Mesa Glen Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendora, California.
- Location
- 638 E Colorado Avenue, Glendora, California 91740
- CMS Provider Number
- 555854
- Inspections on file
- 79
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Mesa Glen Care Center during CMS and state inspections, most recent first.
Surveyors found that hot foods served during meal service were not maintained at or above the required 140°F, with test tray measurements showing pasta and turkey at 105°F and green beans between 110°F and 120°F. The Dietary Supervisor acknowledged ongoing problems with a malfunctioning plate warmer that may have contributed to inadequate food temperatures, especially during morning meals, and explained that staff reheat food for about 15 seconds to reach approximately 160°F upon resident request. Facility policy requires that hot TCS foods be maintained above 140°F during trayline service, and the deficient practice was noted as having the potential to cause rapid bacterial growth leading to foodborne illness and insufficient intake with weight loss.
Two residents with physician orders and care plans for continuous 1:1 supervision were not provided the required level of monitoring. One resident had hemiplegia, contractures, high fall risk, and needed maximal assistance with ADLs, while the other had dementia, Alzheimer’s disease, anxiety, impaired cognition, and a history of aggression, exit-seeking, and unprovoked agitation. Despite orders specifying that each resident receive their own 1:1 sitter and not be left unattended, the facility scheduled a single sitter to cover both residents, requiring the sitter to move back and forth between rooms and leaving each resident alone at times. Staff interviews, including from an LVN, CNAs, an RN supervisor, the DON, and the administrator, confirmed that 1:1 meant continuous, dedicated supervision and that residents should not be left alone, yet observations showed the sitter leaving each resident unattended while checking on the other.
A resident with hemiplegia, hemiparesis, contractures, and high fall risk was found with the bed placed against a wall on one side and a Geri chair wedged tightly against the other side, creating a barrier that restricted the resident from getting out of bed. The care plan called for 1:1 supervision due to confusion and prior unassisted bed-exit attempts, but there was no physician order for Geri chair use. A sitter reported the DON had permitted the Geri chair placement, and an LVN stated it was intentionally used as a restraint to prevent the resident from rising, with the Administrator and DON aware. Facility staff, including an RN supervisor, later acknowledged this setup constituted a restraint and conflicted with facility policies that limit restraint use to treatment of medical symptoms and prohibit use for staff convenience or fall prevention.
A resident with paranoid schizophrenia, severely impaired cognition, and a documented history of aggressive behavior, including prior attempts to hit others and a hospital transfer for aggression, was care planned with vague, non–behavior-specific interventions after psychiatric hospitalization. Another resident with pneumonia, anxiety disorder, and moderately impaired cognition, who required substantial/maximal assistance with ADLs and mobility, was seated in a lobby area when the aggressive resident approached in a wheelchair and struck the resident on the back of the head, causing significant head pain and emotional distress. An RN at the nearby nursing station heard a cry of pain, separated the residents, and observed the aggressive resident making a fist-like motion. Both the RN and the DON acknowledged that residents with known aggressive histories require individualized, specific, and measurable behavioral interventions, and that the lack of such detailed guidance left staff without clear direction to prevent escalation, resulting in this incident of physical abuse in violation of the facility’s abuse prevention and resident rights policies.
A resident with paranoid schizophrenia and severely impaired cognition had repeated episodes of aggression, including attempting to hit others and requiring hospital transfer and a 5150 hold. After readmission, the facility opened a behavior care plan but did not individualize it, omitting monitoring parameters, behavioral triggers, and clear staff guidance on approach and redirection. Although the care plan problem was initiated, specific interventions were not implemented for several weeks, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
The facility failed to post current daily nurse staffing information in a prominent area accessible to residents, staff, and visitors. Surveyors observed outdated "Census and Direct Service Hours Per Patient Day" postings near a nursing station on multiple days, with dates that did not reflect the current day. The DON acknowledged the postings were not current and stated they should be updated daily. A CNA reported being responsible for entering RN, LPN, LVN, and CNA hours into a computer program to generate the daily staffing printout but was unable to report on time due to personal circumstances. The CNA also stated that projected staffing hours had been prepared and left for weekend nurses to post near two nursing stations. Review of facility policy confirmed that licensed nurse and CNA staffing numbers must be posted within two hours of each shift’s start, which did not occur as required.
A resident with multiple chronic conditions and intact cognition exhibited ongoing hoarding behavior, resulting in significant clutter and safety hazards in their room. Despite initial interventions and education, the resident refused assistance, and the care plan was not updated or revised to address the continued issues, leading to a deficiency in maintaining a safe and clean environment.
A resident's room was found to be excessively cluttered with boxes, clothing, and personal items, creating accident hazards and leaving the call light out of reach. Despite the resident's need for assistance with daily activities and documented refusals of cleaning, staff did not effectively implement care plan interventions or maintain a safe environment as required by facility policy.
Surveyors observed that an expired water filter was connected to the icemaker in the kitchen, and the Dietary Manager was unsure of the replacement schedule. The maintenance log lacked a clear date, and the manufacturer's guidelines for annual replacement were not followed, resulting in unsanitary ice and water handling practices.
A resident with multiple medical conditions, including ESRD and diabetes, experienced a fall and fracture after attempting to rise from a rollator walker without a care plan in place for its use. The facility did not develop or implement a care plan addressing the resident's specific needs for the assistive device, and there was a lack of communication between therapy and nursing staff regarding recommendations and safety instructions, contrary to facility policy.
A resident with a history of elopement, seizures, and depression exited the facility without staff knowledge or supervision. Despite being assessed as cognitively intact but at risk for wandering, the resident was last seen in bed and later could not be found, leading to a facility-wide search. Staff interviews confirmed the resident was ambulatory and frequently walked the facility, but no prior signs of intent to leave were noted. The facility's policy required targeted interventions and supervision, which were not effectively implemented, resulting in the resident's unsupervised exit.
Staff did not promptly respond to call lights and toileting requests for three residents, including individuals with dementia, incontinence, and mobility deficits. Delays of up to several hours were reported and observed, leading to residents feeling ignored and frustrated. Facility policy and the DON both indicated that prompt response is necessary to maintain resident dignity, but this standard was not met.
A resident with severe cognitive impairment was readmitted with orders for multiple psychotropic medications, but the facility failed to verify or obtain informed consent from the resident's representative as required. Medication changes made during a recent hospital stay were continued without proper notification or consent, and documentation inaccurately indicated that consent had been obtained. This resulted in the resident receiving psychotropic medications without the necessary informed consent process.
A resident with severe cognitive and psychiatric impairments was subjected to physical abuse when an RN deliberately threw juice in the resident's face and chest after the resident, during an agitated episode, threw juice at the RN and a CNA. The RN admitted to intentionally mirroring the resident's behavior, contrary to the resident's care plan and facility abuse prevention policies. The incident left the resident visibly distressed and was later reported to facility leadership.
A resident with severe cognitive impairment and behavioral issues was subjected to physical abuse when an RN threw juice at the resident after the resident threw juice at the RN. The incident was witnessed by a CNA, but was not reported to the Abuse Coordinator or Administrator within the required two-hour timeframe, as mandated by facility policy. The delay in reporting was confirmed through staff interviews and review of facility records.
Two residents were not treated with dignity when one was referred to as a "feeder" by an Activity Assistant and another was assisted with eating by a staff member standing over them, contrary to facility policy. Both residents had significant cognitive or physical impairments and required substantial staff assistance.
Three residents with cognitive impairments and fall risks were not adequately supervised, including one who was left unsupervised while the assigned sitter was distracted by a personal phone. Additionally, two residents who experienced multiple falls did not receive timely interdisciplinary team reviews as required by facility policy.
Nursing staff did not consistently administer medications on time or document administration immediately after giving each medication, as required by facility policy. This included missed and late doses for residents with complex medical conditions, and delayed documentation by nurses who cited workflow and technical issues.
Staff did not clean the doorknob and door of a resident room daily, leaving visible dirt and smudges for several days. The area was confirmed to be dirty by the infection preventionist, despite facility policy requiring regular cleaning of high-touch surfaces. The room was occupied by three residents with multiple medical conditions and varying care needs.
A resident with multiple medical conditions experienced a significant unintentional weight loss, but staff did not notify the physician as required by facility policy. Review of records and interviews with nursing staff and the DON confirmed that no Change in Condition Evaluation was created and the physician was not informed of the resident's weight loss.
A CNA was recorded by an LVN while sitting in a resident's room, and the video—showing the resident's personal property and views into other rooms—was posted to TikTok. This action violated facility policies and the resident's rights to privacy and confidentiality, as confirmed by interviews and policy review.
A resident with dementia and legal blindness was not provided a comprehensive admission assessment, resulting in delayed pain interventions for a red and swollen right hand and forearm. Staff failed to perform required vision and pain assessments, did not follow physician orders for immobilization, and inconsistencies were found in documentation regarding the resident's impairments and safety needs. The resident did not receive timely pain assessment or medication, and there was no documentation of activities or engagement by the activities director.
The facility did not provide necessary behavioral health care and services to residents who required them, resulting in unmet behavioral health needs.
A resident with severe cognitive impairment and a history of UTI was not monitored for vital signs every shift as required by the care plan. Instead, staff only checked vital signs weekly, resulting in a failure to promptly identify signs of infection. The resident developed severe symptoms and was transferred to a hospital, where UTI and sepsis were diagnosed. The DON confirmed that the care plan and facility policy were not followed.
A resident with a mood disorder and lacking capacity to make medical decisions was subjected to verbal and mental abuse by a CNA, who threatened the resident during a loud verbal exchange. The incident was witnessed by another staff member and substantiated through investigation, despite facility policies prohibiting such behavior.
A resident with severe cognitive impairment was administered Ativan without documented informed consent from their responsible party, despite facility policy requiring such consent for psychoactive medications when the resident lacks decision-making capacity.
A nurse administered cetirizine instead of the physician-ordered loratadine to a resident with multiple medical conditions, due to using the available house supply. The order for loratadine was not followed, and facility policy requiring verification of the correct medication was not adhered to, resulting in a medication error.
A resident with severe cognitive impairment and multiple psychiatric diagnoses received a PRN order for Ativan that was not limited to 14 days, as required by regulation and facility policy. The order lacked both an end date and documented rationale for extension, and this oversight was confirmed by the DON during record review.
A licensed nurse failed to perform hand hygiene before and after administering and preparing medications for two residents with complex medical conditions, contrary to facility policy and infection control standards. Interviews with the IPN and DON confirmed that hand hygiene is required at these times to prevent infection spread.
A resident with depression and hypertensive heart disease was not notified of incoming phone calls from a family member because the receptionist failed to relay messages or notify staff when the resident was not in the lobby. The family member reported missed communications, and the receptionist admitted to not always paging staff if unavailable. Facility policy required that residents be given telephone messages and have access to communication, but this was not followed, resulting in the resident missing important contact.
A resident with hypertensive heart disease did not have a care plan addressing this condition or the physician-ordered blood pressure monitoring for orthostatic hypotension. The care plan instead referenced unrelated diagnoses, and the DON confirmed it was not updated to include the necessary monitoring.
A resident with hypertensive heart disease and depression was not monitored for blood pressure as ordered by the physician, and there was no documentation of the required assessment in the MAR. Staff confirmed that the assigned nurse did not complete or document the blood pressure check, and the care plan did not address the monitoring requirement.
Nursing staff failed to demonstrate competency by not following physician orders for orthostatic BP monitoring for a resident with hypotension. The required assessment was not documented, and the care plan did not address the resident's diagnosis. Interviews confirmed that both an LVN and RNs did not fulfill documentation and care responsibilities as outlined in their job descriptions.
A resident with cognitive and psychiatric diagnoses was physically assaulted by their roommate, leading to a closed head injury and nasal bone fracture. Staff responded after hearing yelling and separated the residents, but the incident resulted in both residents sustaining injuries. The event highlights a failure to prevent abuse and ensure resident safety, particularly for those with known aggressive behaviors.
Two residents experienced preventable injuries due to staff failing to implement required supervision and safety interventions. One resident with cognitive impairment and behavioral issues was not monitored as ordered, resulting in self-inflicted injury and a subsequent altercation causing further harm. Another cognitively impaired, dependent resident was left unsupervised with a meal tray, leading to a fall. Staff interviews and documentation confirmed that care plans and physician orders for supervision were not followed.
The facility did not consistently provide or accurately document information regarding residents' rights to formulate Advance Directives and complete POLST forms. Several residents, including those with cognitive impairments and complex medical needs, had incomplete or missing AD Acknowledgement Forms, and in some cases, forms were signed by unauthorized individuals. Staff interviews confirmed these documentation lapses occurred during the admission process and were not in line with facility policy.
Three residents experienced deficiencies in their environment, including a missing personal wheelchair that was not reported, a broken toilet seat left unrepaired, and a patio door that could not be fully closed, allowing cold air into a resident's room. These issues were observed by staff and confirmed through interviews and record reviews, with facility policies not followed in each case.
The facility did not develop or implement individualized care plans for four residents with complex medical and psychological needs, including those with dementia, PTSD, and on anti-psychotropic medication. Staff were unaware of some diagnoses, and care plans were missing for significant events such as resident altercations and elopement attempts, contrary to facility policy and federal requirements.
Two residents did not receive care according to professional standards: one did not have their PICC and Midline catheters flushed as ordered, with multiple missed or undocumented treatments, and another did not receive required weekly skin assessments, with no documentation of ongoing monitoring despite having a sore. These failures were confirmed by staff interviews and record reviews.
Four residents did not receive proper interventions to prevent or heal pressure ulcers, including two residents whose low air loss mattresses were left on static mode instead of alternating pressure, one resident who did not have prescribed heel boots applied, and another whose mattress was set at an incorrect weight. Staff interviews and documentation reviews confirmed these failures, which were inconsistent with physician orders, manufacturer instructions, and facility policy.
Two residents did not receive appropriate pain management due to staff failing to communicate pain specialist recommendations to the MD and not notifying a physician when pain medications were ineffective. One resident with neuropathy pain did not have nonpharmacological interventions attempted as recommended, and another resident with multiple comorbidities experienced ongoing high pain levels without physician notification or adjustment of pain management. The DON confirmed these failures were not in line with facility policy.
Multiple residents with complex medical needs experienced significant delays in receiving assistance with personal care, toileting, and medical equipment due to insufficient nursing staff and inconsistent adherence to facility policies on care coverage and call light response. Staff interviews and resident council feedback confirmed that care was not always endorsed between CNAs during breaks, leading to prolonged wait times and unmet resident needs.
A resident with acute osteomyelitis and cellulitis did not receive prescribed IV antibiotics, Zosyn and Daptomycin, on multiple occasions as indicated by blank spaces in the IMAR. Staff confirmed that these blanks meant the medications were not administered, contrary to physician orders and facility policy requiring immediate documentation after administration.
Two residents were affected when the facility failed to ensure a PRN order for Ativan included a required 14-day end date and did not obtain signed informed consent for the use of Olanzapine and Lorazepam. One resident, who was cognitively intact, refused medication and reported not signing any consent, while records confirmed the absence of a supporting diagnosis and missing signatures. Staff interviews and policy review confirmed these actions did not meet regulatory requirements.
Surveyors observed that the facility exceeded the allowable medication error rate when a nurse prepared the wrong dose of acetaminophen for a resident with severe cognitive impairment and failed to check heart rate before administering Metoprolol and Amlodipine to another resident with cardiac conditions, contrary to physician orders and facility policy.
Two residents experienced significant medication errors when a nurse failed to check heart rate before administering antihypertensive medications as ordered, and intravenous antibiotics were not administered as prescribed on several occasions. These actions were confirmed by staff interviews and record reviews, showing noncompliance with physician orders and facility policy.
The facility did not provide required monthly in-service training to dietary staff, resulting in a staff member being unaware of proper dishwashing sanitization procedures and failing to check chlorine levels in the dishwashing machine. The Dietary Supervisor confirmed the lack of in-services, which was contrary to facility policy.
Surveyors found that food items were not properly dated upon receipt or opening, and some expired or unsanitary items were stored in the kitchen. Additionally, dishwashing procedures were not followed, with chlorine levels not checked or maintained within the required range, resulting in unsanitized dishes. These failures were confirmed by dietary staff and were not in accordance with facility policies.
The facility did not follow its infection prevention and control protocols after a CNA was diagnosed with scabies, failing to promptly notify the infection preventionist, initiate line listing, or conduct contact tracing and monitoring. Staff also did not use required PPE during high-contact care, did not post necessary signage or provide PPE for residents on Enhanced Barrier Precautions, left a nasal cannula on the floor during use, and inappropriately cohorted a resident on contact isolation with another resident who had an invasive device.
A resident with an indwelling catheter, who was dependent on staff for mobility and had multiple medical conditions, was observed without a privacy bag covering the catheter drainage bag. Staff interviews confirmed that the privacy bag was not in use, despite facility policy requiring catheter bags to be covered to maintain resident dignity and privacy.
Failure to Maintain Required Hot Food Temperatures During Meal Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain hot foods at or above 140°F during meal service, as required by facility policy for time/temperature control for safety (TCS) foods. During a test tray observation conducted with the Dietary Supervisor (DS) at 12:25 PM, food temperatures were recorded as pasta at 105°F, turkey and sauce at 105°F, and green beans at 120°F. A repeat test tray observation at 12:35 PM, again in the presence of the DS, showed that the temperatures remained below required levels, with pasta at 105°F, turkey at 105°F, and green beans at 110°F. In a concurrent interview, the DS reported that the facility had been experiencing issues with a malfunctioning plate warmer, which the DS believed may have contributed to food being served at inadequate temperatures, particularly during the morning meal service. The DS also stated that if residents request reheating, staff reheat food for approximately 15 seconds to reach about 160°F, not exceeding that temperature. Review of the facility’s policy and procedure on cooling and reheating of potentially hazardous or TCS food during meal service confirmed that hot foods are to be maintained at temperatures greater than 140°F during meal service. This deficient practice was documented as having the potential to result in rapid growth of bacteria that can cause foodborne illness and can lead to insufficient meal intake and weight loss due to cold or improperly heated food.
Failure to Provide Ordered 1:1 Supervision and Continuous Observation for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and care plan interventions for 1:1 supervision and continuous observation for two residents, resulting in both residents being left unattended at various times. Resident 1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and contractures of the right upper arm and right knee. Assessment documents showed Resident 1 required substantial/maximal assistance with most ADLs and had a high fall risk score of 19 on the facility’s fall risk evaluation, with a care plan identifying risk for falls related to confusion and a history of attempting to get out of bed unassisted. The care plan and physician orders required 1:1 supervision, maintenance of 1:1 observation at all times, and that Resident 1 not be left unattended. Resident 2 was admitted with dementia, Alzheimer’s disease, and an anxiety disorder, and had moderately impaired cognition. The MDS indicated Resident 2 required supervision or touching assistance for toileting, bathing, dressing, footwear, and personal hygiene. Physician orders and care plans dated 1/30/26 documented 1:1 supervision for Resident 2 due to episodes of aggression toward staff, exit-seeking behavior, unprovoked agitation, crying, and aggression, with interventions specifying that a 1:1 sitter be placed with the resident for safety, that the resident not be left unattended, that a reliever be requested before the sitter went on break, and that 1:1 observation be maintained at all times. Despite these orders and care plan directives, the facility’s sitter schedule for the night shift on 2/1/26 showed a single sitter (S1) assigned simultaneously to both residents. Observations and staff interviews confirmed that the 1:1 supervision orders were not implemented as written. During an early morning observation in Resident 1’s room, S1 was present with Resident 1, whose bed was positioned against a wall with a Geri chair wedged tightly against the bed frame on the other side, creating a physical barrier. S1 reported having permission from the DON to place the Geri chair next to the bed. LVN 1 stated that S1 was assigned as a 1:1 sitter for both residents and had to go back and forth between their rooms every 15–20 minutes, even though a 1:1 order meant one sitter should be dedicated to one resident for the entire shift. LVN 1, CNA 1, CNA 2, the RN supervisor, the DON, and the Administrator all acknowledged that each resident with a 1:1 order should have continuous supervision, should not be left alone, and that another staff member should cover when the sitter left the room. Direct observation showed S1 leaving Resident 1 alone to walk down the hallway and around a corner to briefly check on Resident 2, then leaving Resident 2 alone to return to Resident 1, while S1 also described Resident 2 as unpredictable, with a history of hitting other residents and staff and throwing objects. These observations and interviews demonstrated that both residents, each with a physician’s order and care plan for continuous 1:1 supervision and not to be left unattended, were in fact left alone at times, and that one sitter was inappropriately assigned to cover both residents.
Improper Use of Geri Chair as Bedside Restraint Without Physician Order
Penalty
Summary
Surveyors identified that a resident was not kept free from physical restraints when the resident’s bed was positioned against a wall on one side and a Geri chair was wedged tightly against the bed frame on the other side, creating a physical barrier that restricted the resident’s ability to get out of bed. The resident had been admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, as well as contractures of the right upper arm and right knee. The resident’s history and physical documented that the resident had the capacity to understand and make decisions. The Minimum Data Set showed the resident required substantial/maximal assistance for multiple ADLs, and a fall risk evaluation identified the resident as high risk for falls. The care plan documented the resident was at risk for falls related to confusion and a history of attempting to get out of bed unassisted, with interventions including 1:1 supervision and maintaining constant observation without leaving the resident unattended. During an early-morning observation in the resident’s room, the bed was seen placed against the wall on the left side and the Geri chair was placed directly against the right side of the bed, wedged against the bed frame. The resident was lying in the center of the bed in a fetal position, wrapped in a blanket from head to toe. Interview with the sitter assigned to the resident revealed that the DON had given permission to place the Geri chair next to the bed. An LVN confirmed awareness that the Geri chair was placed against the bed and stated it was being used as a restraint to prevent the resident from rising from the bed because the resident tended to “wiggle out” of bed. The LVN reported that the Geri chair had been in that position since the day shift two days earlier and that both the Administrator and the DON were aware of its use in this manner. Record review showed there was no physician’s order for the use of a Geri chair for this resident, despite its use as a device that restricted the resident’s movement and access to getting out of bed. The facility’s policies on restraint use stated that restraints were to be used only to treat medical symptoms and never for discipline, staff convenience, or fall prevention, and policies on safety and supervision emphasized maintaining an environment free from accident hazards and promoting resident dignity and well-being. In interviews, the RN supervisor, DON, and Administrator each acknowledged that placing the Geri chair against the bed in this way constituted a restraint, could result in entrapment, and was not acceptable, and that other alternatives should have been used instead of using the Geri chair as a restraint for this resident.
Failure to Prevent Resident-to-Resident Physical Abuse Despite Known Aggressive History
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in accordance with its Abuse Prevention/Prohibition and Resident Rights policies. One resident (Resident 3) had a history of aggressive behavior, including an SBAR on 8/8/2025 documenting attempts to hit others in the hallway and a transfer to a general acute care hospital on 8/11/2025 for aggressive behavior, shouting, screaming, and attempting to hit others. Resident 3’s MDS dated 11/3/2025 showed severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility. After a psychiatric hospitalization and readmission on 9/23/2025, the facility initiated a care plan for aggressive behavior, but the DON later acknowledged that the interventions in this care plan were vague, not individualized, and not behavior-specific, despite Resident 3’s known history of aggression. Resident 4 was admitted on 12/5/2025 with diagnoses including pneumonia and anxiety disorder, with an MDS indicating moderately impaired cognition and a need for substantial/maximal assistance with ADLs and mobility. On 1/19/2026, an SBAR documented that Resident 4 was sitting by the time clock on the North Station when Resident 3 hit Resident 4 on the back of the head. Resident 4 reported head pain rated 7/10 and was transferred to a general acute care hospital for further evaluation and treatment. In an interview, Resident 4 stated they were seated in the lobby watching the clock when Resident 3 approached in a wheelchair; Resident 4 attempted to move out of the way but was struck in the back of the head before they could reposition, describing the contact as sudden and unexpected and reporting emotional distress and feeling shaken by the incident. In interviews, Resident 3 demonstrated a fist motion as if punching Resident 4 and stated being angry because Resident 4 was blocking the way, though did not verbally admit to striking the other resident. RN 2 reported being at the North Nursing Station, hearing someone yell, “Ow, he hit me,” and immediately separating the two residents; RN 2 did not witness the actual strike but saw Resident 3 making a fist-like motion. RN 2 stated that when a resident has a known history of aggressive behavior, the care plan must be individualized and include specific, measurable interventions such as defined supervision levels, identification of triggers, early intervention strategies, de-escalation techniques, environmental modifications, redirection methods, staff approach guidelines, and escalation criteria, and that vague, generalized interventions without behavior-specific guidance leave staff without clear direction to prevent escalation. The DON similarly stated that without detailed individualized interventions for a resident with a known history of aggressive behavior, staff lack clear direction to proactively prevent escalation, increasing the risk for resident-to-resident altercations, even when aggressive behaviors have been dormant for months. The facility’s policies defined abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and guaranteed residents the right to be free from abuse and neglect.
Failure to Timely Implement Individualized Care Plan for Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, individualized, person-centered care plan to address a resident’s known aggressive behaviors. The resident was admitted with diagnoses including paranoid schizophrenia and diabetes mellitus, and had documented episodes of aggression. On one occasion, an SBAR Communication Form recorded that the resident was in the hallway attempting to hit others. A subsequent Skilled Nursing Facility to Hospital Transfer Form documented that the resident was transferred to a general acute care hospital for aggressive behavior, shouting, screaming, and attempting to hit others. Following a 5150 psychiatric hold for being physically aggressive to staff, the resident was readmitted, and a care plan addressing aggressive behavior was initiated on 9/26/2025. However, this care plan was not individualized or resident-specific. It lacked documented monitoring parameters, did not identify behavioral triggers, and did not provide staff guidance on how to approach, redirect, and manage the resident’s aggressive behaviors. Although the care plan problem was opened on 9/26/2025, the specific interventions were not added or implemented until 11/5/2025, resulting in a significant delay in putting any concrete strategies into practice. The resident’s MDS dated 11/3/2025 indicated severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility, underscoring the need for clear, structured behavioral interventions. During interviews, an RN and the DON both acknowledged that the care plan did not reflect a comprehensive, individualized, person-centered approach and was missing resident-specific guidance related to monitoring, triggers, and staff direction for managing aggressive behaviors. The facility’s own policy on comprehensive, person-centered care plans requires measurable objectives, timeframes, and services derived from thorough assessment and ongoing review, including after hospital readmission, which was not followed in this case.
Failure to Post Current Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current nurse staffing information was posted daily in a prominent location accessible to residents, staff, and visitors, as required by its policy. On 1/2/26 at 12:08 PM, surveyors observed a posting titled "Census and Direct Service Hours Per Patient Day" in front of Nursing Station 1 near the entrance lobby with a date of 12/31/25, indicating the information was not current. During an interview at 12:10 PM, the DON acknowledged the posting was not current and explained that the Director of Staff Development had resigned and the staff member responsible for posting the staffing information did not come to work due to personal circumstances. At 1:00 PM the same day, CNA 1 stated that CNA 1 had been responsible for creating the posting by entering licensed nurse and CNA hours into a computer program that generated the daily nursing hours for posting, and that a personal circumstance had prevented CNA 1 from reporting on time to print and post the information. On 1/5/26 at 8:50 AM, surveyors again observed the same type of staffing posting in front of Nursing Station 1 near the entrance lobby, now dated 1/2/26, showing that the information still had not been updated daily. In a concurrent observation and interview at 9:10 AM, the DON stated that the posting needed to be updated every day. At 10:00 AM, CNA 1 reported that projected nursing hours for posting had been prepared and placed in a bin in front of the staffing office, and that nurses working the weekend were expected to retrieve these projected hours and post the staffing information near the two nursing stations. CNA 1 stated that the nursing hours needed to be posted so staff, residents, and families would have staffing information. Review of the facility’s July 2016 policy "Posting Direct Care Daily Staffing Numbers" confirmed that within two hours of the beginning of each shift, the numbers of licensed nurses and unlicensed nursing personnel directly responsible for resident care must be posted in a prominent, accessible, clear, and readable format, which was not done as observed on multiple days.
Failure to Update Care Plan for Resident with Hoarding Behavior
Penalty
Summary
The facility failed to reevaluate and update the care plan interventions for a resident exhibiting hoarding behavior, despite ongoing issues with clutter and refusal of assistance. The resident, who had diagnoses including bilateral primary osteoarthritis of the knee, COPD, anxiety disorder, and personality disorder, was observed to have intact cognition and the capacity to make medical decisions. The resident required setup or clean-up assistance with several activities of daily living. Observations revealed significant clutter in the resident's room, including boxes, clothing, personal items, and food scattered around the bed, with the call light cord not within reach. Interviews and record reviews indicated that the Social Services Director had discussed the hazards of the clutter with the resident in early September, but there were no further documented interventions or encouragement to address the issue in the following months. Nursing notes showed that the resident refused deep cleaning and continued to decline assistance, despite being educated on proper cleaning and hygiene. The care plan for hoarding, initiated in late July and last revised in early August, included interventions such as encouraging the resident to organize belongings, offering to clean and organize, explaining risks, and assisting with expired food, but these interventions were not updated or revised after the resident's continued refusal and persistent clutter. The facility's policy required ongoing assessment and revision of care plans when desired outcomes were not met or when there was a significant change in the resident's condition. However, the care plan for this resident was not reevaluated or updated in response to the lack of progress and continued safety hazards, resulting in a deficiency related to the failure to maintain a safe and clean environment for the resident.
Failure to Maintain Resident Room Free of Accident Hazards Due to Excessive Clutter
Penalty
Summary
A deficiency was identified when a resident's room was observed to be excessively cluttered, with multiple boxes, clothing, bags, food, drinks, and personal grooming items scattered around the bed and on the floor. The call light cord was found on the floor and not within the resident's reach. These conditions were noted during an observation and interview, where the resident stated that the facility would not assist with moving boxes to storage or provide additional boxes for organizing belongings. The resident had a history of bilateral primary osteoarthritis of the knees, COPD, anxiety disorder, and personality disorder, but was assessed as having intact cognition and the capacity to make medical decisions. The Minimum Data Set indicated the resident required setup or clean-up assistance with several activities of daily living. Despite this, the room remained cluttered, and the resident had refused deep cleaning services, as documented in housekeeping and nursing progress notes. Social services had previously discussed the hazards of the clutter with the resident, but there were no further documented interventions or encouragement to address the issue in the following months. The resident's care plan included goals to maintain a safe and clean living area and interventions such as encouraging the resident to organize belongings and offering staff assistance with cleaning. However, the care plan interventions were not effectively implemented, as the clutter persisted and the environment remained hazardous. Facility policies required a safe, clean, and homelike environment, but these standards were not met in this instance.
Expired Water Filter on Icemaker and Inadequate Maintenance Documentation
Penalty
Summary
The facility failed to maintain safe and sanitary practices for ice and water handling by not replacing an expired water filter connected to the icemaker in the kitchen. During an observation, the expired filter was noted, and the Dietary Manager (DM), who was new to the position, was unsure of the replacement schedule for the filter. A log sheet attached to the icemaker was reviewed, but it only indicated the month of December without specifying the year, making it unclear when the last replacement occurred. The manufacturer's specifications for the water filter recommend replacing the cartridge at least once per year or when the flow rate becomes inconveniently slow. A review of the facility's policy and procedure for maintenance service indicated that the Maintenance Department is responsible for ensuring all equipment, including the icemaker, is maintained in a safe and operable manner according to manufacturer recommendations. The policy also assigns the Maintenance Director the responsibility of developing and maintaining a maintenance schedule. However, the observation and interviews revealed that these procedures were not followed, resulting in the use of an expired water filter and a lack of clear documentation regarding maintenance activities.
Failure to Develop and Implement Care Plan for Assistive Device Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of a rollator walker for a resident with end-stage renal disease on hemodialysis and diabetes mellitus type 2. Despite the resident being at risk for falls due to gait and balance problems, psychoactive drug use, and weakness, there was no individualized care plan in place for the safe use of the rollator walker. The resident's care plan only generally addressed fall risk but did not include specific interventions or measurable objectives related to the assistive device, as required by facility policy. On the day of the incident, the resident attempted to get up from the rollator walker on the outside patio, lost balance, and fell, resulting in an acute humeral neck fracture that required hospitalization. Documentation revealed that the physical therapy department had discharged the resident from services without completing an assessment or evaluation for rollator walker use, and there was no communication of recommendations to the nursing staff. The lack of a care plan and communication between therapy and nursing staff contributed to the resident's fall and injury. Interviews with the DON and occupational therapist confirmed that there was no care plan for the use of the rollator walker and that nurses were not made aware of the resident's needs regarding the device. Facility policies required comprehensive, person-centered care plans and documentation of assistive device use based on assessment, but these were not followed. The deficiency was further compounded by the absence of interdisciplinary communication and failure to adhere to established policies and procedures.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident exited the facility without staff knowledge or supervision. The resident had a history of elopement at home, wandering behavior, and an elopement risk score of 6.0 upon admission. The resident was admitted with diagnoses including seizures and depression, and had fluctuating capacity to make medical decisions. The Minimum Data Set assessment indicated the resident was cognitively intact and required limited assistance for activities of daily living. Despite these risk factors, the resident was last observed in bed early in the morning, and staff were unable to locate the resident during subsequent checks, prompting a facility-wide search. Interviews with staff revealed that the resident was ambulatory and frequently walked around the facility. The Director of Nursing stated that the elopement was unexpected, as the resident had not previously shown signs of wanting to leave. The facility's policy on safety and supervision emphasized the importance of targeting interventions to reduce individual risks and providing adequate supervision. However, the lack of effective supervision allowed the resident to leave the premises unnoticed, constituting a failure to prevent accidents as required by facility policy.
Failure to Promptly Respond to Call Lights and Toileting Requests
Penalty
Summary
Facility staff failed to promptly respond to call lights and requests for toileting assistance for three of five sampled residents, as required by the facility's policy on dignity. One resident with severe cognitive impairment and significant assistance needs for toileting and hygiene was reported by a family member to experience long delays in staff response, often requiring the family member to seek help directly from the nurses' station. Another resident, who was incontinent and at risk for skin breakdown, reported waiting up to 30 minutes or more for assistance after activating the call light, including a specific incident where the resident waited a total of three hours to be changed after an incontinent episode. This resident described feeling ignored and demeaned by the delays. Observations confirmed that call lights remained on for extended periods before staff responded. In one instance, a resident waited 30 minutes for help with a soiled brief, and in another, a resident waited for assistance after an episode of incontinence, with staff not returning as promised. Interviews with residents revealed that these delays were not isolated incidents, with reports of waiting hours for assistance, particularly during nighttime hours. Residents expressed feelings of frustration and a lack of dignity due to these prolonged waits. Staff interviews corroborated that residents should not have to wait long for assistance, especially when in need of changing soiled briefs. The Director of Nursing stated that residents should not wait longer than five minutes for such assistance to maintain their dignity, as outlined in the facility's policy. The policy specifically prohibits practices that compromise dignity and requires prompt response to toileting requests, which was not consistently followed in these cases.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was properly obtained for psychotropic medications prescribed to a resident with severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety disorder, and hypertension, was readmitted to the facility with orders for multiple psychotropic medications. Documentation indicated that the resident was severely impaired in cognitive skills and required substantial assistance with daily activities. Upon review, it was found that the facility continued the psychotropic medication regimen initiated during a recent hospital stay without verifying or obtaining new informed consent from the resident's representative. Interviews with the resident's daughter revealed that medication changes, specifically an increase in depression medication dosage, were made without her notification. The Social Service Director and MDS Nurse confirmed that the medication changes occurred during the resident's hospital stay and were continued upon readmission to the facility. However, there was uncertainty about whether proper notification or consent had been obtained for these changes. The facility's records included informed consent forms for the psychotropic medications, but the psychiatric nurse practitioner stated that they did not actually obtain consent from the resident's representative as indicated on the forms. The facility's policy required verification of prior informed consent for psychoactive medications upon admission or readmission, and if such documentation was not present, the admitting physician was responsible for obtaining consent. In this case, there was no verified documentation from the discharging hospital, and the admitting provider did not obtain informed consent from the resident's representative. This resulted in the resident receiving psychotropic medications without the required informed consent process being completed.
Physical Abuse of Resident by Registered Nurse
Penalty
Summary
A deficiency occurred when a registered nurse (RN) engaged in physical abuse against a resident with severe cognitive impairment and multiple psychiatric diagnoses, including intellectual disability, schizoaffective disorder, and anxiety disorder. The resident, who required substantial assistance with daily activities and had a history of verbal aggression but not physical aggression, was subjected to an incident where the RN threw a cup of juice in the resident's face and chest. This action was in response to the resident having thrown juice at the RN and a certified nursing assistant (CNA) during a period of agitation. The RN later admitted to 'mirroring' the resident's behavior by intentionally throwing juice back at the resident, believing it might discourage future incidents, despite recognizing afterward that this was not permitted. Observations and interviews confirmed that the resident was left visibly distressed, crying intermittently and unable to articulate their feelings following the incident. The care plan for the resident included interventions for staff to use calm approaches, provide cues, and allow the resident time to adjust when agitated, but these were not followed during the event. Staff interviews indicated that the resident's aggressive behaviors were typically managed through verbal de-escalation, medication, or giving the resident time alone, and that the resident was not considered a physical threat. The facility's policies on abuse prevention and resident rights explicitly prohibit willful infliction of injury or punishment and require staff to treat residents with kindness, respect, and dignity. Despite these policies and staff education on abuse, the RN's actions constituted physical abuse, as confirmed by both facility leadership and the abuse coordinator. The incident was reported internally after another RN received a text message confession from the involved RN, which was then escalated to the administrator.
Failure to Timely Report Physical Abuse Incident
Penalty
Summary
The facility failed to report an incident of physical abuse involving a resident with severe cognitive impairment and multiple psychiatric diagnoses within the required two-hour timeframe to the California Department of Public Health. The resident, who had a history of behavioral issues and required significant assistance with daily activities, was involved in an altercation where a registered nurse (RN) threw juice at the resident after the resident had thrown juice at the nurse. This incident was witnessed by a certified nursing assistant (CNA), who did not report the event as required due to being occupied with other duties. The facility's policies and procedures, as well as staff interviews, confirmed that all staff are mandated reporters and are required to report any suspected abuse, neglect, or mistreatment immediately, and no later than two hours after the incident. Despite this, the CNA failed to report the incident to the Abuse Coordinator or Administrator. The RN involved in the incident later sent a text message to another RN describing the event, but this message was not seen until the following day, further delaying the reporting process. Record reviews and staff interviews indicated that the facility's abuse prevention and reporting policies were not followed in this case. The delay in reporting the incident resulted in a violation of the resident's rights and had the potential to delay the investigation of abuse and expose the resident to further harm. The deficiency was identified through interviews, record reviews, and examination of facility policies.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to treat two residents with dignity during daily care activities. For one resident with severe cognitive impairment and multiple diagnoses, an Activity Assistant referred to the individual as a "feeder" while the resident was seated in the dining room. This terminology was used in the presence of the resident and was confirmed during an interview with the staff member. The resident's records indicated a high level of dependence on staff for daily activities, including eating and personal hygiene. In a separate incident, another resident with Huntington's disease, dysphagia, and moderate cognitive impairment was assisted with eating by a staff member who stood over the resident at the bedside. The resident later stated that being assisted at eye level would have maintained their dignity. The staff member involved acknowledged standing while assisting and confirmed awareness that sitting at the same level is the appropriate practice. Facility policies reviewed indicated that residents should be treated with dignity and respect, specifically noting that staff should not stand over residents while assisting with meals and should avoid using labels such as "feeder."
Failure to Provide Adequate Supervision and Post-Fall Review
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision for three residents. One resident, who was severely cognitively impaired and required a 1:1 sitter due to aggressive behaviors and a history of losing balance, was left unsupervised on the patio while the assigned sitter was inside the facility using a personal phone for four minutes. The sitter acknowledged being distracted by personal emails and not observing the resident as required by facility policy, which prohibits personal phone use during supervision duties. Additionally, two other residents with significant cognitive impairments and histories of falls experienced multiple unwitnessed and witnessed falls. Despite these incidents, the facility did not conduct required interdisciplinary team (IDT) meetings after each fall, as outlined in their policies. Record reviews confirmed that no post-fall IDT meetings were held for these residents following their falls in July and August, even though the facility's procedures mandate such reviews within 24 hours to analyze causes and update care plans. The lack of supervision and failure to follow post-fall protocols were confirmed through staff interviews, record reviews, and direct observation. The Director of Nursing and other staff acknowledged that the facility's policies require constant supervision for high-risk residents and timely IDT meetings after falls, but these procedures were not followed for the residents in question.
Failure to Administer and Document Medications Timely
Penalty
Summary
Nursing staff failed to follow the facility's medication administration policy and procedure in several instances, resulting in deficiencies related to timely medication administration and proper documentation. For one resident with a history of seizures, hypotension, and acute kidney failure, scheduled medications including antipsychotics and anticonvulsants were not administered as ordered on one evening, and there were multiple instances where medications were given late or documentation was delayed. The Director of Nursing confirmed that the resident did not receive the scheduled medications and that the responsible nurse could not provide a reason for the omission. Additionally, two nurses admitted to documenting medication administration after completing medication passes for multiple residents, citing issues such as unreliable Wi-Fi, rather than immediately after each administration as required by policy. Another resident with metabolic encephalopathy, dementia, UTI, and arthritis had six medications scheduled for administration at a specific time in the morning. Observation revealed that these medications were administered more than one and a half hours late. The nurse involved acknowledged the delay and confirmed that medications should be administered on time according to physician orders to ensure effectiveness. A third resident with Parkinsonism, epilepsy, and COPD had multiple instances where scheduled medications for seizure control were documented as being administered late. Interviews with nursing staff revealed that documentation was not completed immediately after each medication was given, contrary to facility policy. Staff acknowledged that they should have documented each administration before proceeding to the next medication, but this was not consistently done.
Failure to Clean High-Touch Surfaces in Resident Room
Penalty
Summary
The facility failed to ensure that the doorknob and door of a resident room, occupied by three residents, were cleaned daily as required by facility policy. Observations on two separate occasions revealed visible brown specks and smudges on the doorknob and surrounding door area, which remained uncleaned over several days. The infection preventionist confirmed that these areas were dirty and acknowledged that the doorknob is considered a high-touch surface that should be cleaned daily to prevent the spread of infection. The three residents involved had various medical conditions, including metabolic encephalopathy, chronic kidney disease, bipolar disorder, pneumonia, dementia, anxiety disorder, hypertensive heart disease with heart failure, and paranoid schizophrenia. Their levels of cognitive and physical functioning varied, with some requiring supervision or assistance for activities of daily living. Review of facility records and policies indicated that environmental surfaces are to be cleaned regularly and when visibly soiled, but this was not followed for the doorknob and door in question.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to follow its policy and procedure regarding notification of a change in a resident's condition or status. Specifically, staff did not notify a resident's physician of a significant unintentional weight loss, as required by facility policy. The resident experienced a weight decrease from 144 pounds to 127 pounds over a 30-day period, which was documented in the progress notes. Despite this significant weight loss, there was no Change in Condition Evaluation created for June, July, or August, and the physician was not notified of the change. The resident involved had multiple medical diagnoses, including multiple rib fractures, hypertensive heart disease, urinary tract infection, and protein-calorie malnutrition. The resident was assessed as having moderate cognitive impairment and required varying levels of assistance with activities of daily living. Facility policies required staff to report significant weight changes to the physician, but review of records and interviews with nursing staff and the DON confirmed that this notification did not occur for the resident's significant weight loss.
Resident Privacy Breach via Social Media Video
Penalty
Summary
A Certified Nursing Assistant (CNA) was recorded sitting in a resident's room by a Licensed Vocational Nurse (LVN), and the video was subsequently posted to TikTok. The video included identifiable personal property and pictures belonging to the resident, as well as a view into four other resident rooms. The resident involved had a history of hereditary and idiopathic neuropathy and dementia, with fluctuating capacity to understand and make decisions. The facility's policies and employee handbook explicitly prohibit recording and sharing videos of residents or their personal spaces on social media, and require safeguarding resident privacy and confidentiality. Interviews with the CNA and the Director of Nursing (DON) confirmed that the video was recorded in the facility and that such actions were not permitted, as they violate residents' rights to privacy and confidentiality. Review of facility policies further supported that employees are required to treat residents with respect and protect their personal information, including video and audio recordings. The posting of the video to a public social media platform constituted a failure to honor these rights and maintain confidentiality as required by facility policy.
Failure to Complete Comprehensive Admission Assessment and Timely Pain Management
Penalty
Summary
The facility failed to provide an accurate and comprehensive admission assessment for one resident with multiple diagnoses, including unspecified dementia and legal blindness. Upon admission, documentation inconsistencies were noted across various records, including the care plan, admission notes, and progress notes. The resident's care plan indicated the need for a wanderguard for safety, but other records failed to accurately reflect the resident's cognitive impairment, visual impairment, and safety concerns. Additionally, the baseline care plan and progress notes did not document the presence of pain or injury, despite the resident having a red and swollen right hand and forearm, and a physician's order for immobilization of the right forearm with a splint and ACE wrap. Observations and interviews revealed that staff did not perform necessary assessments, such as vision and pain assessments, nor did they follow physician orders for immobilizing the resident's right forearm. The resident was observed to have visible swelling and redness in the right hand and forearm, and demonstrated difficulty lifting the affected arm. Despite these findings, there was no documentation of a right arm injury in the resident's hard chart, and the medication administration record showed that the resident did not receive a pain assessment or pain medication until several days after admission. Further interviews with staff indicated a lack of awareness and documentation regarding the resident's impairments and needs. The activities director did not engage with the resident during the initial interdisciplinary team meeting, and there was no documentation of activities provided. Facility policies required comprehensive admission assessments, including pain and functional assessments, but these were not completed as required, resulting in delayed interventions for the resident's pain and inadequate accommodation of the resident's cognitive and visual impairments.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents with behavioral health needs did not receive the appropriate care and services as required by regulations.
Failure to Monitor Vital Signs per Care Plan Leads to Delayed UTI and Sepsis Identification
Penalty
Summary
The facility failed to promptly identify and monitor signs and symptoms of a urinary tract infection (UTI) for one resident, as required by the resident's care plan. The care plan, dated 1/23/2025, specified that the resident, who had a history of UTI and was at risk for further complications, should have vital signs monitored every shift. However, records and interviews confirmed that staff only checked the resident's vital signs once a week, with the last recorded check occurring on 5/28/2025, prior to a significant change in the resident's condition on 6/4/2025. The Director of Nursing acknowledged that the care plan was not followed and that the facility's policy for care plans was not implemented as required. The resident, who had diagnoses including encephalopathy, dementia, and anxiety, and was severely cognitively impaired and incontinent, experienced a rapid decline. On 6/4/2025, the resident developed severe shortness of breath, high fever, and low oxygen saturation, leading to emergency transfer to a general acute hospital, where the resident was diagnosed with UTI and sepsis. The failure to monitor vital signs as outlined in the care plan resulted in delayed identification of the resident's deteriorating condition.
Failure to Protect Resident from Verbal and Mental Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse, as evidenced by an incident involving a certified nurse assistant (CNA) and a resident with diagnoses including hyperlipidemia and mood disorder, who lacked the mental capacity to make medical decisions. During the incident, a CNA was observed by another staff member yelling at the resident and threatening physical harm, stating, "If you hit me I'm gonna F . you up," while picking up a chair. The resident acknowledged a loud verbal exchange but reported feeling safe and voiced no complaints at the time of the interview. No visible injuries or signs of distress were observed during the assessment. The facility's policies clearly prohibit verbal abuse, intimidation, or threats from staff and require immediate reporting of such incidents. Despite these policies, the incident occurred, and the facility's internal investigation substantiated the occurrence of verbal and mental abuse. The deficiency was identified through staff interviews, resident interviews, and review of facility records and policies.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of Ativan (lorazepam), a psychoactive medication, for a resident with severe cognitive impairment. The resident was admitted with diagnoses including dementia, anxiety disorder, and psychosis, and was determined by a physician to lack the capacity to understand and make decisions. The resident's Minimum Data Set assessment confirmed severe cognitive impairment and indicated the use of antianxiety medication. A physician order was present for Ativan to be administered as needed for inconsolable yelling. However, upon review of the resident's medical record, the Social Services Director was unable to locate a signed informed consent for the use of Ativan. Further investigation confirmed that the resident's responsible party had not provided documented consent for the medication. Interviews with facility staff, including the Director of Nursing, confirmed that facility policy requires informed consent to be obtained and documented prior to administering psychoactive medications, especially when the resident is unable to provide consent. The policy specifies that consent must be obtained from the resident's representative if the resident is not capable. Despite this, there was no evidence that informed consent was obtained or documented for the use of Ativan in this case.
Plan Of Correction
Corrective Action: Resident 77's informed consent for use of Ativan was obtained and verified by a licensed nurse from RP1 on 4/16/25. Other Residents Affected Identification: All residents taking Psychotropic Medications are at risk for deficient practice. On 4/17/25, all residents on Psychotropic Medications were reviewed for completion of Informed Consents. No other residents were affected by the deficient practice. Measures and Systemic Changes: On 04/17/2025, the DON initiated in-service to Licensed Nurses and SSD to ensure that consents are obtained prior to giving psychotropic medication. Upon admission, any residents receiving psychotropic medications shall be audited by the Medical Records to verify if the informed consent has been completed. During weekly Behavior Management Meetings, the IDT shall monitor and audit the compliance of informed consent verification, and the copy of the audit will be provided to the administrator, DON, and the IDT. Findings on the audit will be addressed by the SSD and IDT immediately. MONITORING PERFORMANCE: Medical Records will audit psychotropic medications once weekly for 3 months or until substantial compliance is achieved, reporting any deficits to the DON for follow-up. Issues and trends, along with a copy of the report, will be forwarded to the DON/Administrator for further review and immediate corrective action as necessary. The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved. Upon admission, any residents receiving psychotropic medications shall be audited by the Medical Records to verify if the informed consent has been completed. During weekly Behavior Management Meetings, the IDT shall monitor and audit the compliance of informed consent verification, and the copy of the audit will be provided to the administrator, DON, and the IDT. Findings on the audit will be addressed by the SSD and IDT immediately. MONITORING PERFORMANCE: Medical Records will audit psychotropic medications once weekly for 3 months or until substantial compliance is achieved, reporting any deficits to the DON for follow-up. Issues and trends, along with a copy of the report, will be forwarded to the DON/Administrator for further review and immediate corrective action as necessary. The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Medication Error: Wrong Antihistamine Administered
Penalty
Summary
A deficiency occurred when a licensed vocational nurse administered cetirizine 10 mg to a resident instead of the physician-ordered loratadine 10 mg. The resident, who had diagnoses including Type 2 Diabetes Mellitus, acute osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb, was admitted and readmitted to the facility with intact cognition. The physician's order specifically required loratadine 10 mg by mouth once daily for skin allergy, but during a medication pass, the nurse gave cetirizine, which was not ordered for the resident. The nurse explained that cetirizine was administered because it was the house supply provided by the pharmacy, despite the absence of a physician's order for cetirizine. The Director of Nursing confirmed that the order was for loratadine and that cetirizine should not have been given. Facility policy required medications to be administered as prescribed and for staff to verify the correct medication, dose, and resident before administration. The error resulted in a medication error and had the potential to cause adverse side effects for the resident.
Plan Of Correction
F755: Pharmacy Services/Procedure/Pharmacist/Records CORRECTIVE ACTION: On 4/17/25, Resident 27 was assessed by a licensed nurse and no adverse reaction was noted. Change of Condition for the Medication Error was initiated and MD was made aware with no new order but to continue to monitor resident. Resident was monitored for 3 consecutive days with no adverse reaction noted related to medication error. On 04/17/25, Medication Cart was supplied with Loratadine. LVN 4 is no longer working at the facility. OTHER RESIDENTS AFFECTED IDENTIFICATION All Residents had the potential to be affected by the deficient practice. On 04/17/25, an audit of all Medication Carts for availability of over-the-counter medications for residents with orders for its use was conducted. All over-the-counter medications were available and none were identified to be affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES Inservice was initiated on 04/17/2025 by DON regarding proper medication administration as ordered by MD. On 04/17/2025, DON/Designee initiated a weekly medication administration observation to 2 random nurses to ensure administration of correct medication as ordered by MD. Medical record will include in the daily audit the MAR for any missed dose of medications ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings from weekly medication administration observation and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
The facility failed to ensure compliance with federal regulations regarding the administration of psychotropic medications, specifically Ativan (lorazepam), for a resident diagnosed with dementia, anxiety disorder, and psychosis. The resident, who had severe cognitive impairment and lacked decision-making capacity, had a physician order for Ativan 0.5 mg to be given orally every eight hours as needed for inconsolable yelling. The order, dated 4/8/2025, did not include a required 14-day limitation for PRN (as needed) use, nor was there documentation of the prescriber's rationale or specified duration for extending the order beyond 14 days, as mandated by both federal regulation and the facility's own policy. During interviews and record reviews, it was confirmed that the Ativan PRN order remained active without an end date or appropriate documentation to justify its continuation past 14 days. The Director of Nursing acknowledged that the order should have been limited to 14 days and that the necessary documentation for extension was missing. The facility's policy, consistent with federal requirements, clearly states that PRN orders for psychotropic medications must be limited to 14 days unless properly justified and documented by the prescriber.
Plan Of Correction
F758: Free from Unnecessary Psychotropic Meds/PRN Use {F 758) CORRECTIVE ACTIONS: On 04/16/2025, Resident 77's Ativan order was followed up with MD and a new order was obtained with a duration of 14 days. OTHER RESIDENTS AFFECTED IDENTIFICATION: On 4/16/2025, all residents with PRN orders of psychotropics were audited and no other residents were noted to be affected by the deficient practice. All other residents with PRN psychotropics are noted with a 14-day stop date. Measures and Systemic Changes: The DON/Designee initiated education to licensed staff on 4/17/25 to ensure that any residents receiving PRN psychotropics must have a 14-day stop date initially upon ordering, and MD has to have a documentation of the rationale on the resident's medical records if MD wishes to continue its PRN use. The DON/DSD will monitor daily all new orders for PRN psychotropics prescribed to ensure the order is limited to 14 days. This will be followed by bimonthly reviews for 2 months, then monthly reviews for 3 months, and quarterly thereafter. MONITORING PERFORMANCE: The DON/SSD will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to perform hand hygiene during medication administration for two residents. The LVN was observed handing medications and water to one resident, then documenting the administration without performing hand hygiene after handling the medications and after the medication pass. In a separate instance, the same LVN prepared medications for another resident without performing hand hygiene before or after handling the medications. The two residents involved had significant medical histories. One resident had end stage renal disease, was dependent on renal dialysis, and had Type 2 diabetes mellitus, requiring supervision or assistance with several activities of daily living. The other resident had Type 2 diabetes mellitus, acute osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb, requiring substantial or maximal assistance with personal care tasks. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that facility policy and standard infection control practices require hand hygiene before and after medication administration and resident contact. Review of the facility's hand hygiene policy further supported these requirements, stating that hand hygiene is the primary means to prevent the spread of infections and must be performed before and after direct contact with residents and before preparing and handling medications.
Plan Of Correction
F880: Infection Prevention and Control Corrective Action: On 04/17/25, Resident 27 and Resident 62 were assessed by a licensed nurse. Both residents did not show any adverse reaction or signs of infection caused by the deficient practice. LVN 4 is no longer working in the facility. In-service initiated on 04/17/2025 by DON regarding infection control with an emphasis on hand hygiene during medication pass and also before and after care with residents. Other Resident Affected Identification: All residents have the potential to be affected by the deficient practice. On 04/17/25, DON/Designee conducted a random observation of 4 licensed nurses during medication pass. All licensed nurses observed performed hand hygiene appropriately. No other residents were affected by the deficient practice. On 05/02/2025, IP nurse/Designee initiated a weekly random medpass observation to 2 random licensed nurses to ensure proper hand hygiene is performed. PERFORMANCE MONITORING: DON/designee will report any findings/trends during monthly QAA meeting for review x90 days or until substantial compliance has been achieved.
Failure to Notify Resident of Incoming Phone Calls
Penalty
Summary
A deficiency occurred when a facility failed to ensure a resident was able to communicate with persons outside the facility, specifically when the receptionist did not notify the resident of incoming phone calls from a family member. The resident, who had diagnoses of hypertensive heart disease without heart failure and depression, was admitted with a responsible party listed as a family member. Although the resident's history and physical indicated a lack of capacity to make decisions, the Minimum Data Set assessment showed the resident was cognitively intact. The family member reported that the receptionist would not notify the resident of calls if the resident was not visible in the lobby, and messages left with the receptionist were not relayed to the resident. The family member noted that when another receptionist was on duty, communication with the resident was facilitated promptly. The receptionist admitted that if the resident was not in the lobby, she would only page the assigned CNA, and if the CNA was unavailable, she would not notify anyone else, nor would she page the LVN, citing their busyness. The receptionist acknowledged that it was the resident's right to have access to phone calls. The Director of Nursing confirmed that the facility's expectation was for the receptionist to notify the CNA, LVN, or RN supervisor when a family member called for a resident. Facility policies reviewed indicated that residents should be given telephone messages when unable to take incoming calls and that residents have the right to communication with people and services both inside and outside the facility. The failure to notify the resident of incoming calls resulted in the resident not receiving important communication from their family member.
Plan Of Correction
F 550 Resident Rights Corrective Action: One-on-one in-service was provided to Receptionist 1 on 05/02/2025 and 05/07/25 by DON/Designee regarding the proper transferring of calls when residents have a phone call. DON/DSD initiated in-service on 05/02/2025 and 05/07/25 to all receptionists and staff regarding residents' rights to receive calls from outside the facility and properly communicate residents' concerns. Corrective Action Continued: Resident 1 is no longer in the facility. Other Residents Affected Identification: All residents have the potential to be affected by the deficient practice. Random residents who frequently received phone calls were interviewed on 04/30/25 and 05/07/25 by SSD/Designee to determine if there were any concerns about making or receiving phone calls. No other residents were affected by the deficient practice. Measures and Systemic Changes: Department Head room round form was updated on 05/07/2025 to include asking residents if they have any issues receiving calls. Any findings will be reported during stand-up to Admin and DON 5 times per week. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Failure to Develop and Implement Care Plan for Hypertensive Heart Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with hypertensive heart disease without heart failure. Although the resident was admitted with this diagnosis and had a physician's order to monitor for orthostatic hypotension by checking blood pressure once a week, the care plan did not address hypertensive heart disease or include the required blood pressure monitoring. Instead, the care plan only referenced coronary artery disease related to atrial fibrillation, which was not supported by the resident's Minimum Data Set or medical records. Record reviews showed that the resident's Minimum Data Set listed active diagnoses of hypertension and depression, and the physician order summary specifically required monitoring for orthostatic hypotension. The Director of Nursing confirmed that the care plan was not updated to reflect the physician's order for blood pressure monitoring. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and services to meet residents' needs, but this was not followed for the resident in question.
Plan Of Correction
F 656 Develop/ Implement Comprehensive Care plan Corrective Action: Resident was discharged on 04/03/2025. Corrective Action Continued: DON initiated in-services to licensed nurses on 05/02/2025 regarding the importance of developing accurate care plans based on diagnosis and ensuring they reflect the related interventions. Other Residents Affected Identification: All residents have the potential to be affected by the deficient practice. On 05/02/25, all residents with a diagnosis of Hypertension were audited by DON/Designee to ensure a care plan is present and reflects current interventions that might include Blood Pressure Monitoring. No other residents were affected by the deficient practice. Measures and Systemic Changes: DON provided an in-service to MDS nurse on 05/02/25 to ensure care plans reflect residents' diagnoses with their corresponding interventions. Care plans will be reviewed by the MDS nurse upon admission and quarterly at minimum thereafter for accuracy. The DON initiated an in-service to Licensed Nurses on 05/02/25 regarding quality of care, with an emphasis on the importance of monitoring BP and updating care plans based on physician's orders. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved. Date: 05/07/25
Failure to Monitor and Document Blood Pressure as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document a resident's blood pressure as ordered by the primary physician. The resident, who was admitted with diagnoses including hypertensive heart disease without heart failure and depression, had a physician's order to be monitored for orthostatic hypotension once a week on Saturdays. On the specified date, there was no documentation in the Medication Administration Record (MAR) that the blood pressure monitoring was completed. An interview with a licensed vocational nurse confirmed that the assigned nurse did not assess or document the resident's blood pressure, and that if documentation was missing, the assessment was not performed. The resident's care plan did not address hypertensive heart disease or the required blood pressure monitoring, despite the resident having an active diagnosis of hypertension. The facility's policy required nurses to assess and document vital signs, including blood pressure, as part of baseline information for acute condition changes. The lack of documentation and assessment was confirmed through record review and staff interview, indicating the ordered monitoring was not carried out as required.
Plan Of Correction
F6841 Quality of Care Corrective Action: Resident 1 was discharged on 04/03/2025. LVN 4 is no longer employed at the facility. Other Residents Affected Identification: On 5/2/2025, IP Nurse reviewed residents with Blood Pressure monitoring orders. All Blood Pressure Monitoring reflecting on MAR are all being done and documented as ordered by MD. There are no other residents affected by the deficient practice. Measures and Systemic Change: MRD/Designee will initiate a weekly audit on 05/02/25 of all residents with Blood Pressure Monitoring to ensure it is done and documented on the MAR per MD's order. Monitoring Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Failure to Ensure Nursing Staff Competency in Following Physician Orders for BP Assessment
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LVN and RNs, demonstrated the necessary competencies and skills to follow physician orders for blood pressure assessment for a resident. The resident in question was admitted with diagnoses including toxic encephalopathy and depression, and was determined by a physician to lack capacity for decision-making, though the Minimum Data Set indicated cognitive intactness. The resident's care plan did not address the diagnosis of hypotension, despite a physician order to monitor for orthostatic hypotension once weekly. Review of the Medication Administration Record showed that the required monitoring for orthostatic hypotension was not documented on the specified date. During interviews, it was confirmed that the LVN did not follow the facility's job description, which requires accurate and timely documentation of resident assessments and care. The absence of documentation was interpreted by staff as evidence that the assessment was not performed. Further interviews with the DON and review of job descriptions for both LVNs and RNs revealed that the nursing staff did not fulfill their responsibilities for documentation and implementation of physician orders. The DON acknowledged that the RNs did not complete the required documentation or provide the ordered care, and stated that additional training was needed for the involved staff.
Plan Of Correction
F 726 Competent Nursing Staff Corrective Action: LVN 4 is no longer employed at facility. Other Residents Affected Identification: There are no other residents affected by this deficient practice. Measures and Systemic Change: DON/Designee initiated skills competency (on 05/02/25) regarding accurate blood pressure monitoring for all Licensed Nurses on 05/02/2025. DSD to ensure all new hires have a skills competency prior to starting. Monitor Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Resident-to-Resident Physical Altercation Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was physically assaulted by their roommate, resulting in significant injuries. The incident involved two residents, both with complex psychiatric and cognitive diagnoses, including schizophrenia, major depressive disorder, and dementia. On the day of the incident, one resident approached the other's bed and began making the bed while the other was still sleeping. This led to a confrontation where one resident grabbed the other's hair, and the other responded by hitting and scratching, resulting in a closed head injury and a nasal bone fracture for one of the residents. Both residents sustained visible injuries, including scratches, bleeding, and pain. Staff, including a CNA and an LVN, responded to the altercation after hearing yelling and screaming from the room. Upon entering, they observed the residents physically engaged and separated them. The injured resident was subsequently transferred to a hospital for evaluation and treatment, where imaging confirmed a nasal bone fracture and a closed head injury. The other resident was later transferred to another hospital on a psychiatric hold due to ongoing aggressive behavior. The report details that both residents had a history of mental health and cognitive impairments, and staff interviews indicated that residents with aggressive behaviors should be closely monitored to prevent such incidents. The facility's policy emphasized the commitment to protecting residents from abuse by anyone, including other residents. However, the actions and inactions leading up to the event, including the lack of effective monitoring or intervention prior to the altercation, resulted in a failure to ensure the right of residents to be free from abuse and physical harm.
Plan Of Correction
CORRECTIVE ACTION: On 3/20/25, Resident 4 was assessed by the licensed nurse, initial treatment was provided, Analgesic was provided for pain and was transferred to a General Acute Care Hospital for further evaluation. Resident 4 returned the same day and room change was initiated. Treatment for scratches to face continued until resolved on 3/31/25. Resident did not have any complaints of pain upon return and throughout the stay at the facility. On 3/21/25 and 3/24/25, Social Services Director conducted a room visit to Resident 4 and Resident 4 had no concerns regarding care or safety. On 3/21/25, Psychiatrist consult was conducted and Resident 4 had no new onset of any Psychiatric concern and stated she feels safe in the facility. On 4/9/25, x-ray of nose was ordered but resident refused. On 4/10/25, x-ray was re-offered but resident still refused stating she does not have any pain. Risks and benefits explained but still refused. Primary Physician and Responsible Party was notified. On 3/20/25, Resident 5 was assessed by the licensed nurse, initial treatment was provided, Analgesic was provided for pain, one-on-one sitter was initiated and was transferred to a General Acute Care Hospital for further evaluation. Resident 5 returned to the facility the same day with no major injuries noted. On 3/20/25 and 3/21/25, Social Services Director conducted a room visit to Resident 5 and Resident 5 had no concerns regarding care or safety after she was separated from Resident 4. Resident 5 continued to have one-on-one sitter until transferred to another facility per Resident 5's request. Resident 5 will not return to the facility. On 3/21 and 3/24, all staff was provided in-servicing on Resident-to-resident altercation/abuse prevention, reporting and investigation. On 4/10/2025, an All Staff meeting was conducted with outside resources to in-service on behavior management of residents. **IDENTIFYING OTHER RESIDENTS AT RISK** All residents had potential for harm due to the deficient practice. On 4/10/25, facility audited residents with a history of aggressive behavior and 16 residents were identified. 2 of 16 identified residents had an altercation on 3/30/25 that was immediately de-escalated by staff with no negative outcome. On 4/10/25, SSD/designee interviewed 48 residents with capacity to make decisions and make needs known to ensure resident safety and roommate compatibility. 2 residents who verbalized concerns with roommates were moved to another room per resident's request. **SYSTEMIC CHANGES** Hallway Monitor Program (24/7 monitoring) was initiated on 3/29/25. All Hallway Monitoring Aides have undergone Skills Competency conducted by DSD/Designee. Monitoring aides will do rounds every two hours to identify residents with potential escalating behaviors that could lead to aggression. Findings will be logged onto a Hallway Monitor Form and will be reported and addressed accordingly. A certified Management Assaultive Behavior trainer resource initiated an in-person training on 4/10/25 to staff regarding preventing resident-to-staff and resident-to-resident altercation by identifying potential behaviors and how to de-escalate situations that may lead to altercation. Psychology visits will be increased to weekly at minimum for all residents with a history of aggressive behavior and will be referred to a Psychiatrist as needed. **MONITORING EFFECTIVENESS** The SSD/designee will report concerns or issues related to the deficient practice to the DON and/or Administrator for follow-up. Staff will also be encouraged to identify trends and vocalize concerns related to the deficient practice by utilizing the Administrator's open door policy and by participating in providing feedback at the mandatory monthly All Staff Meeting. Reports and findings will be submitted to the QAA Committee for further review and recommendations. Submissions to the committee will be monthly for a period of 3 months or until full compliance is achieved.
Failure to Provide Adequate Supervision and Safe Environment Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for two residents, resulting in preventable injuries. For one resident with Huntington's Disease and dementia, staff did not implement care plan interventions designed to reduce self-injurious behavior, such as anticipating needs and providing positive interaction. Additionally, staff failed to follow a physician's order for hourly monitoring of this resident's aggressive behavior. As a result, the resident sustained a self-inflicted scalp laceration and contusion after banging their head on a door, requiring hospital treatment. Subsequently, the same resident was involved in a physical altercation with a roommate, resulting in a nasal fracture, scalp hematoma, and severe facial pain, again necessitating hospital evaluation. Interviews with staff and review of records confirmed that the required hourly monitoring was not performed prior to these incidents, and staff were unaware of the monitoring order. Another resident, who was dependent on staff for eating due to severe cognitive impairment and upper extremity dysfunction, was left unsupervised with a lunch tray placed within reach. Despite being assessed as a moderate fall risk and requiring total assistance for eating, staff delivered the meal tray to the resident's room before being ready to assist. The resident attempted to reach for the tray independently and fell. Staff interviews confirmed that the tray should not have been delivered until assistance was available, and the DON acknowledged that the resident's confusion and inability to recognize hazards contributed to the fall. Facility policy required individualized supervision and environmental adjustments based on resident risk factors, including cognitive status and physical limitations. However, in both cases, staff failed to adhere to these requirements, resulting in injuries. Documentation and interviews revealed that staff were either unaware of or did not follow care plans and physician orders for supervision and monitoring, directly leading to the incidents described.
Plan Of Correction
F 689: FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CORRECTIVE ACTION Resident #37 was transferred to a General Acute Hospital on 3/2/25 for evaluation following self-inflicted injuries. On 3/4/25, the resident was placed under 1:1 sitter supervision for close monitoring. A healthcare provider ordered a helmet for the resident to wear while out of bed to prevent further self-inflicted harm. The IDT convened on (date) to review and update Resident #37's comprehensive care plan. On 3/24/2025, the DSD/Designee provided nursing staff with education on the importance of hourly monitoring for Resident #37, emphasizing behavioral observations and self-inflicted injuries. Resident #294 attempted to retrieve his lunch tray from the bedside table independently and was found on the floor on 3/5/25. The resident was assessed for injuries and placed under Close Observation and Care (COC) monitoring from 3/5/25 to 3/8/25. No injuries were noted from the fall. CORRECTIVE ACTION (CONTINUED) On 3/25/2025, the DON/Designee conducted an in-service training for licensed staff covering: - Comprehensive care planning for managing residents with self-inflicted injuries and aggressive behaviors - Abuse and neglect prevention and prohibition On 3/25/2025, the DSD/Designee provided CNAs with education on: - Abuse and neglect prevention and prohibition - Close supervision of residents during behavioral escalations and the immediate reporting of any behavioral changes to licensed staff - Safety and supervision during mealtimes, with a focus on residents requiring total assistance with eating OTHER RESIDENTS AFFECTED IDENTIFICATION All residents had the potential to be affected by the alleged deficient practice. From 3/21/25 to 3/25/25, licensed staff and the IDT conducted facility rounds to observe residents for any behaviors indicating self-inflicted injuries. No additional residents were observed with self-inflicted injuries. CORRECTIVE ACTION (CONTINUED) On 3/25/2025, the DON/Designee conducted an in-service training for licensed staff covering: - Comprehensive care planning for managing residents with self-inflicted injuries and aggressive behaviors - Abuse and neglect prevention and prohibition On 3/25/2025, the DSD/Designee provided CNAs with education on: - Abuse and neglect prevention and prohibition - Close supervision of residents during behavioral escalations and the immediate reporting of any behavioral changes to licensed staff - Safety and supervision during mealtimes, with a focus on residents requiring total assistance with eating OTHER RESIDENT AFFECTED (CONTINUED) On 3/28/25, the DSD/Designee monitored meal times to assess whether residents requiring total assistance with eating had their meal trays left on the bedside table before receiving assistance. No residents were observed experiencing the alleged deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/21/25, the Director of Nursing (DON) or designee conducted an additional in-service training session for licensed staff, focusing on the following topics: - Comprehensive care planning for residents with self-inflicted injuries and aggressive behaviors - Strategies for preventing and prohibiting abuse and neglect - Licensed staff rounds during mealtimes to ensure resident safety and supervision From 3/21/25 to 3/25/25, the Director of Staff Development (DSD) or designee provided training to CNA staff, which included: - Close supervision during behavioral escalations, along with immediate reporting of concerns to licensed staff - Accurate documentation for residents requiring close monitoring - Safety and supervision during mealtimes, specifically for residents who need total assistance with eating On 3/29/25, facility will initiate a hallway monitoring program where a monitoring aide will do rounds every two hours to identify residents with potential escalating or self-inflicting injuries behaviors. Findings will be logged on a Hallway Monitor Form and will be reported and addressed accordingly. As part of new hire orientation and annual performance evaluation, the DSD/Designee shall provide ongoing staff training and competency development in safety, supervision, and abuse prevention. PERFORMANCE MONITORING The safety committee will perform monthly audits of behavioral incident reports, staff training compliance, and the effectiveness of the hallway monitor program. Findings will be received during monthly safety QAPI meetings, where necessary adjustments to training and monitoring programs will be made based on recommendations. The Administrator/Designee will oversee the continued effectiveness of these systemic interventions and allocate additional resources as needed.
Failure to Ensure Accurate and Complete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were properly informed about their rights to formulate an Advance Directive (AD) and that documentation regarding ADs and Physician Orders for Life-Sustaining Treatment (POLST) was accurate and complete. In several cases, forms were either incomplete, not signed by the appropriate party, or not filled out at all. For example, one resident's POLST and AD Acknowledgement Form were signed by an individual who was not the documented responsible party, and the facility's records did not clarify the authority of the signer. In another instance, a resident's AD Acknowledgement Form was missed entirely during the admission process, which was later acknowledged by the Social Services Designee (SSD) as an oversight. Multiple residents with varying degrees of cognitive impairment and medical complexity were affected by these documentation failures. Some residents were cognitively intact and able to make their own medical decisions, while others were severely or moderately impaired and dependent on staff or responsible parties for decision-making. In several cases, the AD Acknowledgement Forms were not fully completed, with key sections left unchecked regarding whether the resident had executed an AD. Additionally, some POLST forms were not signed and dated by the resident, and in at least one case, the responsible party was incorrectly identified and allowed to sign critical documents. Interviews with facility staff, including the SSD, RNs, LVNs, and the Director of Nursing (DON), confirmed that these omissions and inaccuracies were due to lapses in the admission and documentation process. Staff acknowledged that the forms should be completed upon admission and that incomplete or missing documentation could result in staff not knowing the resident's wishes in emergency situations. The facility's own policy required inquiry about advance directives prior to or upon admission, but this was not consistently followed, as evidenced by the incomplete or missing forms for several residents.
Plan Of Correction
F578: Request/Refuse/Discontinue Treatment; Formulate Adv Dir CORRECTIVE ACTION From 3/21/25 to 3/25/25, the SSD and SSA added an accurately completed copy of the Advance Directive Acknowledgement Form (ADAF) and Physician Orders for Life-Sustaining Treatment (POLST) to the medical records of Residents 5, 6, 11, 35, 37, 41, and 75 signed by residents or appropriate Responsible Party depending on residents' capacity to make decisions. On 3/21/25 the DON conducted an in-service for Licensed Staff, SSD, Medical Records regarding the importance of completing the Advance Directive Acknowledgement Form and Physician Orders for Life-Sustaining Treatment (POLST) accurately signed by resident or appropriate Responsible Party depending on residents' capacity to make decisions upon admission. OTHER RESIDENTS AFFECTED IDENTIFICATION From 3/21/25 to 3/25/25, the SSD and SSA conducted a comprehensive review of all active residents to ensure they had been provided with information on formulating an Advance Directive and that any completed POLST forms were accurate. Upon completion of the review, no additional residents were found to be affected by this deficient practice. MEASURES AND SYSTEMIC CHANGES Upon admission, new residents will be provided with information on how to formulate an Advance Directive. If an Advance Directive is already in place, a copy will be obtained from the resident or their representative and promptly placed in the resident's medical record upon receipt. The SSD/SSA, in coordination with the Medical Records (MR) department, will ensure that all residents receive information on Advance Directives and that a copy is obtained from the resident or their representative, if applicable, and placed in their medical record. The SSD/SSA, in coordination with the Medical Records Director (MRD), will ensure that the Advance Directive Acknowledgment Form (ADAF) is completed and that residents' POLST forms are accurately completed upon admission. MONITORING PERFORMANCE The Social Service Director (SSD) and Administrator will ensure that the above process is consistently maintained. The SSD or designee will report any trends or issues related to providing residents with information on creating an Advance Directive and completing a POLST, as well as confirming whether a copy of the ADAF and POLST is included in the resident's medical record. These reports will be submitted to the QAA Committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Three deficiencies were identified regarding the facility's failure to provide a safe, clean, and homelike environment for three residents. One resident's personal wheelchair went missing two to three weeks prior and was not reported to the Social Services Director as required. The resident, who had moderate cognitive impairment and relied on the wheelchair for mobility, reported the loss to a CNA, but no theft and loss report was initiated. The absence of the wheelchair limited the resident's ability to move freely and participate in activities such as going outside to smoke. Another resident, who had severe cognitive impairment and required assistance for toileting, was found to have a broken toilet seat in their bathroom. The seat was loose and missing a screw, leaving it detached from the toilet rim. The issue was reported by the resident's responsible party to staff, but the seat remained unrepaired at the time of observation. The resident's care plan indicated a risk for injury due to falls, and the broken seat presented a potential hazard during transfers. A third resident, who was dependent for all activities of daily living and had severe cognitive impairment, was found in a room where the patio sliding door could not be fully closed. Cold air was entering the room, and the maintenance supervisor was unable to close the door due to dirt in the track. The door had no screen, and it was noted that it was going to rain that day. The DON confirmed that such conditions were not homelike and could lead to discomfort or illness for the resident. Facility policies required prompt investigation of missing property, maintenance of equipment in good repair, and provision of a homelike environment, but these were not followed in the cited instances.
Plan Of Correction
F 584: Safe/Clean/Comfortable/Homelike Environment CORRECTIVE ACTION Resident 11's personal wheelchair was reported missing to the Social Services Director (SSD), and on 3/7/2025, a replacement wheelchair was provided for Resident 11. On 3/7/2025, Maintenance Director secured and fully attached the toilet seat in Resident 63's bathroom. On 3/10/2025, Maintenance Director repaired Resident 68's patio door to ensure it could be fully closed. OTHER RESIDENT AFFECTED IDENTIFICATION On 3/7/2025, the administrator and maintenance supervisor conducted environmental rounds to ensure all residents had a clean and safe environment. They confirmed that all patio doors could be fully closed and toilet seats were securely attached. No other residents were found to be impacted by the alleged deficiencies. On 3/7/2025, the SSD performed an inventory of residents with personal wheelchairs. No other residents were found to be affected by the alleged deficiency. MEASURES AND SYSTEMIC CHANGES Department heads will perform daily room rounds from Monday to Friday, ensuring that equipment in residents' rooms is in good working condition. Findings will be communicated to the leadership team during the daily standup. Maintenance staff will conduct monthly room rounds for all residents' rooms to verify that doors and toilet seats are in proper working condition. Upon a resident's new admission or issuance of a personal wheelchair, licensed staff must inventory the wheelchair and ensure it is marked for the resident's use only. Any missing or lost personal wheelchairs must be documented in the theft and loss log by the SSD/SSA for resolution. MONITORING PERFORMANCE The Maintenance Supervisor will present the findings from maintenance logs, specifically regarding the environmental inspections of patio doors and toilet seats, to the monthly Safety Committee for three months or until compliance is achieved for further review and recommendations. The Administrator is responsible for ensuring the continuity and sustainability of this process. The SSD will report any instances of lost or missing personal wheelchairs to the monthly QAA Committee for monitoring. 3/28/2025
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for four residents, as required by federal regulations. For one resident with end stage renal disease, Type 1 diabetes mellitus, and a history of myocardial infarction, there was no care plan addressing the administration of an anti-psychotropic medication (Olanzapine). The resident was cognitively intact and able to make medical decisions, but the absence of a care plan meant that staff did not have documented goals or interventions related to the use of this medication. The facility's own policy required individualized care plans with measurable objectives and timetables to be developed within seven days of the comprehensive assessment, but this was not followed. Another resident, with a history of hyperlipidemia, dementia, and cerebral infarct, was involved in a resident-to-resident altercation and attempted to elope from the facility. Despite these significant events, there was no care plan created to address the altercation or the risk of elopement. Staff interviews confirmed that the lack of care plans for these incidents placed the resident at risk for recurrence, as interventions to prevent future incidents were not implemented and the care team was not made aware of the resident's history. A third resident, admitted with respiratory failure, a gastrostomy, and dementia, did not have a care plan for dementia upon admission, despite severe cognitive impairment and total dependence for activities of daily living. Staff and the DON acknowledged that a care plan should have been created at admission to guide care. Similarly, another resident with sickle-cell disease, bipolar disorder, and PTSD did not have a care plan addressing PTSD. Staff were unaware of the diagnosis, and both nursing staff and the DON stated that a care plan was necessary to ensure consistent, individualized care and to address the resident's specific psychological needs. The facility's policy required comprehensive, person-centered care plans for all residents, but this was not consistently implemented.
Plan Of Correction
F656: DEVELOP/ IMPLEMENT COMPREHENSIVE CARE PLAN CORRECTIVE ACTIONS Resident 5 was reassessed on 3/13/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. Resident 196 was transferred to an acute hospital on 3/6/25 for evaluation and treatment per MD order. Resident readmitted to the facility, and the comprehensive care plan was updated reflecting the resident's current status. Resident 37 was reassessed on 3/4/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident to resident altercation and the resident's current status. Resident 68 was reassessed on 3/5/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. Resident 47 was reassessed on 3/5/25, no decline from baseline noted, and the comprehensive care plan was updated reflecting the resident's current status. OTHER RESIDENTS AFFECTED IDENTIFICATION IDT conducted chart review on 3/25/25 and 3/28 to all active residents, including newly admitted residents, to ensure that the plan of care is current and updated to meet the resident needs. Two other residents were found to have been affected by the deficient practice. The comprehensive care plan was reviewed and updated for the affected residents on 3/28/25. DON and/or designee provided in-service to the RNs and LVNs on 3/21/25 about the importance of initiating care plans timely upon admission and updating the resident's care plan for any change of conditions. MEASURES AND SYSTEMIC CHANGES Resident's clinical records will be reviewed by the IDT within 48 hours of admission to check for care plan completion and if special care issues reported by the endorsing hospital are addressed in the care plan. MDS staff will complete the comprehensive care plan within 7 days of a resident's comprehensive assessment to outline the resident's needs, goals, and interventions to promote their well-being. OTHER RESIDENTS AFFECTED IDENTIFICATION IDT conducted chart review on 3/25/25 and 3/28 to all active residents, including newly admitted residents, to ensure that the plan of care is current and updated to meet the resident needs. Two other residents were found to have been affected by the deficient practice. The comprehensive care plan was reviewed and updated for the affected residents on 3/28/25. DON and/or designee provided in-service to the RNs and LVNs on 3/21/25 about the importance of initiating care plans timely upon admission and updating the resident's care plan for any change of conditions. MEASURES AND SYSTEMIC CHANGES Resident's clinical records will be reviewed by the IDT within 48 hours of admission to check for care plan completion and if special care issues reported by the endorsing hospital are addressed in the care plan. MDS staff will complete the comprehensive care plan within 7 days of a resident's comprehensive assessment to outline the resident's needs, goals, and interventions to promote their well-being. MEASURES AND SYSTEMIC CHANGES (CONTINUED) Licensed nurse will update the resident's plan of care within 24 hours for any resident’s COC and special needs lists. PERFORMANCE MONITORING The IDT will conduct care plan meetings within 7 days after admission to discuss the resident's overall care and level of assistance required, then quarterly and as needed for any unusual occurrence. The DON/designee will review the special needs list for accuracy and completeness weekly and as needed. The DON/designee will monitor the corrective action for continuous compliance. Findings will be reviewed by the Director of Nursing/Designees weekly for the first three months and will be presented to the QA committee monthly for three months for further evaluation and recommendations. 3/28/2025
Failure to Follow Professional Standards for Catheter Care and Skin Assessments
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident, who had diagnoses including acute osteomyelitis and cellulitis, there were medical orders to flush a Peripherally Inserted Central Catheter (PICC) and a Midline catheter with normal saline before and after medication administration and at regular intervals for maintenance. Review of the Treatment Administration Record (TAR) revealed multiple blank entries on specific dates, indicating that the required flushing was not performed or not documented. Both the RN Supervisor and the Director of Nursing confirmed that if the procedure was not documented, it was considered not done, and that failure to flush the lines could compromise the patency of the intravenous access. For another resident, who was severely cognitively impaired and dependent for activities of daily living, there was a failure to perform and document weekly skin assessments as required by facility policy. The resident reported having a sore, and observation confirmed the resident was in bed. Interviews with the DON and the treatment nurse revealed that the last documented skin assessment was shortly after the resident's readmission, with no subsequent weekly assessments found in the records. The treatment nurse acknowledged the importance of regular skin assessments and was unable to provide documentation of ongoing monitoring for the resident's skin condition. These deficiencies were identified through interviews, record reviews, and observations, and were confirmed by facility staff. The lack of adherence to medical orders for catheter care and the absence of required skin assessments represented failures to provide care in accordance with professional standards and facility policy.
Plan Of Correction
F684: Quality of Care CORRECTIVE ACTION On 3/27/2025, review of Resident 27 MAR regarding IV flushing showed that flushing is rendered by RN before and after IV medication administration per MD's order. On 3/19/2025 and 3/25/2025, Treatment Nurse with the Nurse Practitioner assessed the skin of Resident 49, and the skin is improving with no complications noted. OTHER RESIDENTS AFFECTED IDENTIFICATION All residents with IV orders were reviewed on 3/10/2025, and no other residents were affected by the deficient practice identified. On 3/27/2025, all residents with skin conditions were reviewed for appropriate assessment and documentation. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, in-service was provided by the DON to Licensed Nurses regarding the importance of flushing pre- and post-medication administration per MD's order for prevention of complications such as clotting and maintaining patency of the access site. On 3/25/2025, in-service was provided by the DON/Designee to Licensed Nurses regarding the importance of weekly skin assessments for residents with skin conditions. DON, ADON, RN Supervisor/Designee will monitor three times weekly the IV MAR to ensure flushing before and after medication administration is rendered per MD's order and is documented promptly in the IV MAR. OTHER RESIDENTS AFFECTED IDENTIFICATION All residents with IV orders were reviewed on 3/10/2025, and no other residents were affected by the deficient practice identified. On 3/27/2025, all residents with skin conditions were reviewed for appropriate assessment and documentation. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, in-service was provided by the DON to Licensed Nurses regarding the importance of flushing pre- and post-medication administration per MD's order for prevention of complications such as clotting and maintaining patency of the access site. On 3/25/2025, in-service was provided by the DON/Designee to Licensed Nurses regarding the importance of weekly skin assessments for residents with skin conditions. DON, ADON, RN Supervisor/Designee will monitor three times weekly the IV MAR to ensure flushing before and after medication administration is rendered per MD's order and is documented promptly in the IV MAR. MEASURES AND SYSTEMIC CHANGES (CONTINUED) DON/Wound IDT, during a weekly wound meeting, will conduct an audit ensuring all residents with skin conditions have skin assessments completed and documented on residents' medical records. MONITORING PERFORMANCE ADON/RN Supervisor will conduct weekly monitoring for four weeks, then monthly thereafter, of IV flushing and skin assessments until 100% compliance is obtained. These reports will be submitted to the QAA committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations. MEASURES AND SYSTEMIC CHANGES (CONTINUED) DON/Wound IDT, during a weekly wound meeting, will conduct an audit ensuring all residents with skin conditions have skin assessments completed and documented on residents' medical records. MONITORING PERFORMANCE ADON/RN Supervisor will do weekly monitoring for four weeks, then monthly thereafter, of IV flushing and skin assessments until 100% compliance is obtained. These reports will be submitted to the QAA committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations.
Failure to Ensure Proper Use of Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The facility failed to provide appropriate treatments and services to prevent the development and promote the healing of pressure ulcers for four residents. For two residents, the low air loss mattresses (LALM) intended for wound management and prevention were found to be set on static pressure rather than alternating pressure, contrary to physician orders and manufacturer instructions. Observations confirmed that the static mode was engaged during times when the residents were not receiving care, and documentation of LALM settings was missing for certain shifts. Staff interviews confirmed that leaving the mattress on static mode could prevent wound healing and increase the risk of skin breakdown, especially for residents unable to reposition themselves. Another resident, who was dependent for activities of daily living and mobility, did not have prescribed heel boots in place for offloading purposes as ordered by the physician. The absence of heel protectors was observed during a room check, and staff acknowledged the importance of following physician orders to prevent pressure ulcers, particularly for residents with limited mobility and increased risk of skin breakdown. Facility policy also emphasized the need to "float heels" or use protective devices as recommended by clinical staff or the physician. Additionally, a fourth resident was found lying on a bariatric LALM that was set at a weight significantly higher than the resident's actual weight. Staff interviews indicated that incorrect mattress settings could compromise the effectiveness of pressure redistribution, increasing the risk of skin breakdown. The resident's physician order required monitoring of proper mattress functioning and placement every shift, but the observed setting did not match the resident's documented weight. Facility policy and the user manual for the mattress system both highlighted the importance of correct settings for optimal support and pressure relief.
Plan Of Correction
F686: Treatment/Service to prevent/heal Pressure ulcer CORRECTIVE ACTION On 3/7/2025, LALM setting was corrected for residents 36, 20, and 16. On 3/7/2025, offloading boots were put on resident 1's feet. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/7/2025, the treatment nurse and licensed nurses checked all residents with LALM and offloading boots to verify that they are being utilized as ordered. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/21/2025, DON/Treatment nurse provided an in-service training to licensed nurses on how to operate air loss mattress for correct setting. DON/designee will randomly check residents' LALM setting weekly to verify that they are correctly set per MD orders. DON/designee will randomly check residents with offloading boots orders if they are properly carried out. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.
Failure to Communicate Pain Management Recommendations and Ineffective Pain Control
Penalty
Summary
The facility failed to implement its pain assessment and management policy for two residents by not communicating pain specialist recommendations to the medical doctor and by not notifying a physician when a resident's pain management was ineffective. For one resident with major depressive disorder and neuropathy pain, the pain specialist recommended attempting nonpharmacological interventions before administering medications and discontinuing Gabapentin. These recommendations were documented in progress notes but were not communicated to the attending physician, and there were no orders or documentation of nonpharmacological interventions being attempted. The resident reported that staff did not try any nonpharmacological interventions for their bilateral leg pain, and the nurse confirmed that the recommendations were not relayed to the physician as required. For another resident with end stage renal disease, Type 1 diabetes, and a recent myocardial infarction, pain management orders included Hydrocodone-Acetaminophen and Gabapentin. Despite ongoing reports of significant pain, with pain scores ranging from 6 to 9 out of 10 over several days, the resident stated that the pain medication was not effective and had informed nurses of this. The medication administration record showed persistent high pain levels, and there was no evidence that the physician was notified about the lack of pain control. A nurse acknowledged not contacting the physician due to being busy, despite recognizing that the pain management was not effective. Both cases demonstrated a failure to follow the facility's policy, which requires a multidisciplinary approach to pain management, including communication of recommendations and monitoring the effectiveness of interventions. The director of nursing confirmed that the pain specialist's recommendations and the resident's complaints should have been communicated to the attending physician, and that these omissions placed the residents at risk of not achieving optimal pain relief.
Plan Of Correction
F 697: Pain Management CORRECTIVE ACTION On 3/6/25, Resident 25 pain medication was reviewed, and non-pharmacologic intervention prior to administering pain medication ordered was given by MD. On 3/27/25, Resident 5 returned to the facility and pain assessment was reviewed and completed. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/27/2025, DON reviewed all orders for residents with pain management to ensure pain medications and non-pharmacologic intervention were performed prior to pain medication administration. No other resident was affected. 3/28/2025
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to meet the needs of three residents, as evidenced by multiple delays in care and unmet resident needs. Resident 5, who was cognitively intact and required assistance with personal hygiene and dressing, reported waiting up to an hour for staff to assist with her nasal cannula for oxygen, both at night and during the day. Resident 6, who was severely cognitively impaired, legally blind, and required substantial assistance with toileting, stated she often waited an hour or more for staff to change her incontinence pad, and had developed a sore on her bottom. Resident 41, who was moderately cognitively impaired and required maximal assistance with bathing and toileting, was observed calling for help from her bed and reported waiting up to two hours for restroom assistance. Staff interviews revealed that CNAs did not consistently follow facility policy regarding the endorsement of resident care when leaving their assigned areas for breaks or lunch. One CNA admitted to not informing another CNA upon returning from lunch, resulting in a lack of coverage for assigned residents. Other CNAs confirmed that the policy required them to endorse care to another CNA when leaving the unit, but this was not always practiced. The DON stated that all staff, including housekeeping, were trained to answer call lights and that call lights should be answered within ten minutes, but observations and resident reports indicated this standard was not consistently met. Resident council feedback and direct resident interviews further corroborated the staffing issues, with residents reporting frequent and prolonged waits for assistance. Facility policies reviewed indicated a requirement for sufficient and competent nursing staff and prompt response to call lights, but these procedures were not consistently followed, resulting in unmet care needs for multiple residents.
Plan Of Correction
CORRECTIVE ACTION On 3/6/2025, staff answered the call lights timely. On 3/21/25, staff were provided in-service by the DON regarding the importance of answering call lights timely and the importance of endorsing resident care before going on breaks and/or leaving for the day. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/24/25, the SSD interviewed 7 alert residents to ask if the call lights are being answered timely. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES During the shift huddle, staff will be reminded to answer call lights promptly and to endorse resident care before going on breaks and/or leaving for the day by the RN supervisor/designee. DON/designee will interview 5 random residents weekly to check if their lights are being answered timely. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.
Failure to Administer and Document IV Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that intravenous antibiotics, Zosyn and Daptomycin, were administered according to the physician's orders for a resident diagnosed with acute osteomyelitis of the left foot and ankle and cellulitis. The resident was admitted and readmitted with these diagnoses and had intact cognitive abilities. Physician orders specified Zosyn IV every eight hours and Daptomycin IV once daily for a set period. Review of the resident's Intravenous Medication Administration Record (IMAR) revealed blank spaces on multiple dates for both medications, indicating missed doses. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that blank spaces on the IMAR meant the medications were not administered as ordered. The facility's policy required that the individual administering the medication document the administration in the resident's Medication Administration Record immediately after giving the dose. The failure to document and administer the antibiotics as ordered was confirmed through interviews and record reviews, with staff acknowledging that the missed doses could impact the resident's treatment for infection. The deficiency was identified through direct review of medical records and staff interviews, which established that the resident did not receive prescribed antibiotics on several occasions.
Plan Of Correction
F755: Pharmacy Services/ Procedure/ Pharmacist/ Records CORRECTIVE ACTION MD notified on the missed dosage of Daptomycin and Zosyn on 3/10/25 on Resident 27. MD's recommendation was to monitor adverse reaction and complication of the missed medication. Resident was assessed by RN on 3/10/25 and no new onset of acute distress noted. OTHER RESIDENTS AFFECTED IDENTIFICATION Review of the residents with IV medication orders was conducted on 3/10/2025 and no other deficient practice was noted. All IV medication orders were being administered as ordered. MEASURES AND SYSTEMIC CHANGES DON/Designee to monitor IV documentation QD x2 weeks then 2x/week x 2 weeks then monthly thereafter to ensure all IV medications are being administered as ordered by MD. Medical record will include in the daily audit the IV MAR for any missed dose of IV medications ordered by MD. DON conducted an in-service on 3/25/2025 to Registered Nurses regarding the importance of administration of IV Medication as ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. DON conducted an in-service on 3/25/2025 to Registered Nurses regarding the importance of administration of IV Medication as ordered by MD. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.
Failure to Follow Psychotropic Medication Policies and Informed Consent Requirements
Penalty
Summary
The facility failed to follow its own policy and federal regulations regarding the use of psychotropic medications for two residents. For one resident, an order for Ativan (lorazepam) 0.5 mg every six hours as needed for anxiety did not include a required 14-day end date. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that PRN psychotropic medications must have a 14-day limit, and the absence of an end date was acknowledged as a risk for unnecessary medication use. The facility's policy also specified this 14-day limitation for PRN psychotropic orders. For another resident, the facility did not obtain a signed informed consent for the use of Olanzapine (an antipsychotic) and Lorazepam. The resident was cognitively intact and had the capacity to make medical decisions, as documented in the medical record. The resident reported refusing the medication and stated that no consent had been signed. Review of the resident's records confirmed that the informed consent forms for these medications were not signed by the resident. The DON and LVN both stated the importance of informed consent, and the facility's policy required written informed consent before initiating psychotropic medications. Additionally, the resident prescribed Olanzapine did not have a documented diagnosis supporting the use of this medication in the admission record, as confirmed by the DON. The facility's policy required that psychotropic medications be prescribed only after a personal examination and with a specific diagnosis documented. The lack of a supporting diagnosis and missing informed consent for psychotropic medication use were direct violations of both facility policy and federal requirements.
Plan Of Correction
F758: Free from Unnecessary Psychotropic Meds/ PRN Use CORRECTIVE ACTIONS Resident 197's Ativan was discontinued on 3/18/25 as ordered by MD. No reports of new onset of acute distress noted related to previously not having a 14-day stop date. On 3/21/25, the SSD validated that the informed consent for Resident's 5 the use of Olanzapine and Lorazepam has been obtained. The informed consent verification was done on 3/21/25. OTHER RESIDENTS AFFECTED IDENTIFICATION The DON/Designee audited all residents on 3/21/25 to 3/28/25 receiving Psychotropic medications if a valid informed consent has been verified. There are 72 residents receiving Psychotropic medications - all informed consents for residents on Psychotropics have been verified from 3/21/25 to 3/28/25. All other residents with PRN psychotropics are noted with a 14-day stop date. MEASURE AND SYSTEMIC CHANGES The DON/Designee initiated education to licensed staff on 3/21/25 to ensure that any residents receiving psychotropic medications shall have an informed consent verified prior to initial administration and all PRN Psychotropics must have a 14-day stop date initially upon ordering. DON/DSD to monitor all PRN medication prescribed to ensure order is limited to 14 days. Bimonthly for 2 months, then monthly for 3 months, then quarterly thereafter. MONITORING PERFORMANCE The DON/SSD will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Medication Error Rate Exceeds Regulatory Limit Due to Dosing and Monitoring Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by federal regulations, resulting in a 12% error rate during a medication administration observation. Specifically, three medication errors were identified out of 25 opportunities involving two residents. One error involved a nurse preparing and nearly administering the wrong dose of acetaminophen to a resident with severe cognitive impairment and a physician's order for a specific dose. The nurse placed two 500 mg tablets in the medication cup instead of the ordered two 325 mg tablets, and acknowledged the error upon review. Another error occurred when a nurse administered Metoprolol and Amlodipine to a resident without first checking the resident's heart rate, as required by the physician's order. The order specified that both medications should be held if the systolic blood pressure was less than 110 or the heart rate was less than 60. The nurse admitted to not checking the heart rate prior to administration, which could have resulted in the medications being given outside of the prescribed parameters. Both residents involved had documented medical histories and cognitive assessments. One resident had dementia and schizophrenia with severely impaired cognitive abilities, while the other had hypertension and heart failure with intact cognition. The facility's policy required staff to verify the correct medication, dose, and administration parameters, but these procedures were not followed during the observed medication passes.
Plan Of Correction
F759: Free of Medication Error Rates 5 Percent or More CORRECTIVE ACTION On 3/7/25, LVN 4 was provided 1:1 in-service regarding checking of heart rate and blood pressure prior to administration of metoprolol and amlodipine. DON/Designee conducted in-service following 5 rights of medication administration, which are the standard of safe practice. OTHERS AFFECTED RESIDENTS IDENTIFICATION On 3/25/2025, the DON randomly followed nurses during med pass to check if residents were given metoprolol or amlodipine after heart rate was checked. No other residents were affected by the deficient practice. On 3/25/25, the DON conducted an in-service for 5 rights in medication of safe practices: > right patient > right dose > right route > right time > right drug And to follow up on the parameter for medications metoprolol and amlodipine and monitor heart rate and blood pressure. MEASURING AND SYSTEMIC CHANGES DON/Designee will perform random skill checks on licensed staff weekly to ensure that blood pressure and heart rate are checked prior to administering medications. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for two residents by not adhering to physician orders and established medication administration protocols. For one resident with a history of hypertension and heart failure, a nurse administered Metoprolol and Amlodipine without first checking the resident's heart rate, despite clear physician orders to hold the medications if the heart rate was below 60 or systolic blood pressure was below 110. The nurse acknowledged not checking the heart rate prior to administration, which was confirmed during observation and interview. For another resident admitted with acute osteomyelitis and cellulitis, intravenous antibiotics Zosyn and Daptomycin were not administered as ordered on multiple occasions, as evidenced by blank entries on the Intravenous Medication Administration Record. Both the nurse supervisor and the Director of Nursing confirmed that the absence of documentation indicated the medications were not given. The facility's policy required medications to be administered according to physician orders, which was not followed in these instances.
Plan Of Correction
F760: Residents are Free of Significant Med Errors CORRECTIVE ACTION On 3/7/25, LVN 4 was provided 1:1 in-service regarding checking of heart rate and blood pressure prior to the administration of metoprolol and amlodipine. Don/Designee conducted in-service following the 5 rights of medication administration, which are the standard of safe practice. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/25/2025, the DON randomly followed nurses during med pass to check if residents were given metoprolol or amlodipine after heart rate was checked. No other residents were affected by the deficient practice. On 3/25/25, the DON conducted an in-service for the 5 rights in medication safe practices: > right patient > right dose > right route > right time > right drug And to follow up on the parameters for medications metoprolol and amlodipine and monitor heart rate and blood pressure. MEASURING AND SYSTEMIC CHANGES DON/Designee will perform random skill checks on licensed staff weekly to ensure that blood pressure and heart rate are checked prior to administering medications. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.
Failure to Provide Required Monthly In-Services to Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff received required monthly in-service training, as evidenced by the lack of in-services provided to food and nutrition services staff. During interviews, the Dietary Supervisor confirmed that no in-services were conducted in 2024 and only a few were held in 2023, despite facility policy requiring monthly in-services. This lapse was further highlighted when a dishwasher staff member, who had been working morning shifts for the past three months, stated they did not check the chlorine parts per million (ppm) in the dishwashing machine, did not know the purpose of chlorine in the machine, and had never checked the chlorine ppm prior to washing dishes. Observation in the kitchen revealed that the chlorine ppm was at zero, when it should have been at 100 ppm, indicating a failure in proper sanitizing practices. The Dietary Supervisor acknowledged that without regular in-services, staff would not be aware of the correct and current procedures for sanitizing and handling equipment. The facility's own policy and procedure document specified that food and nutrition services staff should be in-serviced at least monthly, a requirement that was not met.
Plan Of Correction
F801: Qualified Dietary Staff CORRECTIVE ACTION On 03/11/25, Dietary Supervisor conducted a 1:1 staff in-service to dishwasher 1 regarding the facility policy and procedure of sanitizing, dishwashing practice, and handling equipment. On 03/11/25, Dietary Supervisor performed skills check regarding sanitizing, dishwashing practice, and handling equipment. OTHER RESIDENTS AFFECTED IDENTIFICATION On 03/11/25, Dietary supervisor conducted in-service to dietary staff regarding the facility policy and procedure of sanitizing, dishwashing practice, and handling equipment. On 03/11/25, Dietary supervisor performed skills check to dietary staff regarding sanitizing, dishwashing practice, and handling equipment. Dietary staff will conduct daily dishwasher chlorine check and temperature using the form titled "Daily Dishwasher Chlorine and Temperature Log." MEASURES AND SYSTEMIC CHANGES Dietary supervisor/designee will conduct in-service upon hire and monthly every 1st of the month for 3 months, and annually thereafter, regarding dietary staff duties and responsibilities. Dietary supervisor/designee will conduct competency skills training upon hire and monthly every 1st of the month for 3 months, and annually thereafter, regarding dietary staff duties and responsibilities. Dietary supervisor will review the daily dishwasher chlorine check and temperature log; any significant findings will be discussed with the administrator. MONITORING PERFORMANCE The Administrator/Designee will review the daily dishwashing chlorine and temperature log weekly, and any significant findings or trends will be reported to the QAA committee during the monthly meeting for review and recommendations for any deficient practice for 3 months.
Deficient Food Storage and Dishwashing Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's food storage and sanitation practices. Food items such as apple sauces, mandarin oranges, fruit cocktail, and boxes of milk were not dated with the received date, and several opened items including muffin mix, powdered sugar, baking soda, peanut butter, cottage cheese, cream cheese, pepperoni, salad dressing, and milk lacked an opened date. Additionally, a peanut butter canister was found with crusted peanut butter and jelly on its exterior and stored unsanitarily in dry storage. Other issues included undated grilled cheese sandwiches and expired chicken pozole in the refrigerator. The Dietary Supervisor confirmed that these items should have been properly dated and stored, and acknowledged the unsanitary condition of the peanut butter canister, which could attract pests. Further deficiencies were observed in the facility's dishwashing and sanitation procedures. The dishwasher's chlorine parts per million (ppm) was not checked before use, and a reading of zero ppm was recorded during the survey, indicating that dishes were not being sanitized. The Dietary Supervisor and Registered Dietician confirmed that the chlorine level should be between 50 to 100 ppm and that staff were not consistently monitoring or reporting out-of-range chlorine levels. Review of the facility's logs showed missing and out-of-range chlorine readings that were not reported or addressed. Facility policies required proper labeling, dating, and dishwashing procedures, but these were not followed, leading to the cited deficiencies.
Plan Of Correction
F812: Food Procurement, Store/Prepare/Serve - Sanitary CORRECTIVE ACTION Dietary supervisor/staff discarded apple sauces, mandarin oranges, fruit cocktail, and boxes of milk that were not dated. Removed the vanilla extract from the dry storage when it was opened on 11/22/2024 and removed the chicken pozole from refrigerator 1 (Ref 1) when the use-by date of 2/27/2025 had passed. Also removed opened muffin mix, powdered sugar, baking soda, peanut butter, cottage cheese, cream cheese, pepperoni, salad dressing, and a liter of milk, peanut butter, and a bag of grilled cheese sandwiches in Ref 1. On 03/11/25, Dietary Supervisor conducted a 1:1 staff in-service with dishwasher 1 regarding the facility policy and procedure of sanitizing, dishwashing practice, and handling equipment. On the same day, the Dietary Supervisor performed a skills check with dishwasher 1 regarding sanitizing, dishwashing practice, and handling equipment. Additionally, on 03/11/25, the Dietary Supervisor conducted an in-service to dietary staff regarding the facility policy and procedure of sanitizing, dishwashing practice, and handling equipment, followed by a skills check with dietary staff on the same topics. On 03/17/25, the Dietary supervisor/designee conducted an in-service and skills check regarding food safety, specifically focusing on labeling and dating of food. On 03/25/25, the Dietary supervisor conducted an in-service to dietary staff regarding the policies and procedures for Kitchen logs, including food temperature, dishwasher log, refrigerator logs, and thawing. OTHER RESIDENTS AFFECTED IDENTIFICATION The Dietary supervisor removed all other food that was not labeled and dated. Dietary supervisor/designee conducted an in-service and skill check on 03/17/25 regarding food safety, specifically labeling and dating of food. Dietary staff will check refrigerator temperature using the form titled "Refrigerator/Freezer Temperature Log" and check chlorine levels during dishwashing using the form titled "Daily Dishwasher Chlorine and Temperature Log." MEASURES AND SYSTEMIC CHANGES Dietary supervisor/designee will review the Refrigerator/Freezer Temperature Log and the Daily Dishwasher Chlorine and Temperature Log. Any significant findings will be discussed with the Administrator. Dietary supervisor/designee will conduct in-service upon hire, monthly on the 1st of the month for three months, and annually thereafter regarding food safety, including labeling and dating of food. They will also conduct competency skills training upon hire, monthly on the 1st of the month for three months, and annually thereafter on the same topics. The Administrator/Designee will review the daily dishwashing chlorine and temperature logs and the Refrigerator/Freezer Temperature Log weekly. Any significant findings or trends will be reported to the QAA committee during the monthly meeting for review and recommendations for three months.
Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control program for 58 out of 91 sampled residents by not initiating appropriate measures after a certified nursing assistant (CNA) was diagnosed with scabies. The CNA had worked multiple shifts and had direct contact with numerous residents before being diagnosed. Despite the CNA notifying the Director of Staff Development (DSD) about her diagnosis and expressing concerns about a possible outbreak, the DSD did not immediately notify the Infection Preventionist (IP), and no timely line listing, contact tracing, or monitoring was initiated. The facility's own policies required immediate communication and surveillance in such cases, but these were not followed, and only a limited number of residents with rashes were later identified and seen by a dermatologist. Staff also failed to use proper personal protective equipment (PPE) during high-contact care activities. In one instance, a licensed vocational nurse (LVN) provided direct care to a resident on Enhanced Barrier Precautions (EBP) due to a dialysis port without donning the required PPE. The LVN acknowledged the lapse and stated that gloves, gown, and mask should have been used. Additionally, for another resident with a gastrostomy tube and an EBP order, there was no PPE or EBP signage posted outside or inside the room, and staff confirmed that EBP should have been implemented immediately upon admission or readmission. Other infection control lapses included a nasal cannula being left on the floor while in use for a resident receiving oxygen, which staff recognized as a risk for infection. Furthermore, a resident with an active infection requiring contact isolation was cohorted with another resident who had a dialysis catheter, contrary to facility policy that prohibits such cohorting when the roommate has invasive devices. These failures were confirmed by staff interviews and review of facility policies, which outlined the necessary precautions and procedures that were not followed.
Plan Of Correction
F880: Infection Prevention and Control CORRECTIVE ACTION On 3/6/2025, IP nurse started the line listing and isolation for residents who were exposed to CNA 12. On 3/7/2025, the residents who were exposed to CNA 12 were put on isolation precautions. On 3/7/2025, LVN 3 was provided an in-service regarding the importance of following isolation protocol. Sign for EBP was posted and isolation cart was put outside of resident 68's room on 3/6/2025 by the IP nurse. CORRECTIVE ACTION (CONTINUED) On 3/5/2025, the oxygen tubing was immediately replaced by the charge nurse. On 3/3/2025, resident 27 was already off isolation. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/13/2025, residents who were not in CNA 12's run but had rashes were put on isolation precautions. On 3/14/2025, residents who were exposed to CNA 12 who had rashes and residents who were not in CNA 12's run but had rashes had skin scrapings done to test for scabies. On 3/17/2025, the results for the skin scraping were negative for all the tested residents. Isolation precautions were removed. On 3/10/2025, CNA 12 was cleared back to work by the IP nurse. On 3/7/2025, the IP nurse reviewed all residents that needed to be on EBP and checked if there were any other rooms that needed signage, and appropriate PPE was provided outside of the room. No other resident was affected by the deficient practice. CORRECTIVE ACTION (CONTINUED) On 3/5/2025, the oxygen tubing was immediately replaced by the charge nurse. On 3/3/2025, resident 27 was already off isolation. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/13/2025, residents who were not in CNA 12's run but had rashes were put on isolation precautions. On 3/14/2025, residents who were exposed to CNA 12 who had rashes and residents who were not in CNA 12's run but had rashes had skin scrapings done to test for scabies. On 3/17/2025, the results for the skin scraping were negative for all the tested residents. Isolation precautions were removed. On 3/10/2025, CNA 12 was cleared back to work by the IP nurse. On 3/7/2025, the IP nurse reviewed all residents that needed to be on EBP and checked if there were any other rooms that needed signage, and appropriate PPE was provided outside of the room. No other resident was affected by the deficient practice. On 3/5/2025, the IP nurse went into the other residents' rooms to check if there are any other oxygen tubing that needed to be replaced. No other resident was affected by the deficient practice. On 3/5/2025, the IP nurse reviewed all isolation orders and verified that they were carried out. No other resident was affected by the deficient practice. On 3/7/2025, resident 62 was assessed to check if there are any infections that were received during cohorting. No negative findings were found. MEASURES AND SYSTEMIC CHANGES On 3/12/2025, the IP nurse/designee started to provide in-services to staff regarding the importance of following isolation protocol and proper PPE for EBP. IP nurse/designee provided an in-service regarding the importance of clear communication between departments, especially regarding infectious conditions like scabies, starting on 3/7/2025. ON 3/21/2025, the clinical consultant provided additional in-service to the DSD and IP regarding the importance of clear communication between departments, especially regarding infectious conditions like scabies. On 3/10/2025, the IP nurse provided an in-service to department heads regarding the daily (Monday to Friday) room rounds to check for oxygen tubing on the floor and replace them as needed. During the daily (Monday to Friday) standup meeting, the department heads will discuss any infection control concerns, including staff and resident being exposed to infectious diseases. Starting 3/10/2025, the IP nurse/designee will do daily rounds to check if staff are following infection control protocols including wearing proper PPE during care for residents on EBP. During the daily (Monday to Friday) standup meeting, the department heads will discuss and correct any found oxygen tubing on the floor. During the daily (Monday to Friday) standup meeting, the DON/designee will review new admissions and verify if isolation/EBP is needed and was carried out. PERFORMANCE MONITORING DON/designee will report any findings/trends during monthly QAA meeting for review x90 days or until substantial compliance has been met.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
Facility staff failed to maintain the dignity and privacy of a resident with an indwelling catheter by not placing the catheter drainage bag inside a privacy bag, as required by the facility's policy and procedure on 'Quality of Life-Dignity.' The resident, who had diagnoses including metabolic encephalopathy, diabetes mellitus, and a sacral pressure ulcer, was dependent on staff for mobility and required substantial assistance with activities of daily living. During an observation, the resident's catheter drainage bag was found uncovered, and both the Treatment Nurse and Director of Nursing confirmed that a privacy bag was not in use, despite acknowledging its importance for resident dignity and privacy. The facility's policy specifically prohibits practices that compromise resident dignity and directs staff to help residents keep urinary catheter bags covered. The failure to follow this protocol was confirmed through staff interviews and record review, demonstrating a lapse in adhering to established standards designed to protect resident privacy and dignity.
Plan Of Correction
F550: Resident Rights/ Exercise of Rights CORRECTIVE ACTION On 3/4/25, the Treatment Nurse for Resident 16 placed the indwelling catheter drainage bag in a dignity privacy (a discreet cover designed to conceal a urine drainage bag). On dates: 3/4/25 to 3/7/25, the Licensed Staff monitored any changes of condition, particularly behavior changes as it relates to resident 16's dignity, privacy, and comfort. Resident 16 did not have any changes of condition at the time, and all needs were met. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/21/25, the Treatment Nurses (TN) checked all residents with orders for indwelling catheter to ensure that all have privacy dignity bags. No other residents were affected by this alleged deficient practice. All residents with indwelling/condom catheter orders have privacy dignity bags as of 3/21/25. MEASURES AND SYSTEMIC CHANGES In-service was conducted by DON/Designee to Nursing Staff from 3/21/25 to 3/25/25 regarding placement of privacy dignity bags for all residents with indwelling catheters to ensure that quality of life, care tasks, toileting, and promote dignity and respect. The TNs shall monitor daily placement of privacy dignity bags for all residents with indwelling catheters. On 3/21/25, the DSD/Designee provided education to CNAs to ensure that all residents with urinary catheters shall have a privacy dignity bag in place QS. PERFORMANCE MONITORING The Department Managers, during daily rounds Monday to Friday, shall monitor the placement of privacy dignity bags for residents with indwelling catheters. Any negative findings shall be escalated to the licensed staff for correction and reported during daily stand-up meetings to the DON/Designee. PERFORMANCE MONITORING (CONTINUED) The Administrator/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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