had documented changes in condition and positive influenza A results, but not all tests performed by the IP were recorded. One resident with dementia and anxiety had a change in condition note indicating a positive influenza A test, nasal congestion, and a nonproductive cough. Another resident with malignant neoplasm of the lung and secondary neoplasm of the brain had a change in condition with shaking, weakness, altered responsiveness, and low oxygen saturation, and the IP stated she tested this resident for influenza before transfer to an acute care hospital but did not document the test. The IP also stated she tested this resident’s roommate, who had diagnoses including Type 2 diabetes mellitus, hypertension, and muscle weakness, but could not find documentation of that influenza test in the EMR. Additional residents were involved in the undocumented testing. One resident with Parkinsonism, Type 2 diabetes mellitus, and anxiety developed respiratory symptoms with a nonproductive cough, and the IP stated she tested this resident for influenza but confirmed there was no documentation of the test in the EMR. Another resident with hemiplegia and hemiparesis following intracerebral hemorrhage, respiratory failure, and hypoxia developed a nonproductive cough, and the IP recalled testing this resident but found no documentation of the test or results in the EMR. During an interview, the DON and ADON confirmed they were present when the IP tested residents for influenza and stated that if tests were not documented, they were considered not done, and that the medical record was not complete without documentation of the influenza tests. They further stated it was the IP’s responsibility, not the charge nurse’s, to document the tests she performed.
Non-Functioning ABHR Dispensers Undermine Hand Hygiene Accessibility
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when 12 of 65 alcohol-based hand rub (ABHR) dispensers located in hallways and nurses’ stations failed to dispense product during testing with the Infection Preventionist (IP). The non-functioning dispensers were located near multiple resident rooms (Rooms 2, 6, 17, 20, 30, 39, 52, 54, 56, 61), next to the Station 3 shower room, and next to the maintenance office. The IP stated that housekeeping was responsible for refilling or replacing ABHR dispensers and acknowledged that it was important for dispensers to work properly to prevent the spread of germs and infections. The IP also stated that staff were expected to perform hand hygiene when entering and exiting resident rooms, before and after glove use, after using the restroom, before eating, and when hands were soiled. Staff interviews further demonstrated awareness of non-functioning ABHR dispensers and the impact on hand hygiene practices. An LVN reported knowing that some dispensers did not work and therefore kept ABHR gel on the medication cart for hand cleaning. A CNA reported that some hallway dispensers did not work and explained that when encountering a non-functioning dispenser after leaving a resident room, she had to walk down the hall to find another working dispenser to clean her hands. Another CNA stated that ABHR was needed when going in and out of resident rooms, before and after resident care, and before and after passing meal trays. The DON and ADON both stated it was very important for hand sanitizer dispensers to function properly and described expectations for staff hand hygiene, including at the start and end of shifts, in and out of resident rooms, between resident care, after bathroom use, and before and after meals. Review of the facility’s hand hygiene policy indicated that hand hygiene products and supplies were to be readily accessible and convenient for staff use, with ABHR dispensers placed in areas of high visibility and hand hygiene required before and after resident contact and after contact with the resident environment.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and did not provide adequate supervision to prevent accidents in two significant instances. In the memory care unit, a slide barrel lock was installed at the top right corner of an exit door leading to a patio. This lock was positioned out of reach for most individuals, including staff and residents, and required fine motor skills and cognitive understanding to operate. No environmental hazard risk assessment was conducted for this lock, and some staff were unaware of its placement. The lock's presence created a situation where residents and staff could be unable to exit in an emergency, potentially leading to entrapment. The facility's policy required exit doors to remain unlocked, and the Life Safety Code mandates that doors be readily operable from the egress side without special knowledge or effort. Additionally, the facility did not address the hazard posed by the path of travel to the designated smoking area, which required residents to cross a busy parking lot. One resident, who was assessed as cognitively intact and an independent smoker, was struck by a vehicle while returning from the smoking area in his wheelchair. The incident resulted in multiple fractures and hospitalization, with the resident experiencing increased pain and dependence on staff for activities of daily living. Staff interviews confirmed that there was no safe pathway or sidewalk from the facility to the smoking area, and residents had to navigate behind parked cars in a busy parking lot. Multiple staff members acknowledged the lack of safety and the absence of staff assistance for residents traveling to the smoking area. Facility policies required ongoing identification of safety risks and environmental hazards, as well as the development of strategies to mitigate or remove hazards when identified. However, the facility did not conduct a risk assessment for the exit door lock or the route to the smoking area, nor did it implement measures to ensure resident safety in these areas. The deficiencies affected all residents in the memory care unit and placed residents who smoked at risk of serious harm.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for two residents when their wheelchairs were observed to be covered with black and brown unknown substances. Both residents were found lying in bed asleep during the observation, and their wheelchairs, which were visibly soiled, were accessible and visible to passersby. The Assistant Director of Nursing (ADON) confirmed that housekeeping staff were responsible for cleaning the wheelchairs weekly, but this was not done. The ADON also acknowledged that the substances on the wheelchairs could be a source of bacterial growth and potentially cause illness. Housekeeping staff confirmed that the wheelchairs had not been cleaned the previous week due to staffing problems and agreed that unclean equipment could lead to illness. The Director of Nursing (DON) and the Administrator both stated that wheelchairs were expected to be cleaned weekly and as needed, and that all staff were responsible for ensuring a clean and homelike environment. Review of facility policy and job descriptions confirmed the expectation for maintaining cleanliness and a homelike environment. The failure to clean the wheelchairs as scheduled resulted in a violation of the residents' rights to a comfortable and homelike environment, as well as a potential source of infection.
Failure to Maintain Clean Wheelchairs and Effective Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the condition of two residents' wheelchairs, which were observed to be covered with black and brown unknown substances. Both residents were found asleep in their beds during the observation, and their wheelchairs' metal frames and wheels were visibly soiled. The Assistant Director of Nursing (ADON) confirmed that the housekeeping staff were responsible for cleaning the wheelchairs weekly, but this had not been done. The ADON acknowledged that the facility did not provide a comfortable and homelike environment and that the substances on the wheelchairs could be a source of bacterial growth and illness. Housekeeping staff confirmed that the wheelchairs were dirty and should have been kept clean at all times, but due to staffing problems, the scheduled cleaning was missed. The Housekeeper stated that unclean equipment such as wheelchairs could make residents ill and that the facility failed to provide a comfortable homelike environment for the affected residents. The Director of Nursing (DON) also reviewed photos of the wheelchairs and stated that she expected them to be cleaned as scheduled and as needed for soilage. The DON indicated that the housekeeping department was responsible for cleaning wheelchairs weekly and as needed, and that licensed nurses and CNAs were expected to report dirty wheelchairs to housekeeping for follow-up. The Administrator stated that all wheelchairs were expected to be cleaned weekly and as needed, and that providing a clean, comfortable, and homelike environment was the responsibility of all staff. The facility's job description for housekeepers and its policies and procedures for assistive devices and infection control both indicated that maintaining a clean and safe environment was required. However, these policies were not followed, resulting in the deficiency.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective individualized interventions to prevent falls for two residents identified as high risk. One resident, who had right-sided paralysis, severe cognitive impairment, and was dependent on staff for repositioning, was frequently observed leaning to the left against a side rail in bed. Despite staff awareness of this behavior and the resident's inability to reposition himself, the care plan did not address these specific risks. The resident experienced an unwitnessed fall from bed, resulting in a nasal fracture and lacerations requiring emergency department treatment and sutures. Staff interviews confirmed that the resident's positioning issues and use of the electric bed were known, but interventions were not updated to address these hazards. Another resident, with diagnoses including Alzheimer's disease, dementia, and impaired mobility, was assessed as needing staff supervision to ambulate more than 50 feet and had known behaviors of putting herself on the ground. Despite these risks, the resident was allowed to ambulate outside to the memory care unit patio without staff supervision, leading to an unwitnessed fall. The resident sustained a laceration to the back of her head and required emergency department assessment. Staff and care plan reviews revealed that the need for supervision during ambulation and the resident's specific behaviors were not adequately addressed in the care plan prior to the fall. Both incidents demonstrated a lack of individualized, resident-centered interventions and supervision as required by facility policy and assessment findings. Staff interviews and record reviews indicated that known risks and behaviors were not incorporated into care plans or daily supervision practices, directly resulting in avoidable falls and injuries for both residents. The facility's failure to implement and update interventions based on each resident's assessed needs contributed to the deficiencies observed.
Failure to Provide Ongoing Infection Control Training During Outbreaks
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) possessed and demonstrated the necessary competencies and skills to provide ongoing in-service training and education to staff during outbreaks of Norovirus and Influenza. The IP did not conduct refresher or make-up in-service sessions after the initial training, despite confirmed cases and an active outbreak. Interviews with dietary staff, nurses, and certified nursing assistants revealed that many did not recall attending infection control in-services provided by the IP after the outbreak began, and there was no evidence of reminders or posted schedules for such training. The IP acknowledged that in-service training on Norovirus was provided 15 days before the first confirmed case, but no additional sessions were held after the outbreak started. Attendance at subsequent in-services on Influenza and related precautions was low, and the IP did not communicate this to facility leadership or attempt to ensure all staff received the necessary education. The Director of Staff Development (DSD) and Director of Nursing (DON) both stated that they were not informed of the low attendance and did not provide or coordinate additional training, with the DSD indicating she would have assisted if asked. Facility policies required ongoing education and competency evaluation for staff during outbreaks, but these were not followed. The lack of comprehensive and timely in-service training for all staff, especially those providing direct care, resulted in staff being inadequately prepared to manage and prevent the spread of infection among residents, staff, and visitors during the Norovirus and Influenza outbreaks.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the required timeframe for two residents. In the first instance, a Certified Nursing Assistant (CNA) observed another CNA allegedly pushing a resident roughly onto her bed. The incident occurred in the early morning, but the witnessing CNA did not report the event to facility staff until nearly 22 hours later, despite being aware of the requirement to report such incidents within two hours. The resident involved had severe cognitive impairment, a history of falls, and required assistance with personal care. The facility's internal investigation was not initiated until the incident was reported, and the final report was not sent to CDPH until several days after the event. In the second case, a family member of another resident contacted the local police department on two separate occasions, alleging that the resident was being abused by facility staff. The police conducted welfare checks and informed facility staff of the abuse allegations. Despite this, the facility did not report the allegations to CDPH or the Ombudsman as required by both federal regulations and the facility's own policies. The resident in question was severely cognitively impaired, frail, and on hospice care, with a history of skin breakdown and bruising. Staff were aware of the family member's repeated concerns and the police visits but did not escalate the allegations to facility management or external authorities. Interviews with facility staff, including CNAs, LVNs, the Director of Nursing, and the Administrator, confirmed that all were aware of the mandated reporting requirements, which stipulate that all allegations of abuse must be reported within two hours. However, in both cases, staff either delayed reporting or failed to report the allegations altogether, resulting in untimely investigations and notifications to the appropriate authorities. Facility policies and in-service training documents reviewed during the survey reiterated the immediate reporting requirements, which were not followed in these instances.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall prevention interventions for multiple residents identified as high fall risks. One resident with a history of falls, moderate cognitive impairment, Parkinsonism, and muscle weakness was found on the bathroom floor after an unwitnessed fall. Staff interviews revealed that this resident required supervision and touch assistance for ambulation and was known to be forgetful and noncompliant with using the call light. Despite these known risks, the resident did not have individualized fall prevention interventions in place prior to the incident, and was found barefoot, contrary to care plan instructions for appropriate footwear. The care plan interventions were not followed, and the root cause of the fall was not clearly identified by the interdisciplinary team. Another resident with left-sided paralysis, severe cognitive impairment, and a history of repeated falls experienced multiple unwitnessed falls while sitting unsupervised at the edge of the bed. This resident had poor balance and safety awareness, and staff acknowledged that he was impulsive and unable to maintain stability while sitting up. The care plans for this resident were not person-centered, lacked specificity regarding the level of supervision required, and did not address the root causes of his falls. Staff and therapy personnel confirmed that the resident needed assistance to sit safely, but interventions were not effectively implemented, resulting in repeated injuries, including lacerations requiring emergency care. A third resident, assessed as needing supervision during transfers and known to self-transfer between a wheelchair and an armchair, was left unsupervised in a hallway armchair. This resulted in an unwitnessed fall causing significant injuries, including a hip fracture and a forearm fracture, necessitating surgical intervention and hospitalization. The facility's failure to provide adequate supervision and individualized interventions for these residents, despite their assessed needs and known behaviors, led to serious harm and demonstrated a pattern of non-compliance with accident prevention requirements.
Removal Plan
- Facility added 1:1 support and supervision while awake and will remain in sight of Residents 1 and 2.
- Staff will assist Resident 2 with stability and balance while sitting on side of the bed to minimize risk for falling.
- Staff will assist Resident 1 with individual toileting plan including upon waking, before and after meals, before bed and every two hours as needed.
- Resident 6 will be placed on a 1:1 while awake after she returns to the facility, assist with safe transfers, cueing and provide direct care for impulsive attempts to rise or transfer.
- IDT reviewed Root Cause (RC) Analysis of accident hazards, supervision and assistive devices to prevent avoidable accidents and have updated care plans with person-centered interventions which will be reviewed by the IDT.
- Facility increased CNA staffing on stations 5 & 6 as identified during RC analysis for falls.
- The facility assigns monitor staff including each unit supervisor for safety checks on identified residents with falls.
- The activity department added additional snack and crafts cart and staff support for identified high fall risk residents with actual falls.
- Director of Staff Development (DSD) initiated in-service for direct care staff with specific focus on resident interventions to reduce falls and injuries from falls.
Failure to Provide Administrative Oversight and Fall Prevention
Penalty
Summary
The facility administrator failed to provide consistent administrative oversight and resources to ensure residents received adequate supervision and care planning, despite being aware of 63 resident falls over a two-month period. The administrator did not establish an effective fall prevention program, and this lack of action resulted in multiple residents experiencing unwitnessed falls with injuries that required hospitalization. Specifically, one resident suffered a right hip fracture after slipping in the bathroom without staff assistance, was found barefoot and without a brief, and reported significant pain following the incident. Interviews with staff revealed that the unit supervisor and the DON were aware of the high number of falls but were unable to clearly identify the root causes or ensure that effective interventions were implemented. The DON, who was new to the facility, had not yet familiarized herself with the facility's policies and procedures and could not articulate the findings of the interdisciplinary team's review of the fall incidents. The Director of Staff Development acknowledged conducting a fall prevention in-service but did not assess staff competency afterward. The administrator admitted to being aware of the high fall rate but considered falls to be a clinical issue under the DON's responsibility and did not participate in fall-related meetings or reviews. The facility's job description for the administrator and its policies emphasized the administrator's responsibility for accident prevention and oversight, including reviewing incident reports and ensuring effective safety programs. However, these responsibilities were not fulfilled, contributing to the ongoing risk and occurrence of resident falls with injury.
Failure to Develop and Implement Effective, Person-Centered Fall Prevention Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with known fall risks, resulting in multiple falls and injuries. One resident, with a history of falls, Parkinsonism, moderate cognitive impairment, and mobility issues, was admitted with significant risk factors. Despite assessments indicating the need for substantial assistance with transfers and ambulation, the care plan only included generic interventions such as ensuring the call light was within reach and encouraging its use, as well as proper footwear. Staff interviews confirmed that the resident was forgetful and did not consistently use the call light, and that no individualized fall prevention interventions were in place prior to the resident's fall. The resident subsequently experienced an unwitnessed fall in the bathroom, resulting in a hip fracture and hospitalization. Another resident, admitted with left-sided paralysis, a history of falls, and severe cognitive impairment, also did not have effective fall prevention interventions in place. This resident had a behavior of sitting at the edge of the bed unsupervised, which was not addressed in the care plan. The resident experienced four falls, two of which occurred on the same day, resulting in a laceration above the eyebrow that required emergency room treatment and sutures. Staff interviews and record reviews revealed that the care plan interventions were not specific to the resident's needs, did not address the behavior of sitting at the edge of the bed, and did not specify the level of supervision or frequency of checks required. The root cause of the resident's behavior and falls was not identified or addressed in the care plan. Facility policies required comprehensive, person-centered care plans with measurable objectives and individualized interventions based on assessment data. However, the care plans for both residents lacked specificity, did not reflect the assessed needs, and failed to implement effective interventions to prevent falls. Staff were unable to articulate the rationale for the interventions in place or how they addressed the residents' specific risks, and documentation did not demonstrate that the care plans were revised in response to changes in the residents' conditions or after falls occurred.
Failure to Ensure Staff Competency in Fall Prevention Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed and demonstrated the necessary competencies in fall prevention, as evidenced by the lack of documented competency checks for all seven sampled nursing staff within the past year. Despite a high incidence of falls—42 occurring over a six-week period—there was no evidence that staff had been evaluated for their ability to implement fall prevention interventions. An in-service on fall prevention was held, but not all staff attended, and there was no follow-up to assess whether those who attended had achieved competency. The Director of Staff Development acknowledged that competency testing was not conducted after the in-service, and the facility could not provide any policy or procedure for staff competency assessment. This deficiency directly contributed to an incident in which a resident, who had involuntary tremors and required assistance with transfers, experienced an unwitnessed fall in the bathroom. The resident sustained a right intertrochanteric hip fracture, resulting in pain, decreased mobility, and a week-long hospitalization. At the time of the fall, the resident did not have fall prevention interventions in place, and staff were unsure how the resident ended up in the bathroom alone. Interviews confirmed that some staff had not attended the fall prevention in-service, and there was no documentation verifying staff competency in this critical area.
Failure to Obtain Signed Hospice Agreements Prior to Initiating Hospice Services
Penalty
Summary
The facility failed to follow its own hospice policy and procedures for two residents who were receiving hospice services without a valid, signed hospice agreement in place. For both residents, the hospice agreements with the respective hospice agencies were found to be unsigned by the hospice agency's authorized representative. The Administrator confirmed that the agreements must be signed by both parties prior to the initiation of hospice services, and acknowledged that this was not done for either resident. The Administrator also stated that it was his responsibility to ensure contracts with outside service providers, including hospice, were reviewed and signed before care or services began. Resident 8 was admitted with diagnoses including congestive heart failure, type 2 diabetes mellitus, hypertension, and pleural effusion, and was under hospice care from admission. Resident 14 was admitted with diagnoses including Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, hypertension, and anxiety disorder, and was also under hospice care. Facility policy required a written and signed agreement with hospice providers before services were furnished to any resident, but this procedure was not followed for these two residents.
Failure to Implement Effective QAPI Program for Fall Prevention
Penalty
Summary
The facility failed to identify, develop, and implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of an effective fall prevention program. Between January 1 and March 4, 2025, there were 63 resident falls, with three resulting in significant injury that required transportation to an acute care hospital. The facility's documentation showed a high number of falls, including 31 in January and 11 in the first 12 days of February. Despite being aware of the high fall rate, the Director of Staff Development only provided an in-service on fall prevention without testing staff competency afterward. Interviews with the Administrator (ADM) revealed that the QAPI committee, which included department heads and the medical director, met monthly to discuss facility issues. However, the ADM was unable to explain how data collected through QAPI was used to reduce falls or what specific performance improvement plans were implemented. The ADM also stated that each department head took their own minutes, and there was no integrated documentation of QAPI discussions or actions related to falls. The ADM deferred responsibility for fall prevention to the Director of Nursing and was not involved in clinical discussions or daily stand-up meetings where falls were reviewed. A review of the facility's QAPI policy indicated that the program should be data-driven, ongoing, and focused on identifying and correcting quality deficiencies. The policy assigned the administrator responsibility for ensuring compliance and required systematic analysis and corrective action. However, the facility did not follow these procedures, as there was no evidence of systematic tracking, analysis, or implementation of effective interventions to address the high rate of resident falls.
Failure to Notify Responsible Party of Room Change and Fall
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident regarding significant events, including a room change and a fall. The resident, who had a history of repeated falls, fractures, paraplegia, muscle weakness, and severe cognitive impairment, was moved to a different room without prior notification to his RP. The facility's own policy required advance notice to the RP before any room change, but documentation and interviews confirmed that no such notification was made. The resident's RP only learned of the room change after another family member visited and found the resident in a different room. Additionally, the resident experienced a fall, and again, the RP was not notified as required by facility policy. The resident's RP stated she was not informed about the fall and only became aware of it through family discussions. Review of the medical record and interviews with staff, including the MDS Coordinator and LVN, revealed no documentation of RP notification for either the room change or the fall. The facility's policy clearly stated that the RP must be notified of any accident, incident, or significant change in the resident's status, but this was not followed in this case. Observations further revealed that the new room was not suitable for the resident's physical needs, as the grab bars in the bathroom were not accessible to him due to his left-sided paralysis. The resident and his RP both expressed concerns about the safety and appropriateness of the new room, and staff confirmed the difficulty in assisting the resident due to the bathroom setup. The Social Services Director acknowledged that the required process and documentation for room change and RP notification were not completed, and the facility's policy was not followed.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Bed
Penalty
Summary
A deficiency occurred when a resident's hospital bed footboard was found to be loose and detached from the bedframe, making it visible to passersby and creating an environmental hazard. The resident, who had a history of cerebrovascular disease, congestive heart failure, generalized muscle weakness, and hypertension, was observed lying in bed asleep at the time of the incident. The resident's cognitive status was severely impaired, as indicated by a BIMS score of 3 out of 15. Certified Nurse Assistants (CNAs) were aware of the ongoing issue with the bed's footboard, but it had not been properly reported or documented for maintenance. The Assistant Director of Nursing (ADON) and the Maintenance Director both confirmed that the loose footboard was an environmental hazard and required immediate repair. The Maintenance Director stated that the issue had not been reported or logged in the maintenance records, and admitted to not checking the maintenance log daily as required. The Director of Nursing (DON) also acknowledged the hazard and emphasized the expectation that staff report equipment issues promptly. Facility policies reviewed indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, and that regular inspections and maintenance logs are required, but these procedures were not followed in this instance.
Failure to Timely Report Unwitnessed Falls with Injury
Penalty
Summary
The facility failed to report two unwitnessed falls with injury involving a resident to the California Department of Public Health (CDPH) within the required time frame. The resident, who had a history of repeated falls, paraplegia, muscle weakness, and severe cognitive impairment, experienced two separate falls from his bed on the same day. Both incidents were unwitnessed, and in each case, the resident struck his head, resulting in a skin tear and later a laceration to the left eyebrow that required emergency room treatment and sutures. Review of the resident's records indicated that the falls were documented, and the attending physician was notified. However, there was no documentation that CDPH was notified of either incident. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the events were not reported to the state agency. The DON stated that the falls were not considered reportable due to the resident's medical condition and history of falls, and interventions were focused on minimizing injury rather than preventing falls. Further review of facility policy revealed that any injury of unknown source or suspected neglect should be reported immediately to the administrator and appropriate authorities, including the state agency. Despite this policy, the administrator and DON did not report the incidents, and the administrator was unaware of the resident's multiple falls during the period in question. This failure resulted in the falls not being investigated in a timely manner as required.
Failure to Set Low Air Loss Mattress According to Manufacturer Guidelines
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, hypertension, sacral pressure ulcer, and anxiety disorder was admitted to the facility and required a low air loss (LAL) mattress for wound management. The physician's order and care plan specified the use of the LAL mattress, and the manufacturer's guidelines required the mattress setting to be adjusted according to the resident's weight. However, the LAL mattress was set at 320 lbs, while the resident's actual weight was 72 lbs, as confirmed by the Minimum Data Set Coordinator (MDSC) during a review of the resident's records and a photo of the mattress settings. The MDSC and the Director of Nursing (DON) both acknowledged that the mattress setting did not follow the manufacturer's recommendations and that this could have contributed to the resident's discomfort and a recent fall. The facility's policy and procedure, as well as the job description for floor nurses, required adherence to manufacturer guidelines and proper equipment operation. The user manual for the mattress also specified that the pressure should be set according to the patient's weight. The failure to set the LAL mattress correctly represented a lack of compliance with professional standards of quality for the care of this resident.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
A deficiency was identified when a resident's oxygen concentrator filter was observed to be covered with dust and lint. The resident, who had been admitted from an acute care hospital with diagnoses including congestive heart failure, type 2 diabetes mellitus, hypertension, and pleural effusion, was receiving oxygen therapy as ordered. During an observation in the resident's room, the Assistant Director of Nursing (ADON) and a registered nurse confirmed the filter's dirty condition and acknowledged that this was not acceptable. The ADON stated that maintaining the cleanliness of the oxygen concentrator was the responsibility of licensed nurses. Interviews with the Director of Nursing (DON) further confirmed that the use of a dirty oxygen concentrator was not in line with facility expectations and could potentially cause residents to become ill. Review of facility policies and procedures indicated that equipment should be maintained according to manufacturer instructions and infection control standards, and that staff are responsible for ensuring equipment is in good working order. The oxygen concentrator's user manual also emphasized the need for frequent inspection and cleaning of the filter, especially in environments with dust and lint.
Failure to Prevent Accidents Due to Inadequate Supervision and Assistive Measures
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents, including falls and elopement, for multiple residents with known cognitive and physical impairments. In one instance, a resident with dementia, epilepsy, muscle weakness, and a history of unsteady gait was left unsupervised on an outdoor patio. Despite staff awareness of his declining functional status and need for supervision while ambulating, no staff was assigned to supervise him. The resident was found on the ground after an unwitnessed fall, sustaining a laceration above the left eyebrow that required emergency department treatment. Interviews with staff confirmed that the resident's health had been declining, he required close monitoring, and that the fall could have been prevented with proper supervision. The facility did not perform fall risk assessments before or after the incident, and the care plan was not updated to reflect the resident's increased need for supervision. Another resident with severe cognitive impairment, poor safety awareness, and a history of repeated falls was not provided with effective supervision or individualized interventions to prevent falls. This resident experienced multiple falls while in bed, despite staff and care plan recognition of her high fall risk and the ineffectiveness of interventions such as reminders to use the call light. The care plan interventions focused on increased monitoring and keeping the resident in visual areas when not in bed, but did not address the cause of her falls, which occurred while she was unsupervised in bed. Staff interviews confirmed that the resident needed one-on-one supervision while in bed to prevent further falls, but this was not implemented. A third resident, identified as having exit-seeking behavior and a high risk of elopement due to severe cognitive impairment, was able to leave the facility undetected when his elopement detection device failed to function and alarm. Staff were aware of the resident's risk and the need to check the placement and function of the wander guard device every shift, but this was not done. The resident was found outside the facility by police after a neighbor reported him as confused and alone. The facility's method for testing the wander guard device did not follow manufacturer guidelines, as they lacked the appropriate testing equipment and instead took the resident to an alarmed door. The failure to ensure the device was functioning properly and to provide direct supervision resulted in the resident's elopement.
Failure to Adhere to Infection Control Protocols During Norovirus Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in two key areas. First, a Certified Nursing Assistant (CNA) assisted a resident who was on contact precautions for symptoms of norovirus without wearing the required personal protective equipment (PPE), specifically a gown and gloves. The CNA physically supported the resident from the bathroom to the bed, despite signage indicating the need for PPE and the facility’s policy requiring its use for residents with norovirus symptoms. The CNA acknowledged during an interview that she should have donned the appropriate PPE before providing care, and both the Director of Nursing (DON) and Infection Preventionist (IP) confirmed that the correct PPE was not used as required by facility policy and CDC guidelines. Additionally, the facility did not provide biohazard receptacles in 11 out of 22 rooms where residents were under isolation precautions. Staff, including a Licensed Vocational Nurse (LVN) and another CNA, were observed doffing contaminated PPE outside of resident rooms or in the hallway due to the absence of proper disposal containers inside the rooms. In one instance, a yellow biohazard bag was left on the hallway floor for PPE disposal, which the IP and DON stated was inappropriate and could lead to contamination of the hallway environment. Both staff and leadership interviews confirmed that contaminated PPE should be removed and disposed of inside the resident’s room to prevent the spread of infection. The facility’s policies and procedures, as well as CDC guidelines, were reviewed and all indicated the necessity of using PPE for contact precautions and the proper disposal of contaminated materials within the resident’s room. The observed failures to follow these protocols occurred during an outbreak of norovirus, with multiple residents symptomatic and on contact precautions. The lack of adherence to established infection control measures was confirmed through direct observation, staff interviews, and policy review.
Failure to Develop and Implement Person-Centered Fall Prevention Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to prevent falls for two residents with significant cognitive and functional impairments. For one resident with dementia, epilepsy, muscle weakness, and difficulty walking, staff were aware of a decline in functional status and poor safety awareness, yet did not update the care plan to specify the required level of supervision for safe ambulation. Despite multiple falls and a recent injury requiring emergency department care, interventions remained generic, such as encouraging use of the call light and bed rest, which were not appropriate for a resident with severe cognitive impairment. Staff interviews confirmed that the care plan did not reflect the resident's current needs or address the specific risks associated with his condition. Another resident with severe cognitive impairment, encephalopathy, cerebral infarction, and a history of repeated falls also lacked an effective, individualized fall prevention plan. The care plan interventions focused on increased monitoring and keeping the resident in visual areas, but did not address the fact that her falls occurred while she was in bed unsupervised. Staff acknowledged that the interventions were not person-centered and did not specify the frequency or type of supervision needed to prevent falls in bed. The care plan was not updated to reflect the actual circumstances of the resident's falls, and interventions were not tailored to her specific risks. Facility policies required comprehensive, person-centered care plans with measurable objectives and individualized interventions based on ongoing assessments and changes in resident condition. However, the care plans for both residents were not revised to address their changing needs, did not include effective or specific interventions, and failed to prevent repeated falls and injuries. Staff and leadership interviews confirmed that the care plans were not accurate, not updated, and not effective in addressing the residents' fall risks.
Failure to Perform Fall Risk Assessments and Properly Test Wander Guard Devices
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for six of nine sampled residents. Nursing staff did not perform fall risk assessments for four residents with severe cognitive impairment, poor safety awareness, and a history of falls, both after falls and on a quarterly basis. Instead, staff completed only a Post Fall Review, which summarized the fall event but did not assess risk factors or provide a fall risk score. Interviews with LVNs and the DON confirmed that formal fall risk assessments were not conducted, despite the facility's policy requiring such assessments to identify risk factors and guide interventions. Medical records and MDS assessments indicated that these residents had severe cognitive impairment and multiple diagnoses that increased their fall risk, yet no fall risk assessments were found in their records. Additionally, licensed nurses did not follow manufacturer guidelines for checking the function of wander guard devices for two residents at risk of elopement. Staff were expected to check the placement and function of these devices every shift, but instead of using the recommended handheld testing device, they took residents to alarmed doors to see if the alarm would sound. This practice did not comply with the manufacturer's instructions, which required daily testing with a specific device. As a result, one resident was able to elope from the facility when their wander guard malfunctioned, and another was placed at risk for elopement. Interviews with staff, including LVNs, the DON, and the wander guard vendor, confirmed that the facility was not following the correct procedures for testing the wander guard devices. The facility's own policies required identification and monitoring of residents at risk for wandering and elopement, but these were not adequately implemented. Documentation and interviews revealed that staff were aware of the deficiencies in both fall risk assessment and wander guard testing, but failed to carry out the required practices, resulting in adverse events and increased risk for the residents involved.
Inaccurate MDS Assessment Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment accurately reflected the resident's healthcare and functional status. The resident in question had a documented history of dementia, epilepsy, muscle weakness, and difficulty walking, with a care plan noting an unsteady gait and declining health since early November. Despite these documented issues, the MDS completed on 11/23/24 assessed the resident as independent in ambulation, which was inconsistent with the care plan and staff observations. Multiple staff interviews confirmed that the resident required supervision to ambulate safely due to cognitive impairment and physical decline. Certified Nursing Assistants (CNAs) and nursing staff reported that the resident's ability to perform activities of daily living had decreased, and he exhibited a shuffling gait and episodes of leaning forward, increasing his fall risk. The resident was left unsupervised on the patio, where he subsequently fell and sustained a laceration above his left eye. Staff acknowledged that the resident did not have the mental capacity to call for help, further emphasizing the need for supervision. Review of facility records and interviews with the MDS Coordinators revealed that the MDS was completed using CNA documentation, but did not accurately reflect the resident's need for supervision. The Director of Nursing and other staff agreed that the MDS coding was incorrect and did not match the resident's actual condition as described in the care plan and by staff. The facility's policy required accurate and comprehensive assessments, but this was not followed, resulting in an inaccurate assessment and a preventable fall.
Failure to Protect Resident from Emotional Distress During Visitor Altercation
Penalty
Summary
The facility failed to protect and promote the rights of a resident to be free from abuse when a Licensed Vocational Nurse (LVN) and other staff left the resident in her room during a verbal altercation between four visitors. The incident occurred when the resident, her former roommate, and two visitors were present in the room, and two additional visitors entered, causing a loud and inappropriate verbal altercation. The resident reported feeling threatened and fearful, experiencing emotional distress, and an exacerbation of her anxiety following the incident. The resident, who was readmitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Major Depressive Disorder, and Anxiety Disorder, was not checked on by the staff after the incident. The LVN acknowledged not assessing the resident's emotional status or offering to move her to another room for safety. The Director of Nursing (DON) confirmed that the staff should have protected the resident from any form of abuse and assessed her for emotional distress, which was not done, violating the resident's rights as outlined in the facility's policy and procedure on resident rights.
Failure to Implement Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to implement its water management plan effectively, which is crucial for preventing the growth and spread of Legionella and other waterborne pathogens. The facility's policy, dated September 2022, outlined the need to identify areas in the water system where Legionella bacteria could grow and spread, and to take specific measures to control its introduction and spread. However, the facility did not conduct a comprehensive assessment to identify potential growth areas for Legionella. Testing conducted by an outside company in August 2023 revealed a sample from the kitchen sink had Legionella present, although at a non-detectable level. The Maintenance Supervisor admitted to not assessing or monitoring for Legionella, only checking water temperatures, and was unaware of the regulation requiring such assessments. Additionally, during an observation, it was noted that the facility's laundry room had wet, stained, and warped floor tiles due to a leaking pipe under a washing machine. The Account Manager confirmed the leak and stated that staff mopped the floor several times per shift to prevent standing water. The Maintenance Supervisor was unaware of the leak and did not routinely flush or clean drains and pipes to minimize standing water. The facility had previously received a positive Legionella test result from the kitchen's three-compartment sink, which led to the replacement of the sink and faucet after a subsequent negative test.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that six residents out of a sample of 36 were informed and provided with written information to formulate an advance directive upon admission. This deficiency was identified through a review of electronic medical records (EMR), which showed no evidence that the facility offered information or assistance related to advance directives to these residents or their families. The residents involved were admitted at various times, and the lack of documentation spanned several years, indicating a systemic issue in the facility's admission process. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed discrepancies in the facility's process for handling advance directives. The SSD stated that her role was to assess and identify if a resident had an advance healthcare directive, while the DON indicated that the Admission Nurse was responsible for collecting advance directives and offering assistance if needed. The facility's policy, dated September 2023, requires that residents or their representatives be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive, which was not adhered to in these cases.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of facility-initiated transfers to residents, their representatives, and the Ombudsman for five out of six sampled residents. This deficiency was identified during a review of the facility's policy and interviews with staff. The policy required that notices of transfer be provided in a form and manner that residents could understand, taking into account their educational level, language, communication barriers, and physical or mental impairments. However, the facility did not adhere to this policy, as evidenced by the lack of written notices for the transfers of several residents. One resident, who had a Power of Attorney on file, was transferred to the hospital without the responsible party being provided a copy of the transfer notice. Another resident, who was his own responsible person, experienced a change in mental status and was transferred to the hospital from a dialysis center without receiving a written notice of the transfer. Similarly, another resident was transferred to the hospital following a fall, and the facility failed to provide a written notice of the transfer to the resident. Interviews with facility staff revealed a lack of awareness regarding the requirement to provide written notifications of transfers. The Director of Nurses stated that nurses only filled out transfer/discharge notification forms if the resident was sent out directly from the facility, and the Administrator confirmed that the facility did not provide written Transfer/Discharge Notices. This lack of compliance with notification requirements was consistent across multiple cases, indicating a systemic issue within the facility's transfer and discharge processes.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for four residents out of a sample of 36. The facility's policy mandates that written information regarding bed hold policies be provided to residents or their representatives both in advance of any transfer and at the time of transfer. However, the facility did not adhere to this policy, as evidenced by the lack of written notices in the cases reviewed. For Resident R96, the facility's electronic medical record indicated a discharge to a hospital, but the bed hold section of the transfer notice did not include reserve bed payment information. Interviews with the resident and staff revealed that the resident did not receive the required paperwork, and the Director of Nursing was unaware of the need to include reserve bed payment information. Similarly, for Resident R130, who experienced a change in mental status and was transferred to a hospital, there was no indication that a written bed hold notice was provided. Resident R148 was transferred to a hospital following a fall, and the transfer notice did not include a written bed hold notice. The facility administrator confirmed that written notices were not provided. Resident R2 was transferred twice to a hospital, and in both instances, the bed hold section of the transfer notice did not indicate that a written notice was provided. Interviews with medical records staff confirmed that only verbal notices were given to the resident's representative, not written ones.
Deficiency in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that accurately reflected the residents' current status, specifically regarding their code status and sex offender registry status. This deficiency was identified for 10 residents out of a sample of 38. The care plans did not include the residents' right to refuse treatment, such as Do Not Resuscitate (DNR) orders, or their status on the sex offender registry. This oversight had the potential to leave staff uninformed about critical aspects of residents' care needs and histories. For several residents, including those with diagnoses such as type 2 diabetes, heart failure, dementia, and multiple sclerosis, the care plans did not address their code status, whether Full Code or DNR. Interviews with the Director of Nursing (DON) and other staff revealed that the omission of code status from care plans was a known issue, and it was not addressed until prompted by the survey team. The DON acknowledged that code statuses were added to care plans only after the survey team requested them. Additionally, the facility failed to document the sex offender status of two residents in their care plans. One resident, who was cognitively intact, had a history of offenses, but this information was not included in his care plan. Another resident was identified as a registered sex offender by the police, but the Social Services Director did not feel it was necessary to include this information in the care plan. These omissions indicate a lack of comprehensive documentation and communication regarding residents' critical care needs and legal statuses.
Deficiency in Room Space Requirements
Penalty
Summary
The facility failed to provide and maintain the required minimum square footage per resident in 32 out of 73 rooms. Specifically, multiple rooms were observed to have less than the required 80 square feet per resident in shared rooms and 100 square feet in single rooms. The rooms in question included Rooms 16 through 50, with various measurements indicating insufficient space for the number of beds present. For instance, Rooms 20 through 32 and others measured 143.75 square feet with two beds, while Rooms 39 through 50 measured 212.75 square feet with three beds, all falling short of the required space per resident. During an observation, it was noted that each room contained essential furniture and amenities such as a bed, bedside table, closet/storage space, overbed table, lighting, call bell, bathroom, and privacy curtains, with space for ambulation and wheelchair access. However, the Administrator acknowledged that a room waiver for multiple rooms had expired, and it was typically renewed upon receiving a deficiency, followed by submitting a plan of correction requesting a waiver. This situation indicates a lapse in maintaining compliance with space requirements, potentially affecting residents' privacy and space adequacy.
Lack of Dialysis Contract for Residents with ESRD
Penalty
Summary
The facility failed to ensure there was a dialysis contract for two residents, R44 and R87, who were receiving dialysis treatments. This deficiency was identified during a review of the facility's policy titled 'End-Stage Renal Disease, Care of a Resident with,' which mandates agreements between the facility and the contracted ESRD facility to manage the resident's care. Despite this policy, the facility did not have a contract in place with the dialysis center where these residents received their treatments. Resident R44 was readmitted with a diagnosis of end-stage renal disease and had physician orders for dialysis at American Renal Associates on specific days. Similarly, Resident R87, who also had end-stage renal disease, had a care plan indicating the need for hemodialysis out of the facility. However, during an interview, the Administrator confirmed the absence of a dialysis contract for the dialysis center used by both residents, highlighting a gap in the facility's compliance with its own policy and potentially affecting the residents' overall care.
Failure to Provide Appropriate Care for Resident with CHF and Edema
Penalty
Summary
The facility failed to ensure that a resident with congestive heart failure (CHF) and other significant medical conditions received appropriate treatment and care according to professional standards of practice. The nursing staff did not act on the deterioration of the resident's physical condition, which included significant weight gain and edema. Despite the resident's critical medical needs, the facility's interdisciplinary team (IDT) did not collaborate effectively to address these issues, leading to the resident's transfer to the emergency department and subsequent admission to an acute care hospital for a right foot infection and sepsis, which contributed to the resident's death. The resident was admitted to the facility with diagnoses including CHF, severe protein-calorie malnutrition, iron deficiency anemia, and atrial fibrillation. Over a period of time, the resident experienced a weight gain of six pounds, which was significant given her underweight status and CHF diagnosis. The nursing staff failed to monitor and document this weight gain adequately, and there was no evidence that the physician was notified of this change. Additionally, the resident developed edema in her lower extremities, which was not properly managed or documented, leading to the development of blisters and a subsequent infection. Interviews with facility staff revealed that the resident's care plans were not personalized or updated to reflect her changing condition. The care plans lacked specific interventions to manage the resident's edema and weight gain, and there was a failure to implement physician orders such as the application of TED hose. The facility's IDT did not meet to discuss the resident's significant weight gain and edema, and there was a lack of communication and coordination among the care team. This lack of proper care and oversight ultimately led to the resident's deterioration and death from complications related to her untreated conditions.
Failure to Notify Physicians and Implement Timely Interventions
Penalty
Summary
The facility failed to ensure licensed nurses immediately consulted with residents' physicians during significant changes in residents' physical status. For Resident 1, licensed nurses did not notify the physician after the resident experienced a severe unplanned weight loss of 18 pounds or 9.8% in 28 days. Despite weekly weight documentation showing a rapid decline, the physician was not informed, and an Interdisciplinary Team (IDT) meeting was not conducted to discuss the change in condition. The Registered Dietitian's (RD) orders to fortify Resident 1's diet were delayed by six days, and the responsible party (RP) was not notified in accordance with the signed Power of Attorney (POA). These failures contributed to Resident 1 being found unresponsive and requiring an ambulance transport to a higher level of care, where they were treated for high levels of ammonia in the blood and hepatic encephalopathy. For Resident 2, the facility failed to ensure timely physician notification after the resident had blood in the urine. The licensed nurses did not promptly notify the physician to provide prompt urinary tract infection (UTI) treatment, resulting in a delay in collecting the urine sample. The urine sample was not collected until five days later, and the resident received the first dose of antibiotics eleven days after the initial observation of blood in the urine. This delay in treatment prolonged the resident's discomfort and the start of necessary medical intervention. The deficiencies in both cases highlight a failure to follow established protocols for notifying physicians and responsible parties about significant changes in residents' conditions. The lack of timely communication and intervention contributed to delays in necessary medical treatments and potentially worsened the residents' health outcomes. The facility's policies and procedures for weight assessment, change in condition, and advance directives were not adequately followed, leading to these critical lapses in care.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure a baseline resident-centered care plan was developed and implemented for two residents within 48 hours of admission. Resident 3, who was admitted with chronic obstructive pulmonary disease (COPD) and end stage renal disease (ESRD), did not have a care plan for COPD until after being discharged from the facility. Additionally, there was no care plan for ESRD and dialysis until after discharge. Licensed Vocational Nurse (LVN) 2 confirmed that care plans should have been developed upon admission, but this was not done. The Assistant Director of Nursing (ADON) also confirmed that the facility's policy required a baseline care plan to be developed within 48 hours of admission, which was not followed in this case. Similarly, Resident 4, who was admitted with COPD, did not have a care plan developed until the onsite investigation. The ADON confirmed that a care plan should have been developed within 48 hours of admission, as per the facility's policy. The lack of timely care plans for these residents placed them at risk for complications, as their immediate health and safety needs were not adequately planned for by licensed nurses. The facility's failure to adhere to its own policy and procedure for developing baseline care plans within the required timeframe was evident in these cases.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two residents diagnosed with chronic obstructive pulmonary disease (COPD). For Resident 3, the physician's order specified oxygen administration at 4 liters per minute (LPM) via nasal cannula continuously. However, documentation revealed that the resident received only 3 LPM on multiple occasions, which was confirmed by Licensed Vocational Nurse (LVN) 2. LVN 2 acknowledged that the oxygen rate should have been set at 4 LPM as per the physician's order and that it is standard practice to follow medical orders to ensure residents receive the correct amount of oxygen. Similarly, Resident 4, who also had a diagnosis of COPD, was observed receiving oxygen at 3.5 LPM instead of the ordered 2 LPM. This discrepancy was confirmed by LVN 3 during an observation and record review. The Assistant Director of Nursing (ADON) reviewed the facility's policy and procedure on oxygen administration, which emphasized the importance of administering the correct oxygen flow as ordered by the physician. Both LVN 2 and LVN 3, as well as the ADON, confirmed that it is a professional standard of practice to follow physician orders precisely to ensure proper care for the residents.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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