Maywood Skilled Nursing & Wellness Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Maywood, California.
- Location
- 6025 Pine Ave, Maywood, California 90270
- CMS Provider Number
- 555130
- Inspections on file
- 33
- Latest survey
- December 26, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maywood Skilled Nursing & Wellness Centre during CMS and state inspections, most recent first.
The facility failed to adequately monitor and care for a resident with a long-term indwelling urinary catheter, leading to septic shock, and another resident with nephrostomy tubes, risking urinary tract infections. The staff did not follow care plans or physician orders, failing to document and communicate changes in the residents' conditions.
The facility failed to maintain appropriate food temperatures during lunch service, with quesadillas and lasagna found at 120°F and 126°F, below the required 140°F. The dietary staff placed these items away from the stove due to space constraints, leading to inadequate temperatures. The Dietary Supervisor confirmed these temperatures were unacceptable, potentially affecting 112 residents' food intake and posing a risk of unplanned weight loss.
The facility failed to maintain safe food temperatures, with quesadillas and lasagna measuring below the required 140°F. This deficiency affected 112 of 115 medically compromised residents, posing a risk of bacteria growth and foodborne illness. The issue arose due to inadequate space on the stove and steam table, leading to improper food storage.
The facility was found to have improper garbage storage practices, as two trash dumpster lids were not closed completely. This was observed during a survey and confirmed by the Dietary Supervisor and Infection Preventionist Nurse, who both stated that the lids should be closed to prevent flies and maintain infection control. The facility's Administrator acknowledged the lack of a specific policy requiring the lids to be closed, despite existing guidelines for covered food waste disposal.
The facility failed to report abuse allegations involving two residents to the State Agency, ombudsman, and police. One resident reported hurtful comments by a CNA, while another alleged inappropriate touching during care. Despite internal reporting, external agencies were not notified, delaying investigation and potentially exposing other residents to abuse.
Two residents reported abuse by a CNA, but the facility failed to conduct thorough investigations or suspend the CNA, leaving other residents at risk. Despite reports of hurtful comments and inappropriate touching, the facility only reassigned the CNA without further action, violating its abuse reporting policy.
The facility failed to respect the rights and dignity of two residents. One resident did not have a public guardian or IDT meeting to facilitate care, resulting in medical treatments without consent. Another resident's nephrostomy bags were not covered with a dignity bag, contrary to facility policy. These actions demonstrate a lack of adherence to policies ensuring resident rights and dignity.
A facility failed to obtain updated informed consents for psychotropic medications for a resident unable to make medical decisions. Despite severe cognitive impairment, the resident was administered Haloperidol, Buspirone Hydrochloride, and Sertraline Hydrochloride without consent from a responsible party or public guardian, nor was an IDT convened. The facility's policy required surrogate decision-making, which was not followed, as confirmed by an LVN.
A resident with aphasia in an LTC facility was not provided with a communication device at her bedside, hindering her ability to communicate effectively. Despite having a care plan that included the use of a communication board, the resident relied on gestures and writing, which were not always understood by staff and visitors. The facility's policy to provide adaptive devices for communication was not followed.
Three residents were found on low air loss mattresses (LALM) set incorrectly for their weights, risking the worsening of pressure ulcers. A resident with a resolved Stage III ulcer was on a LALM set for 300 lbs instead of 170 lbs. Another resident with a surgical wound was on a LALM set for 200 lbs instead of 147.8 lbs. A third resident with a Stage II ulcer was on a LALM set for 550 lbs instead of 190.2 lbs. The facility's policy to ensure proper LALM settings was not followed.
A facility failed to check the gastrostomy tube (GT) placement and gastric residual volume (GRV) for a resident with severe cognitive impairment and multiple medical conditions. The care plan required checking these parameters every shift, but an LVN started the tube feeding without doing so, acknowledging the oversight. The DON highlighted the importance of these checks to prevent complications, as outlined in the facility's policy.
Two residents in the facility were found with unlabeled nebulizer masks, which lacked the resident's name and date of opening, posing an infection risk. Both residents had significant medical conditions, including COPD and dementia, and required assistance with daily activities. The facility's policy required masks to be changed and labeled every seven days, but this was not followed, as confirmed by staff interviews.
A resident with a history of UTI, sepsis, and diabetes reported feeling uncomfortable during a bed bath, alleging inappropriate touching by a CNA. Despite the resident's moderate cognitive impairment, he was capable of making decisions. The LVN reassigned the CNA but did not notify the physician, contrary to facility policy. The RN and DON acknowledged the physician should have been informed to assess and implement necessary interventions.
The facility failed to create care plans for two residents after allegations of inappropriate behavior by a CNA. One resident reported hurtful comments affecting her emotional state, while another alleged inappropriate touching during a bed bath. Despite investigations and reassignment of the CNA, care plans were not developed, contrary to facility policy.
A resident with dementia and known behavioral issues, including biting and elopement risk, did not have a comprehensive care plan in place. This led to an incident where the resident wandered into another resident's room, resulting in an altercation. The facility's policies on care planning and risk management were not followed.
A resident with dementia and behavioral issues was inadequately supervised, leading to an altercation with another resident. Despite care plans requiring frequent checks, staff were too busy to monitor the resident every 15 minutes, allowing them to wander into another resident's room and cause an incident.
Inadequate Monitoring and Care of Urinary Catheters and Nephrostomy Tubes
Penalty
Summary
The facility failed to provide adequate care for a resident with a long-term indwelling urinary catheter, leading to the development of septic shock. The resident's urinary drainage was not monitored for sediment, abnormal color, or foul odor for six months, as required by the facility's policies and the resident's care plan. Despite a urine analysis indicating a urinary tract infection, a urine culture was not performed, delaying the identification and treatment of the infection. This oversight resulted in the resident being admitted to the intensive care unit with septic shock secondary to a urinary tract infection. Another resident with nephrostomy tubes also received inadequate care, as the nephrostomy bags were not positioned to gravity, and sediment in the tubing was not documented or reported to the physician. The nursing staff failed to monitor the nephrostomy bags for signs of infection, as required by the resident's care plan and physician orders. This lack of monitoring and documentation had the potential to cause avoidable urinary tract infections and delay treatment for the resident. Interviews with facility staff revealed a lack of adherence to care plans and physician orders, as well as a failure to document and communicate changes in the residents' conditions. The Director of Nursing acknowledged the importance of monitoring urine output and nephrostomy care to prevent infections and sepsis. The facility's policy on catheter care emphasized the need for regular assessment of urinary drainage and prompt notification of physicians in case of infection signs, which was not followed in these cases.
Inadequate Food Temperature Management
Penalty
Summary
The facility failed to maintain appropriate food temperatures during lunch service, as observed on December 17, 2024. During the tray line service, quesadillas and lasagna were found to be at temperatures of 120°F and 126°F, respectively, which are below the facility's required temperature of greater than 140°F for hot foods. The dietary staff placed these food items on a shelf away from the stove and steam table due to a lack of space, leading to the inadequate temperatures. The Dietary Supervisor confirmed that these temperatures were unacceptable and acknowledged that the food would not be palatable for residents, potentially affecting their food intake. The facility's Policy and Procedure on food temperatures, revised on July 1, 2024, was reviewed and indicated that hot food should be maintained above 140°F. However, there was no policy addressing food palatability or menu planning, which the Dietary Supervisor noted should be in place if there were concerns. The deficient practice had the potential to affect 112 of 115 residents who received food from the kitchen, posing a risk of unplanned weight loss due to poor food intake.
Deficient Food Temperature Control in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. Specifically, the temperatures of quesadillas and lasagna were found to be below the required safe temperature of 140 degrees Fahrenheit. The quesadillas measured 120 degrees Fahrenheit, and the lasagna measured 126 degrees Fahrenheit. These food items were placed on a shelf away from the stove and steam table due to a lack of space, which contributed to the inadequate temperatures. The dietary staff, including Cook 1, acknowledged the temperature readings and the Dietary Supervisor confirmed that these temperatures were unacceptable according to the facility's policy. The deficiency had the potential to affect 112 of 115 medically compromised residents who received food from the kitchen. The Infection Preventionist Nurse indicated that hot food below 140 degrees Fahrenheit could lead to bacteria growth, potentially causing foodborne illness. The quesadillas were intended for residents on regular and mechanical soft diets, while the lasagna was for those on a liquid diet. The failure to maintain appropriate food temperatures posed a risk of cross-contamination and foodborne illness among the residents.
Improper Garbage Storage Practices
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary manner, as observed during a survey. Two trash dumpster lids were not closed completely, which was confirmed during an observation and interview with the Dietary Supervisor (DS). The DS acknowledged that the lids should be closed to prevent flies, which can transport bacteria and potentially cause illness among residents. The Infection Preventionist Nurse (IPN) also confirmed that the lids should be closed for infection control purposes. The facility's Administrator (ADM) admitted that there was no existing policy requiring the lids to be closed, although the facility's policy on garbage and trash can use indicated that food waste should be placed in covered containers.
Failure to Report Abuse Allegations to Authorities
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the appropriate authorities, including the State Agency, ombudsman, and police department. Resident 88, who had a history of urinary tract infection, type two diabetes mellitus, and major depressive disorder, was reported by her Responsible Party to have been subjected to hurtful comments by a Certified Nursing Assistant (CNA). Despite the report, the Registered Nurse (RN) involved did not notify the external agencies, believing that informing the Director of Nursing (DON) was sufficient. The Director of Staff Development (DSD) confirmed that the CNA had not been assigned to Resident 88 for over a month, but the lack of external reporting delayed further investigation. In a separate incident, Resident 259, who had diagnoses including urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable with the care provided by the same CNA during a bed bath. The resident alleged inappropriate touching, which was communicated to a Licensed Vocational Nurse (LVN) and the DSD. Although the CNA assignment was changed to ensure the resident's comfort, the allegations were not reported to the necessary external agencies. The LVN assumed that reporting to the DSD would suffice, but the DSD acknowledged that the allegations should have been reported due to the nature of the claims. Interviews with facility staff, including the DON and Administrator, revealed a misunderstanding of the reporting responsibilities. The facility's policy required that all abuse allegations, regardless of perceived validity, be reported to the Administrator and external agencies within two hours. The failure to adhere to this policy resulted in a delay of an onsite inspection by the State Agency and potentially exposed other residents to ongoing abuse.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, which led to a deficiency in protecting residents from potential abuse. Resident 88, who had a history of urinary tract infection, type two diabetes mellitus, and major depressive disorder, was reported by her Responsible Party to have been subjected to hurtful comments by a Certified Nursing Assistant (CNA 2). Despite the report, the facility did not conduct a thorough investigation, as CNA 2 was not suspended, and no further actions were taken after confirming that CNA 2 had not been assigned to Resident 88 for over a month. In another incident, Resident 259, who had diagnoses including urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable during a bed bath provided by CNA 2. The resident alleged inappropriate touching, which was reported to a Licensed Vocational Nurse (LVN 3) and the Director of Staff Development (DSD). However, the facility only changed the CNA assignment without conducting a thorough investigation or suspending CNA 2, which left other residents potentially vulnerable to similar incidents. The Director of Nursing (DON) and the Administrator (ADM) acknowledged that the facility's policy required immediate reporting and suspension of the alleged perpetrator pending investigation, but these steps were not followed. The facility's failure to adhere to its policy and procedure for abuse reporting and investigation resulted in a lack of protection for residents and a deficiency in addressing the allegations appropriately.
Failure to Ensure Resident Rights and Dignity
Penalty
Summary
The facility failed to respect the rights and provide dignity to two residents, Resident 75 and Resident 95. For Resident 75, the facility did not obtain a public guardian or conduct an interdisciplinary team (IDT) meeting to facilitate the care and medical treatments. Resident 75 was admitted with diagnoses including schizophrenia disorder, depressive disorder, and anxiety, and was found to have severely impaired cognitive skills for daily decision-making. Despite this, there was no documentation indicating efforts to find a surrogate decision-maker or apply for public guardianship, resulting in medical treatments and antipsychotics being administered without consent from an appointed decision-maker. For Resident 95, the facility failed to follow its policy and procedure regarding catheter care by not providing a dignity bag for the resident's nephrostomy bags. Resident 95, who had chronic kidney disease and other related conditions, was observed with nephrostomy bags lying uncovered on the bed, which was against the facility's policy. The Licensed Vocational Nurse (LVN) acknowledged the inappropriate handling of the nephrostomy bags and the lack of documentation regarding any refusal of a dignity bag by Resident 95. The Treatment Nurse (TN) later provided education to Resident 95 about the importance of using dignity bags, but initially, there was no documentation or care plan addressing the issue. These deficiencies highlight the facility's failure to ensure the rights and dignity of its residents, as evidenced by the lack of appropriate decision-making support for Resident 75 and the failure to maintain dignity for Resident 95 by not covering the nephrostomy bags. The facility's policies and procedures were not adequately followed, leading to these oversights in resident care.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain updated informed consents for the administration of psychotropic medications to Resident 75, who was unable to make medical decisions. Resident 75 was admitted with diagnoses including schizophrenia, depressive disorder, and anxiety, and was assessed as having severely impaired cognitive skills for daily decision-making. Despite this, the facility administered Haloperidol, Buspirone Hydrochloride, and Sertraline Hydrochloride to Resident 75 without obtaining consent from a responsible party or public guardian, nor did they convene an interdisciplinary team to make medical decisions on behalf of the resident. The facility's policy required that if a resident lacked capacity to provide informed consent, a surrogate decision-maker should be involved, or an interdisciplinary team should be convened if no surrogate was available. However, the facility did not follow this policy, as evidenced by the lack of documentation for obtaining consent from a responsible party or public guardian. This oversight was confirmed during an interview with LVN 4, who acknowledged the importance of obtaining informed consent and the facility's failure to act promptly in securing a public guardian or conducting an IDT meeting for Resident 75.
Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication device at the bedside for a resident with aphasia, which hindered the resident's ability to communicate effectively. The resident, who had multiple diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, schizophrenia, paraplegia, dysphasia, and aphasia, was observed without a communication board or device in her room. Despite being alert and oriented, the resident was unable to orally communicate and relied on gestures and writing to express her needs. However, her handwriting was not legible, and not all staff and visitors were aware of her communication methods. The resident's care plan, which aimed to improve her communication abilities, included interventions such as allowing time to talk, using a communication board, and providing a pencil and paper. However, these interventions were not fully implemented, as evidenced by the absence of a communication board at the resident's bedside. Interviews with staff revealed that not everyone was aware of the resident's communication methods, and there was a lack of signage to inform visitors. The facility's policy required staff to provide adaptive devices to enable effective communication, but this was not adhered to in the resident's case.
Failure to Properly Set Low Air Loss Mattresses for Residents
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the formation and worsening of pressure ulcers for three residents. Resident 15 was observed lying on a low air loss mattress (LALM) set for a weight of 300 pounds, despite weighing 170 pounds. The resident had a history of chronic obstructive pulmonary disease, generalized muscle weakness, a resolved Stage III pressure ulcer, and schizophrenia. The care plan for Resident 15 indicated the use of a LALM for skin maintenance and wound management, with orders to monitor the settings every shift. However, the LALM was not set correctly, potentially compromising the resident's skin integrity. Resident 94 was also found lying on a LALM set for 200 pounds, while the resident's actual weight was 147.8 pounds. The resident had diagnoses of COPD, malnutrition, generalized muscle weakness, diabetes mellitus, and anemia, with a significant surgical wound on the lower back extending to the buttocks and thighs. The resident's care plan included the use of a LALM for wound management, with instructions to verify its functioning every shift. The incorrect setting of the LALM could have affected the healing of the surgical wound and increased the risk of pressure injuries. Similarly, Resident 36 was observed on a LALM set for 550 pounds, although the resident weighed 190.2 pounds. The resident had a Stage II pressure ulcer, generalized muscle weakness, COPD, and obesity. The care plan required the use of a pressure-reducing device for the bed and chair, with orders to check the LALM settings every shift. The incorrect LALM setting could delay the healing process of the existing pressure ulcer. The facility's policy required staff to ensure the air mattress was inflating properly and to check it routinely, which was not adhered to in these cases.
Failure to Verify GT Placement and Residuals for a Resident
Penalty
Summary
The facility failed to properly check the gastrostomy tube (GT) placement and gastric residual volume (GRV) for Resident 12, who was dependent on tube feeding due to dysphagia and other medical conditions. Resident 12's medical history included type 2 diabetes mellitus, chronic kidney disease, dysphagia, Alzheimer's disease, and dementia, with severely impaired cognition and a lack of capacity to make decisions. The care plan for Resident 12 required checking the GT placement and GRV every shift, with specific instructions to hold feeding if the residual was above 100 ml. During an observation, Licensed Vocational Nurse (LVN) 5 was seen connecting and starting Resident 12's tube feeding without checking the residuals or GT placement, contrary to the care plan and facility policy. LVN 5 acknowledged the oversight and the importance of checking these parameters to ensure proper digestion and prevent complications. The Director of Nursing (DON) also emphasized the necessity of verifying GT placement to avoid potential issues such as peritonitis. The facility's policy outlined specific steps for verifying GT placement, which were not followed in this instance.
Unlabeled Nebulizer Masks Pose Infection Risk
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, Resident 52 and Resident 310, as observed during a survey. In both cases, the nebulizer masks used by the residents were found to be unlabeled, lacking the resident's name and the date of opening. This oversight was noted during observations conducted on December 16, 2024, at different times in the residents' rooms. The absence of labeling on the nebulizer masks posed a risk of infection, as it was unclear when the masks were last changed or to whom they belonged. Resident 52, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, generalized muscle weakness, schizophrenia, and dementia, was observed to have an unlabeled nebulizer mask at their bedside. The resident's medical records indicated that they required supervision and partial assistance with various activities of daily living. The order summary report for Resident 52 included an order for albuterol sulfate via nebulizer, highlighting the importance of proper labeling and infection control practices. Similarly, Resident 310, who also had diagnoses of COPD, generalized muscle weakness, schizophrenia, and dementia, was found with an unlabeled nebulizer mask. The resident's medical records showed severe cognitive impairment and a need for assistance with daily activities. The facility's policy and procedure for oxygen therapy, which was also applied to nebulizer masks, required that masks be changed every seven days and labeled with the resident's name and date. The failure to adhere to these procedures was confirmed through interviews with the Licensed Vocational Nurse and the Infection Preventionist Nurse, who acknowledged the potential for infection due to the lack of labeling.
Failure to Notify Physician of Abuse Allegation
Penalty
Summary
The facility failed to notify the physician of an abuse allegation made by a resident, identified as Resident 259, against a Certified Nursing Assistant (CNA). Resident 259, who had a history of urinary tract infection, sepsis, and type two diabetes mellitus, reported feeling uncomfortable during a bed bath when CNA 2 allegedly touched him inappropriately. Despite Resident 259's moderate cognitive impairment, he was deemed capable of understanding and making decisions. The incident was reported to a Licensed Vocational Nurse (LVN), who reassigned the CNA but did not notify the physician, believing the issue was resolved. The Registered Nurse (RN) and Director of Nursing (DON) both stated that the physician should have been informed of the abuse allegation to assess and implement necessary interventions for Resident 259. The facility's policy required immediate notification of the attending physician upon receiving allegations of sexual abuse. The failure to notify the physician resulted in a delay in any necessary care for Resident 259, as the physician was unaware of the situation and could not determine if further assessments or interventions were needed.
Failure to Develop Care Plans for Abuse Allegations
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, Resident 88 and Resident 259, after allegations of inappropriate behavior by a Certified Nursing Assistant (CNA 2). For Resident 88, the Responsible Party (RP 1) reported to a Registered Nurse (RN 1) that CNA 2 had said hurtful things to the resident, which affected her emotional state and eating habits. Despite an investigation confirming that CNA 2 had not been assigned to Resident 88 for over a month, no care plan was developed to address the resident's psychosocial needs or to monitor for any further issues. Resident 259 reported feeling uncomfortable during a bed bath given by CNA 2, alleging inappropriate touching. A Licensed Vocational Nurse (LVN 3) reassigned CNA 2 to another resident and did not develop a care plan, believing it was unnecessary since the issue was resolved by the reassignment. However, the Director of Nursing (DON) stated that a care plan should have been developed for any abuse allegation to outline the necessary care based on the specific incident. The facility's policy on Comprehensive Person-Centered Care Planning, revised in August 2023, requires updates to the care plan based on assessed needs. The failure to develop care plans for these incidents indicates a deficiency in adhering to this policy, potentially impacting the residents' physical, mental, and psychosocial well-being.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with known behavioral issues and risk factors. Specifically, the facility did not create a care plan for a resident's known behavior of biting and did not timely implement a care plan for the resident's risk of elopement. This oversight resulted in an incident where the resident wandered into another resident's room, leading to an altercation where the resident hit, attempted to bite, and threw water on the other resident. The resident involved in the incident had a history of dementia, anxiety, and mobility issues, with severely impaired cognitive skills as noted in their Minimum Data Set (MDS). Despite being monitored for biting and identified as an elopement risk, the necessary care plans were not in place. The facility's policies required comprehensive person-centered care planning and specific measures for wandering and elopement risks, which were not adhered to in this case.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to adequately monitor a resident with a known history of wandering, aggression, and other behavioral issues, leading to an incident involving another resident. Resident 1, who has dementia, anxiety, and mobility issues, was not properly supervised despite care plans indicating the need for frequent visual checks and one-to-one supervision. This lack of supervision allowed Resident 1 to wander into Resident 2's room, resulting in an altercation where Resident 1 hit Resident 2, attempted to bite them, and threw water at them. Interviews with staff revealed that Resident 1 was known to enter other residents' rooms and take items, and that staff were often too busy to monitor Resident 1 every 15 minutes as required. The facility's policy required resident checks every two hours, but Resident 1's care plan necessitated more frequent monitoring due to their behavioral risks. The failure to adhere to these monitoring requirements led to the altercation between the two residents, highlighting a deficiency in the facility's supervision and safety protocols.
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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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