Mission Carmichael Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 3630 Mission Avenue, Carmichael, California 95608
- CMS Provider Number
- 056304
- Inspections on file
- 31
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mission Carmichael Healthcare Center during CMS and state inspections, most recent first.
Two residents who required assistance with eating, including one with severe cognitive impairment and GERD and another with dysphagia, were observed being fed while not properly positioned upright as required by their care plans and facility policy. Staff fed these residents while they were lying down or with the head of bed below 30 degrees, contrary to established protocols for safe feeding.
Discontinued non-controlled prescription medications and those left after a patient's discharge were not consistently destroyed in the presence of two licensed nurses, as required. Logbook reviews showed missing or incomplete signatures, and interviews with the IP, PC, and DON confirmed that the process was not being followed, increasing the risk for diversion or misuse.
Two residents experienced medication administration errors when a nurse gave insulin before a meal was available and another nurse administered pantoprazole outside the prescribed time window, resulting in a facility-wide medication error rate of 6.67%, which is above the acceptable 5% threshold.
Surveyors identified deficiencies in medication management, including an opened, unlabeled glucose gel tube left in a medication cart, a discharged resident's medications with an open pill bottle stored in a bag in the medication room, and a medication refrigerator operating above the recommended temperature range while containing insulin and other sensitive medications. Staff confirmed these practices did not follow facility policy or professional standards.
Surveyors found that food items in the kitchen, refrigerator, freezer, and dry storage were not properly labeled with open or use by dates, and some had lapsed use by dates. Several dented cans were stored with non-dented cans, and one was being prepared for use. Staff interviews confirmed knowledge of required food safety practices, but these were not followed, creating potential food safety risks.
Personal belongings were stored in medication carts with pharmaceuticals, two CNAs provided care to a resident on enhanced barrier precautions without required PPE gowns, and a nurse practitioner failed to wear a facemask during a respiratory infection outbreak, all contrary to facility policy and infection control standards.
Several residents with severe cognitive and physical impairments were found without accessible or working call light systems, including instances where call light buttons were on the floor, missing, or broken, and where bathroom call systems were not available. Staff and the DON confirmed that call lights should be within reach and functional, as required by facility policy.
A resident admitted with a PICC line for IV Vancomycin due to septic arthritis did not have a baseline care plan initiated within 48 hours of admission. The DON confirmed that no care plan addressing the PICC line was developed, despite facility policy requiring such plans for new admissions.
A resident with multiple medical conditions did not consistently receive wound care treatments as ordered by the physician. Review of treatment records and staff interviews confirmed that wound care was missed on several occasions, despite facility policies and care plans requiring licensed nurses to perform and document these treatments according to physician orders.
A resident with hand contractures did not have the ordered contracture device applied to the right hand on several observed occasions, despite care plan and OT orders requiring devices on both hands at all times. Multiple staff confirmed the device was missing, and facility leadership acknowledged the expectation for compliance with such orders.
A resident with severe cognitive impairment and a history of UTIs experienced increased confusion and frequent urination. Although a STAT urinalysis was ordered to rule out infection, the urine sample was not collected and processed in a timely manner, resulting in delayed detection and care. The resident's condition worsened, leading to transfer to an acute hospital. Facility policy and laboratory agreements required prompt action for STAT orders, but this was not followed.
A resident with respiratory failure, CHF, and asthma was observed receiving oxygen at 5 LPM, despite a physician's order for 2-3 LPM. Multiple staff confirmed the higher setting, and the care plan and facility policy required adherence to prescribed oxygen levels. This failure resulted in improper delivery of respiratory care.
A resident with multiple diagnoses did not have pharmacist-recommended changes implemented for their anti-acid, breathing, and PRN pain medications. The consultant pharmacist's recommendations, including specific administration instructions and the addition of non-pharmacological interventions, were not documented or applied in the resident's orders, as confirmed by the ADON. This was not in accordance with facility policy requiring staff to act on medication regimen review recommendations.
Staff failed to follow facility policy requiring all food brought in by families or visitors to be labeled with the resident's name, date received, and use-by date. Unlabeled food items, including cooked noodles, jam, and juice, were found in a resident refrigerator, and staff confirmed that these procedures were not followed for multiple residents.
A resident with polyosteoarthritis and other conditions did not receive the prescribed frequency of physical therapy sessions, as several sessions were missed. The facility's policy required adherence to the therapy plan, but the frequency was not followed, risking the resident's mobility improvement.
A resident's medications were left unattended at the bedside, posing a safety concern. The resident, with anxiety and chronic pain syndrome, had no documented assessment or care plan for self-administration of medications. Facility policies require medications to be administered within one hour and self-administration to be approved by a physician and interdisciplinary team, but these were not followed.
A resident with paraplegia and moderate cognitive impairment was physically abused by another resident who was cognitively intact, resulting in injury and pain. The incident occurred when the second resident, upset by a racial slur, hit the first resident with a cane. The facility's policy on abuse was not effectively implemented to prevent this incident.
A resident with parkinsonism and depression alleged that a female staff member grabbed his arm, resulting in a wrist fracture. Despite the resident's daughter reporting the incident to nursing staff, the facility failed to report the abuse allegation to the state agency within the required timeframe, delaying the investigation.
The facility failed to hire a qualified Director of Food and Nutrition Services. The Dietary Manager had not completed the necessary certification or training, and the Consultant Registered Dietitian's role did not include supervisory duties. This deficiency had the potential to lead to foodborne illness for the 124 residents eating facility-prepared meals.
The facility failed to store, prepare, and distribute food in accordance with professional standards, leading to potential foodborne illnesses. Issues included improper labeling, expired foods, unsafe storage temperatures, uncovered food items, ice buildup in the freezer, dirty cutting boards, and a rusted can opener.
The facility failed to assist three residents with nail care, resulting in long, dirty, and jagged fingernails. One resident had severe cognitive impairment and required substantial assistance, another had intact cognition but needed moderate assistance, and the third was dependent on assistance for personal hygiene. Staff confirmed the poor condition of the residents' nails, and clinical records showed no documented refusals of care.
The facility failed to maintain pharmacy services when controlled drug record forms were inaccurately signed for five discharged residents, suggesting that controlled drugs were given to residents at discharge instead of being destroyed by the nurse. The DON verified this discrepancy, acknowledging the potential for drug diversion.
The facility failed to ensure proper medication storage and labeling, leading to deficiencies such as loose pills, undated and expired medications, and improper storage. These issues were verified by LNs and acknowledged by the DON, posing risks to resident safety and care quality.
The facility failed to prepare and serve food that conserved nutritive value, flavor, and appearance, and served food at unappetizing temperatures. Vegetables were heated for over two hours, pureed meals were prepared without measuring ingredients, and pureed food was prepared in a dirty food processor bowl. These actions led to potential poor intake, malnutrition, and weight loss among the 124 residents eating facility-prepared meals.
The facility failed to accommodate food allergies and preferences for six residents, leading to potential health risks. Issues included serving incorrect food items, not adhering to dietary restrictions, and serving cold or lukewarm food. The facility's policy required documentation and review of resident preferences, but this was not consistently followed.
The facility failed to maintain an effective infection prevention and control program, including dusty linen carts and shelves, unlabeled nasal cannulas and IV tubing, and a urinary catheter bag touching the floor. These lapses could lead to infection and cross-contamination among residents.
The facility failed to ensure essential kitchen equipment, including the ice machine and oven, were in safe operating conditions. The ice machine had issues with randomly shutting off, and the right side of the oven was non-functional, affecting meal preparation and thermometer calibration.
The facility failed to ensure the privacy and dignity of a resident with severe memory impairment and total dependence on staff for ADLs. During care, the door was open, and privacy curtains were not pulled, exposing the resident's lower body to the hallway. This was confirmed by the Medical Record Assistant and the Director of Nursing, and acknowledged as an oversight by the involved Licensed Nurse.
The facility failed to ensure call light accessibility for two residents, resulting in their inability to call for help when needed. One resident's call light was repeatedly found on the floor, while another resident with hand contractures was not provided with an appropriate call light type.
The facility failed to complete a comprehensive assessment for a resident within the regulatory time frame. The resident, admitted with multiple diagnoses, had an overdue MDS, confirmed by staff. Observations showed the resident was alert but minimally responsive. The delay was due to pending input from social services, as confirmed by the MDS Director.
The facility failed to complete baseline care plans (BCPs) within 48 hours for two residents, leading to incomplete assessments and potential unmet care needs. One resident had missing assessments in the Dietary/Nutritional Status and Social Services sections, while another had an incomplete Social Services section and unaddressed limb prosthesis. Staff confirmed the deficiencies and acknowledged the failure to meet the required timeframe.
The facility failed to provide appropriate treatment and services to maintain or improve mobility for two residents. Both residents did not receive the prescribed restorative nursing program (RNA) exercises three times a week as required, potentially leading to a decline in their range of motion and mobility.
The facility failed to ensure a safe environment for a resident with mobility issues due to an uneven pathway in the designated smoking area. Despite the resident's concerns and the facility's policies emphasizing safety, the cracks in the sidewalks were not addressed, posing a risk of accidents and injuries.
The facility failed to ensure proper delivery of respiratory care for a resident with COPD, respiratory failure, and dementia. The resident was observed using an oxygen concentrator set at 5 LPM instead of the prescribed 2 LPM, with no documentation of titration to maintain oxygen saturation. The DON confirmed that physician's orders should always be followed, and the facility's policy emphasized the importance of adhering to these orders.
Failure to Properly Position Residents During Feeding Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with eating were properly positioned during feeding, as specified in their care plans and the facility's meal assistance policy. One resident, with diagnoses including COPD and GERD and severe cognitive impairment, was observed being fed while lying on their left side with the head of bed lower than 30 degrees, contrary to care plan instructions to keep the head of bed elevated at 30-45 degrees and avoid lying down during and after meals. The staff member confirmed feeding the resident in this improper position. Another resident, dependent on staff for eating and with a diagnosis of dysphagia, was observed being offered food while in a supine position with the head of bed lower than 30 degrees, despite care plan instructions to maintain the head of bed at 30-45 degrees during feeding. The staff member acknowledged attempting to feed the resident in this position and stated that residents should be upright when eating. Facility policies reviewed also required residents to be positioned upright during meals, but these were not followed during the observed incidents.
Failure to Properly Witness and Document Destruction of Non-Controlled Medications
Penalty
Summary
The facility failed to ensure that discontinued non-controlled prescription medications and those remaining after a patient's discharge were destroyed in accordance with policy and regulatory requirements. Specifically, the destruction of these medications was not consistently witnessed and signed by two licensed nurses, as confirmed by a review of the non-controlled medication disposition logbook. Multiple entries in the logbook showed either only one nurse's signature or no signatures at all, indicating that the required process was not being followed on several occasions and with multiple medications. Interviews with the Infection Preventionist, Pharmacy Consultant, and Director of Nursing all confirmed that the destruction of non-controlled medications should be witnessed and signed by two licensed nurses. The facility's own policy also requires that the destruction of unused, contaminated, or expired prescription drugs be witnessed and documented in accordance with state laws, including signatures from the appropriate staff. The lack of proper documentation and witnessing of medication destruction created a potential risk for diversion or misuse of non-controlled medications.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 6.67%, which exceeds the acceptable threshold of 5%. During medication administration observations, two errors were identified out of 30 opportunities involving two residents. In one instance, a nurse administered Insulin Lispro to a resident with type 1 diabetes mellitus before the resident received their meal, despite the physician's order specifying administration before meals. The resident's blood sugar was checked and insulin was given, but the meal tray was delayed, and the resident did not begin eating until nearly an hour after the insulin was administered. The pharmacy consultant confirmed that Insulin Lispro should be given before meals to avoid hypoglycemia, and the nurse did not follow the physician's order in this case. In another instance, a nurse administered pantoprazole to a resident at 9:20 a.m., although the medication was scheduled for 7:30 a.m. per the physician's order and the Medication Administration Record. The pharmacy consultant stated that pantoprazole should be administered within one hour before or after the scheduled time to maintain its efficacy. The facility's policy also requires medications to be administered within 60 minutes of the scheduled time unless otherwise ordered. These actions demonstrate a failure to follow physician orders and facility policy regarding medication administration timing.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. An opened, unlabeled glucose gel tube was found in a medication cart, with confirmation from nursing staff and the pharmacy consultant that the gel was intended for single use only and should have been disposed of immediately after administration. The lack of labeling and improper storage created a risk that the gel could have been administered to more than one resident. Additionally, a discharged resident's medications, including an opened pill bottle with loose pills, were found stored in a plastic bag in the medication room, contrary to facility policy and professional standards. The infection preventionist confirmed that these medications were kept for up to seven days in case the resident returned, but acknowledged that open medication bottles posed a risk for drug diversion and were not suitable for return to the resident. Further, the refrigerator in the North medication room was found to be operating at 51 degrees Fahrenheit, above the recommended temperature range for medication storage. The refrigerator contained insulin vials, emergency medication kits, and vaccination vials. Both the infection preventionist and pharmacy consultant confirmed that storing medications at this temperature could compromise their efficacy and safety. Facility policies reviewed by surveyors required proper labeling, storage, and timely disposal of medications, as well as maintenance of appropriate refrigerator temperatures, but these were not followed in the instances observed.
Improper Food Storage, Labeling, and Use of Dented Cans
Penalty
Summary
Surveyors observed multiple failures in food storage and labeling practices within the facility's kitchen and storage areas. In the freezer, several opened food items, including garlic bread, pork sausage links, and fish fillets, were found without labels indicating the open and use by dates. Similarly, in the walk-in refrigerator, opened containers of mustard and honey mustard dressing were not labeled with open or use by dates. In the dry storage room, items such as corn meal and cake mix were found with lapsed use by dates, while soy sauce and a white powder were missing open and use by date labels, with the latter also having an unreadable name label. Additionally, four dented cans containing various food products were stored alongside non-dented cans, and one dented can of tomato soup was observed being prepared for use. Interviews with the Dietary Manager, kitchen staff, and the Registered Dietician confirmed awareness of the facility's policies requiring proper labeling and removal of expired or damaged food items. Staff acknowledged that perishable foods should be labeled with the product name, open date, and use by date, and that dented cans should not be used due to safety concerns. The facility's own policies and FDA Food Code guidelines were reviewed, supporting the need for these practices to prevent foodborne illness. The observed failures in labeling, storage, and handling of food items had the potential to compromise food safety for the facility's residents.
Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several observed deficiencies. Personal belongings of residents, such as rings, phone chargers, hearing aids, compact discs, eyeglasses, and keys, were found stored in medication carts alongside pharmaceutical products, including controlled medications. Multiple licensed nurses confirmed the storage of these items in the medication carts, stating it was done to keep the items safe. The Infection Preventionist did not initially recognize this as an issue, but the Pharmacy Consultant and Director of Nursing both acknowledged that storing personal items with medications could lead to cross-contamination and was not in line with facility policy. In another instance, two certified nursing assistants provided direct care, specifically bed baths, to a resident with a history of multidrug-resistant organism infection and an unhealed stage 4 pressure ulcer, without wearing the required personal protective equipment (PPE) gowns. Both CNAs acknowledged that enhanced barrier precautions, including gowns, should have been used due to the resident's condition and the presence of a feeding tube and wound. The care plan and facility policy confirmed the need for PPE during high-contact care activities for residents on enhanced barrier precautions. The Director of Nursing and Infection Preventionist both confirmed that the expectation was for staff to wear gowns, masks, and gloves in these situations. Additionally, a nurse practitioner was observed not wearing a facemask in a hallway, despite the facility's active respiratory infection precautions and a directive from the Director of Nursing that all employees must wear masks. The nurse practitioner acknowledged the requirement. Facility policy also indicated that appropriate PPE, including masks, should be used to decrease the risk of transmission during respiratory infection outbreaks.
Failure to Ensure Accessible and Functional Call Light Systems
Penalty
Summary
The facility failed to ensure that the call light system was accessible and functional for five out of 29 sampled residents. In two cases, residents with severe cognitive impairment and significant physical dependencies were found in their rooms with their call light buttons on the floor and out of reach. Staff confirmed that the call light buttons should have been within reach, as documented in the residents' care plans and the facility's policies. Both residents required substantial or maximal assistance with daily activities and were unable to access the call system independently. Another resident, also with severe cognitive impairment and high dependency for daily care, was observed with a broken call light system. The call light wire was on the floor and the button was missing, rendering the system nonfunctional. Staff acknowledged the issue and stated that the resident was capable of using a call light if it were available and working. The DON confirmed that the expectation was for all residents to have a functional call light system. Additionally, two residents did not have an available bathroom call system. The facility's policies require that call lights be accessible to residents in their rooms and that staff ensure the system is within reach and functional. These failures were identified through observation, interview, and record review, and were not in accordance with the facility's own procedures for accommodating residents' needs and ensuring timely response to requests for assistance.
Failure to Initiate Baseline Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to initiate a baseline care plan within 48 hours of admission for a resident who was admitted with a peripherally inserted central catheter (PICC) line for intravenous antibiotic administration. Upon review, it was found that the resident was admitted with a diagnosis of septic arthritis of the right knee and required IV Vancomycin via the PICC line. Despite these needs, there was no care plan in place addressing the care and management of the PICC line following admission. The Director of Nursing confirmed during interview and record review that the resident did not have a care plan for the PICC line, despite facility policy requiring a baseline care plan to be developed and implemented for each resident to ensure effective and person-centered care. The lack of a care plan for the PICC line was verified by both documentation review and staff interview.
Failure to Consistently Provide Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure that physician orders for wound care treatments were consistently followed for one resident with multiple complex medical conditions, including morbid obesity, venous insufficiency, and immunodeficiency. Review of the Treatment Administration Records (TAR) for February and March 2025 revealed that several wound care treatments, as ordered by the physician, were not administered on specific days and shifts. The Assistant Director of Nursing confirmed that these treatments were missed and acknowledged that it was the responsibility of the licensed nurse to perform and document the treatments as ordered. The resident's care plan, initiated in early February 2025, specified that wound care should be provided per treatment orders, and the facility's job descriptions and policies required licensed nurses to perform wound treatments according to physician orders. Despite these requirements, documentation showed that wound care was not provided as ordered on at least three occasions. The facility's policies also emphasized the need for qualified staff to deliver care in accordance with professional standards and individualized care plans, but these standards were not met in this instance.
Failure to Apply Ordered Contracture Device to Resident's Hand
Penalty
Summary
A deficiency was identified when a resident with contractures in both hands did not have the ordered contracture device applied to the right hand on multiple occasions. Observations in the resident's room revealed that the contracture device was consistently missing from the right hand, despite care plan and occupational therapy orders specifying that devices should be worn on both hands 24 hours a day. Certified Nursing Assistants, a Licensed Nurse, and a Restorative Nursing Assistant all confirmed during interviews that the device was not in place and acknowledged the expectation for the device to be applied as ordered. Record reviews showed that the resident's care plan and occupational therapy evaluation required continuous use of contracture devices for both hands. Facility leadership, including the Assistant Director of Rehabilitation, Director of Nursing, and Director of Staff Development, confirmed that staff are expected to follow these orders and care plans. The facility's policy also indicated the importance of maintaining or improving residents' abilities through restorative nursing programs, including the use of splints or braces. The failure to implement the ordered contracture device for the resident's right hand constituted the deficiency.
Delayed STAT Urinalysis Collection and Processing for Resident with Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of metabolic encephalopathy, urinary tract infection (UTI), sepsis, and ESBL resistance exhibited a change in mental status and increased urinary frequency. The resident, who was always incontinent of bowel and bladder and had severely impaired cognition, was observed to be more confused than baseline. A certified nurse assistant notified a licensed nurse, who assessed the resident and contacted the nurse practitioner. A STAT urinalysis (UA) was ordered to rule out a possible UTI, with instructions to collect a urine sample immediately and use straight catheterization if necessary. Despite the STAT order, the urine sample was not collected and picked up in a timely manner. Progress notes indicated that the lab was notified and the order was faxed, but the specimen was not collected until two days later. The laboratory manager confirmed that STAT orders are typically processed within four hours, but in this case, the specimen was only collected and picked up several days after the order was placed. During this period, the resident's confusion worsened, and the resident was eventually sent to an acute hospital for further evaluation due to the deteriorating condition. The facility's agreement with the laboratory service provider required prompt handling of STAT orders, and facility policy mandated timely provision of laboratory services. However, the delay in collecting and processing the urine sample resulted in a failure to provide adequate services for the prevention and early detection of a possible UTI, as evidenced by the abnormal findings in the urinalysis once it was finally completed.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
Staff failed to follow a physician's order for oxygen therapy for one resident with multiple respiratory diagnoses, including respiratory failure, congestive heart failure, and asthma. The resident was admitted in March 2025 and had an intact cognitive status. The physician's order specified oxygen administration at 2-3 liters per minute (LPM) every shift. However, during multiple observations on consecutive days, the resident was found receiving oxygen at 5 LPM via nasal cannula. Both a CNA and a licensed nurse confirmed the oxygen was set at 5 LPM during their respective interviews and observations. The resident's care plan intervention directed staff to administer oxygen as prescribed or per standing order. The facility's policy on oxygen administration required that oxygen be given according to physician orders. The DON confirmed that oxygen should always be administered within the parameters of the doctor's order and acknowledged the potential for negative effects if higher levels are given. Despite these policies and orders, staff did not adjust the oxygen flow to the prescribed rate, resulting in a failure to provide safe and appropriate respiratory care as required.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to act upon irregularities reported by the consultant pharmacist for one resident. The pharmacist conducted a monthly medication regimen review and made specific recommendations regarding the administration of an anti-acid medication, a breathing medication, and PRN pain medications. These recommendations included administering the anti-acid medication on an empty stomach, adding 'shake well before each spray' to the breathing medication order, and including a directive to use non-pharmacological interventions before administering PRN pain medications. There was no documentation that these recommendations were implemented in the resident's medical orders or records. The Assistant Director of Nursing confirmed during an interview and record review that the pharmacist's recommendations had not been carried out and acknowledged that they should have been completed. The facility's policy and procedure required staff to act upon all recommendations from the medication regimen review, but this was not followed for the resident in question, who had multiple diagnoses including heart failure, depression, anxiety disorder, and myalgia, and was noted to have intact cognition.
Failure to Label and Date Food Brought in by Families or Visitors
Penalty
Summary
The facility failed to ensure safe and sanitary practices for food brought in by family or visitors for residents. During observations, it was found that food items stored in the resident refrigerator, such as cooked noodles, wild berry jam, and a juice drink, were not labeled with the resident's name, date received, or use-by date. Both the Dietary Manager and a Licensed Nurse confirmed that facility policy and posted signage require all food items brought from outside to be labeled with the resident's name, date received, and a use-by date, and that unlabeled food should be discarded after three days. However, these procedures were not followed, as evidenced by the presence of multiple unlabeled food items for 25 sampled residents. Interviews with staff, including the DON, further confirmed that the expectation is for all food brought in from outside to be labeled and dated to ensure safety and compliance with dietary orders. The facility's written policy also specifies that prepared food must be approved by nursing, labeled, and consumed within three days, with any unconsumed food to be discarded. Despite these clear policies and reminders, the failure to label and date food items brought in by families or visitors resulted in noncompliance with safe food storage practices.
Failure to Follow Prescribed Physical Therapy Frequency
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for a resident. The resident, who was admitted in May 2024, had diagnoses including polyosteoarthritis, fusion of the spine, and chronic pain syndrome. The resident's Minimum Data Set (MDS) indicated a need for partial/moderate assistance with lower body dressing and supervision or touching assistance with transfers and walking. Despite the resident's need for physical therapy (PT) to improve leg functions, the prescribed frequency of therapy sessions was not followed. The resident was supposed to receive therapy five times a week for two certification periods, but several sessions were missed, and the frequency was not adhered to. Interviews with the Physical Therapist Assistant (PTA) and the Director of Nursing (DON) confirmed that the therapy frequency was not followed, which could risk the resident's condition not improving. The facility's policy and procedure for inpatient rehabilitation services emphasized the importance of following the individualized plan of care, including the frequency and duration of treatment. However, the facility did not adhere to these guidelines, as evidenced by the missed therapy sessions and the lack of documentation for any resident refusals. This oversight had the potential to lead to a decline in the resident's range of motion or mobility.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe medication administration for Resident 1, as medications were left unattended at the bedside. Resident 1, who was admitted in 2024 with diagnoses of anxiety and chronic pain syndrome, had a care plan that emphasized the need for increased communication about care and medications. However, during an observation, a medication cup labeled with Resident 1's room number was found open and unattended on a food tray, containing approximately nine pills of different colors and sizes. This incident was confirmed by the Director of Nursing (DON) and Licensed Nurse 1 (LN 1), who acknowledged the safety concern of leaving medications unattended. The facility's policies and procedures require that medications be administered within one hour of their prescribed time and that self-administration of drugs is only permitted when approved by the attending physician and interdisciplinary team assessment. However, there was no documented evidence of an interdisciplinary team assessment or a care plan for Resident 1's ability to self-administer medications. Additionally, there were no active physician orders allowing Resident 1 to self-administer medications. The DON confirmed that the self-administration assessment was incomplete, and both the Administrator and DON recognized the safety hazard posed by leaving medications at the bedside.
Resident Abuse Incident Involving Cane
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident hit them with a cane. The incident involved two residents, one of whom was admitted with multiple diagnoses including paraplegia, a Stage 4 pressure ulcer, diabetes, and dementia, and had a moderate cognitive impairment. The other resident, who was cognitively intact, had diagnoses including hemiplegia and hemiparesis following a stroke. The altercation occurred when the second resident hit the first resident on the leg with a cane, resulting in injury and pain. The incident was reported by a CNA who witnessed the event and noted that the first resident had called the second resident a racial slur, which upset the second resident. The CNA reported the incident to a licensed nurse, who conducted a body assessment and noted skin discoloration on the first resident's right lower leg. The interdisciplinary team met to discuss the incident, and the Director of Nursing was informed. The first resident reported severe pain and required pain medication following the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, which mandates the protection of residents from abuse and the implementation of procedures to prevent such incidents. The policy defines abuse as the willful infliction of injury resulting in physical harm or mental anguish. Despite these policies, the facility failed to prevent the physical abuse of the resident, as evidenced by the altercation and resulting injury.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of abuse in accordance with section 1150B of the Act. This deficiency involved a resident who alleged that a female staff member grabbed him firmly on the right arm. The resident, who had diagnoses including parkinsonism, care provider dependency, weakness, and depression, reported the incident to his daughter, who then informed the nursing staff. Despite the report, the facility did not initiate the abuse allegation reporting process in a timely manner. The resident's clinical records indicated that he had an intact cognition and required partial assistance with daily activities. An assessment on the day of the incident noted erythema and warmth on the resident's right forearm and wrist, with episodic pain. An x-ray confirmed a fracture in the resident's wrist. The Assistant Director of Nursing acknowledged that the abuse allegation was not reported to the state survey agency within the required timeframe, which delayed the investigation. The facility's policy required immediate reporting of such allegations, but this was not adhered to, resulting in a delayed response to the resident's complaint.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to hire a Director of Food and Nutrition Services with the required qualifications. During an initial kitchen tour, it was observed that there was no certificate or degree in the Food and Nutrition Services office. The Dietary Manager (DM) admitted that she had been working in her role for the past year without completing the process to become a Certified Dietary Manager or receiving the required six hours of Title 22 instruction. This deficiency was further confirmed during an interview with the Consultant Registered Dietitian (CRD), who stated that her role did not include hiring or supervising dietary staff and that her involvement in the kitchen was limited to monthly audits, test trays, and occasional in-services for dietary staff. The job description for the Registered Dietitian indicated that the CRD's responsibilities were not supervisory. The facility's provided Director of Food and Nutrition Services Department documentation stated that the director must meet state requirements. According to the State of California - Health and Safety Code 1265.4, the dietetic services supervisor must meet specific educational requirements, none of which were met by the current DM. This failure to employ a qualified Director of Food and Nutrition Services had the potential to lead to foodborne illness for the 124 residents eating facility-prepared meals.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During an initial kitchen tour, several items were observed without proper labeling, including containers of graham crackers, whipped toppings, butterscotch pudding, cabbage, croissants, spaghetti noodles, and vegetable burgers. The Dietary Manager confirmed that these items did not have the proper labels and acknowledged that improper labeling could lead to foodborne illnesses. Additionally, expired foods such as cake mix, ground cloves, and thyme leaves were found in the dry food storage area, which the Dietary Manager also confirmed could lead to foodborne illnesses. Perishable salads, including egg and tuna salad, were found to be stored at unsafe temperatures above the recommended 41 degrees Fahrenheit. The Registered Dietitian verified these temperatures and suggested that they might be due to food delivery issues. The facility's policies and procedures clearly state that perishable foods should be held at a temperature of 41 degrees Fahrenheit or less to prevent foodborne illnesses. Furthermore, several food items were found uncovered or improperly stored, including an opened bag of cake mix, an unlabeled container of bacon, and open boxes of pork and fish patties with ice crystals and freezer burn. Additional observations revealed an ice buildup in the walk-in freezer, which the Maintenance Supervisor attributed to the door not being closed tightly. Cutting boards with debris and a rusted can opener with a missing metal tip were also found, both of which could lead to contamination. The facility's policies emphasize the importance of cleaning and sanitizing equipment to prevent contamination, but these practices were not followed, as confirmed by the Dietary Manager. These failures collectively had the potential to lead to foodborne illnesses among the 124 residents who received facility-prepared foods.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that three residents were assisted with nail care as part of their Activities of Daily Living (ADLs). Resident 91, who had severe cognitive impairment and required substantial assistance with personal hygiene, was observed with long fingernails and a blackish substance underneath them. Certified Nurse Assistant (CNA) 1 confirmed the condition of Resident 91's nails and acknowledged that the blackish substance could cause an infection. There was no documentation indicating that Resident 91 had refused ADL care, including nail care, in the clinical records or progress notes. Resident 4, who had intact cognition but required moderate assistance with personal hygiene, was also observed with long fingernails and a brownish substance underneath them. Resident 4 expressed a desire to have his nails trimmed and cleaned. CNA 1 confirmed the condition of Resident 4's nails, and the clinical records showed no documented refusals of ADL care. Additionally, the SKIN INTEGRITY/SHOWER SHEET indicated that Resident 4's nails were not clipped on a recent date, despite being signed off by the Licensed Nurse (LN) on duty. Resident 46, who was dependent on assistance for personal hygiene and had severe cognitive impairment, was observed with jagged fingernails with sharp edges and a blackish substance underneath them. LN 1 confirmed the condition of Resident 46's nails and stated that the sharp edges could cause skin injury and the blackish substance could be an infection control issue. The clinical records for Resident 46 also showed no documented refusals of ADL care, and the SKIN INTEGRITY/SHOWER SHEET indicated that Resident 46's nails were not clipped on a recent date, despite being signed off by the LN on duty. The Infection Preventionist and the Director of Nursing both emphasized the importance of maintaining clean fingernails for infection control and hygiene.
Inaccurate Signing of Controlled Drug Record Forms
Penalty
Summary
The facility failed to ensure that pharmacy services were maintained when controlled drug record forms were inaccurately signed for a census of 126 residents. During a review of the controlled drug record forms for five discharged residents, it was found that the nurse who received the controlled medications signed the section indicating 'Doses discharged with Patient' instead of the correct section. This error suggested that the controlled drugs were given to the residents at discharge, which was not the case as the controlled drugs are supposed to be destroyed by the nurse. The Director of Nursing (DON) verified this discrepancy during an observation and interview, acknowledging that the incorrect signing could result in the diversion of controlled drugs. The facility's policy titled 'Controlled Substance Administration and Accountability' dated 12/19/22, requires that the entire amount of controlled substances obtained or dispensed is accounted for, and that two licensed staff must witness any disposal or destruction of a controlled substance and document it on the Drug Disposition Record. The policy also mandates that any discrepancies which cannot be resolved must be reported immediately. The failure to adhere to this policy was evident in the inaccurate signing of the controlled drug record forms, which had the potential to result in the diversion of the residents' medication.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled correctly, leading to several deficiencies. Loose pills were found in the South wing medication cart, and opened vials and a bottle of perishable medications in the North wing medication room were not dated with open or expiration dates. Additionally, packets of medicated powder in the North wing treatment cart did not have expiration dates, and an opened inhaler and glucose strips in the North wing medication cart were not dated. Expired and discontinued medications were also found in the North wing medication cart, and a bag containing medications for a resident was found in the nursing office closet, which was not temperature controlled. Prescription eye ointment was found in a resident's room at the bedside without an open date. During the inspection, Licensed Nurses (LNs) verified the presence of loose pills, undated vials, and expired medications. The Director of Nursing (DON) acknowledged these issues during interviews. The facility's policies on labeling and storing medications were reviewed, indicating that all medications and biologicals should be labeled according to federal and state requirements and stored under proper temperature controls. The policies also specified that multi-use vials must include the date they were initially opened and that expired or discontinued medications should be destroyed according to facility policy. The deficiencies observed had the potential for medication misuse, drug diversion, and diminished medication effectiveness. The facility's failure to adhere to its policies on medication labeling and storage was evident in multiple instances, including loose pills in medication carts, undated and expired medications, and improper storage of medications. These actions and inactions by the facility staff led to the identified deficiencies, posing risks to resident safety and care quality.
Failure to Prepare and Serve Nutritious and Safe Food
Penalty
Summary
The facility failed to prepare and serve food that conserved nutritive value, flavor, and appearance, and served food at unappetizing temperatures. During an initial kitchen tour, it was observed that vegetables were being heated for over two hours, which can lead to nutrient loss. Additionally, pureed meals were prepared without measuring ingredients, and pureed food was prepared in a dirty food processor bowl. These actions were observed during multiple visits to the kitchen, where it was noted that the cook did not follow the facility's recipes and used unmeasured amounts of ingredients, including water instead of broth or milk, which diluted the flavor and nutrition of the food. A test tray confirmed that the pureed tortellini was bland compared to the regular product. The food processor bowl used for pureeing was also found to be dirty, with a tan residue from previous use, posing a risk to residents with sensitivities such as gluten intolerance. During interviews with the Consultant Registered Dietitian (CRD) and Dietary Manager (DM), it was confirmed that the food processor bowl should have been cleaned before preparing another recipe to avoid cross-contamination. The CRD also stated that broth or milk should be added to pureed foods to maintain flavor and nutrition, and adding water could dilute these qualities. The facility's provided recipes and critical control points for food safety were not followed, leading to the potential for poor intake, malnutrition, and weight loss among the 124 residents eating facility-prepared meals.
Failure to Accommodate Food Allergies and Preferences
Penalty
Summary
The facility failed to accommodate food allergies and preferences for six residents, leading to potential health risks. Resident 100, who had a preference for ice cream, was given cake instead, and often did not receive coffee with meals. Resident 26, with a sensitive stomach and a preference to avoid garlic, received food containing garlic and was not allowed to have sausage, which she liked. Resident 34, who disliked carrots and salads, was served green beans for 12 consecutive meals and complained about the food being too salty. The cook was observed adding unmeasured amounts of salt to food, and the dietary manager was unaware of this practice. Resident 57, on a consistent carbohydrate diet, reported receiving less desirable options and frequently being served chicken tenders, which she disliked. Resident 97 mentioned that alternative items were not always available and that the soup was often watery. Resident 89, with a seafood allergy, received shrimp and tuna fish on her meal trays despite a warning sign behind her bed. She also reported that hot food was often served cold or lukewarm. A test tray confirmed that the food temperature was below the acceptable level. The facility's policy and procedure indicated that resident preferences should be documented and reviewed when planning menus, and that the resident council should be included in menu planning. However, the CRD and DM did not attend resident council meetings, believing they were not allowed to. Resident council notes highlighted ongoing issues with food quality, diet adherence, and meal timing, indicating that the facility was not meeting its own standards for accommodating resident preferences and dietary needs.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure an effective infection prevention and control program for a census of 126 residents. A clean-linen delivery cart and two clean linen storage shelves were found with thick layers of dust in the laundry room. The laundry staff confirmed that there was no log for cleaning the cart, and the Maintenance Supervisor acknowledged that there was no schedule for cleaning the carts. The Infection Preventionist and the Director of Nursing both stated that dirty linen carts and storage shelves could transfer dirt or germs to clean linen, potentially spreading infections to residents. Resident 27's nasal cannula was not labeled with the date it was first used, which is necessary to ensure it is changed every 7 days to prevent infection. Licensed Nurse 8 confirmed the missing label and stated that the nasal cannula should be changed weekly. The Director of Nursing reiterated that staff should label the nasal cannula with the date it was changed to prevent infection control issues. Resident 682 had an empty IV medication bag and IV tubing that were not labeled with the date and nurse's initials. The Assistant Director of Nursing confirmed the missing labels and stated that without knowing when the tubing was last changed, it should not be reused due to infection control concerns. Similarly, Resident 131's IV tubing was not labeled with the date, time, and nurse's initials, as confirmed by Licensed Nurse 11 and the Assistant Director of Nursing. Lastly, Resident 19's urinary catheter drainage bag was found touching the floor, which the Assistant Director of Nursing and the Director of Nursing confirmed could cause an infection. The facility's policies and procedures were not followed in these instances, leading to potential risks of infection and cross-contamination among residents.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure essential kitchen equipment, specifically the ice machine and oven, were in safe operating conditions. During an initial kitchen tour, the Maintenance Supervisor revealed that the ice machine had issues with randomly shutting off. Additionally, the right side of the oven was found to be non-functional. On a subsequent visit, the ice machine was again not working, preventing the use of the ice bath method for thermometer calibration. Furthermore, meal preparation and timing had to be adjusted due to the malfunctioning oven. These deficiencies were observed and reported by the survey team, highlighting the facility's failure to maintain equipment in good repair as required by the US Food and Drug Administration's 2022 Food Code section 4-501.11.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the right for privacy and dignity for Resident 33, who had severe memory impairment and was totally dependent on staff for all activities of daily living. During an observation, two staff members provided care to Resident 33 with the door open and privacy curtains not pulled, exposing the resident's lower body to the hallway. This lack of privacy was confirmed by the Medical Record Assistant and the Director of Nursing, who both acknowledged that dignity and privacy should always be maintained during resident care. Licensed Nurse 12, who was involved in the care, admitted to not pulling the curtain or closing the door, stating it was an oversight. The facility's policies on patient privacy and provision of quality care, which were reviewed, clearly indicated that residents should be clothed or appropriately draped during care to maintain their highest practicable physical, mental, and psychosocial well-being. The failure to adhere to these policies resulted in a deficiency in maintaining Resident 33's dignity and privacy.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents, Resident 588 and Resident 28, by not ensuring their call lights were accessible. Resident 588, who had moderate cognitive abilities and required partial assistance with ADLs, was observed on multiple occasions with the call light on the floor and out of reach. Despite the care plan indicating that the call light should be within reach, staff did not comply, resulting in Resident 588 being unable to call for help when needed. This was confirmed by both the CNA and the MDS Coordinator during their observations and interviews. Resident 28, who had moderate cognitive abilities and was dependent on ADLs, was also not provided with an appropriate call light type. Despite having hand contractures and being unable to use the standard call light, no alternative call light system was provided. This was confirmed by the MDS Coordinator and CNA, who acknowledged that Resident 28 was unable to use the call light due to his condition. The facility's policy indicated that special accommodations should be made for residents with unique needs, but this was not done for Resident 28.
Failure to Complete Comprehensive Assessment for Resident
Penalty
Summary
The facility failed to ensure a comprehensive assessment was performed in accordance with the regulatory time frame for one of the sampled residents, Resident 681. Resident 681 was admitted in late 2018 with diagnoses including stroke, muscle weakness, malnutrition, and difficulty swallowing. The admission MDS for Resident 681 was not completed, as verified by multiple staff members, including Licensed Nurse 11, the MDS Coordinator, and the MDS Director. The MDS was due on March 5, 2024, but remained incomplete and overdue as of March 21, 2024. During observations and interviews, Resident 681 was found to be alert and verbal but minimally responsive, expressing a desire to go back to sleep and later stating relief at surviving the previous day. The MDS Director confirmed that the interdisciplinary team assessment, which is crucial for creating an individualized care plan, was delayed due to pending input from social services. The Resident Assessment Instrument (RAI) process, which ensures residents receive the highest quality of care, was not followed as required, leading to the deficiency.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) for two residents within 48 hours of their admission, as required. Resident 681, admitted with diagnoses including stroke, muscle weakness, malnutrition, and difficulty swallowing, had an incomplete BCP dated 3/15/24, with missing assessments in the Dietary/Nutritional Status and Social Services sections. Observations and interviews revealed that Resident 681 was minimally responsive and had not received a complete assessment, which was confirmed by the MDS Coordinator and Licensed Nurse 11. The MDS for Resident 681 was also incomplete and overdue. Similarly, Resident 6, admitted with diagnoses including hip joint surgery aftercare, left artificial knee joint and infection, anxiety, depression, and need for continuous supervision, had an incomplete BCP dated 3/4/24. The Social Services section was not completed, and the limb prosthesis was not checked. Observations and interviews indicated that Resident 6 had experienced an unwitnessed fall and expressed dissatisfaction with the food quality. The MDSD and DON confirmed the incomplete BCP and acknowledged the failure to meet the 48-hour requirement for completing the BCP.
Failure to Follow Restorative Nursing Program Frequencies
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for two residents. Resident 107, who was admitted with multiple fractures and muscle weakness, did not receive the prescribed restorative nursing program (RNA) exercises three times a week as required. Despite the care plan indicating specific exercises and frequencies, the resident only received exercises on a few occasions over a 30-day period. Both the Director of Rehabilitation (DOR) and the Minimum Data Set Coordinator (MDSC) confirmed the discrepancy and acknowledged that the RNA program frequency was not followed, which could potentially result in muscle weakness and decline in mobility for Resident 107. Similarly, Resident 44, who had diagnoses including paraplegia and a malignant neoplasm of the frontal lobe, also did not receive the prescribed RNA exercises three times a week. The resident reported not having her standing-up therapy exercises for about three weeks. The care plan specified that the resident should have sit-to-stand exercises with maximum assistance three times a week. However, the resident only received these exercises on a few occasions over a 30-day period. The DOR confirmed the inconsistency, and the Restorative Nursing Aide (RNA) noted that there were often not enough staff available to perform the exercises as required. The Director of Nursing (DON) emphasized the importance of following the RNA program frequency to prevent a decline in function. The facility's policy on the Restorative Nursing Program also indicated that the frequency of activities should be documented and followed. The failure to adhere to the prescribed RNA program frequencies for both residents had the potential to impair their mobility and result in a decline in their range of motion.
Failure to Maintain Safe Environment in Smoking Area
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards for one of 43 sampled residents, specifically Resident 57, due to an uneven pathway leading to, from, and inside the designated smoking area. Resident 57, who has diagnoses of Spinal Stenosis, abnormalities of gait and mobility, and Major Depressive Disorder, reported feeling unsafe navigating the pathway in her wheelchair. She had previously reported her concerns to the Activities Director (AD) a few months prior to the survey. The AD acknowledged awareness of the cracks but was not aware of any plans to repair them, confirming that the cracks could cause accidents and injuries. The Maintenance Supervisor (MS) was initially unaware of the cracks but confirmed the need for repairs upon reviewing photos and conducting an observation. The Director of Nursing (DON) also agreed that the uneven sidewalks and cracked concrete posed a safety concern. The facility's Smoking Agreement and policies on Resident Smoking and Accidents and Supervision emphasized the importance of maintaining a safe environment for residents, which was not upheld in this instance.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper delivery of respiratory care for Resident 18, whose physician's order for oxygen therapy was not followed. Resident 18, who had diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, and dementia, was observed using an oxygen concentrator set at 5 liters per minute (LPM) instead of the prescribed 2 LPM. The Assistant Director of Nursing (ADON) confirmed this observation. A review of Resident 18's clinical records indicated no documentation that the oxygen was titrated to maintain oxygen saturation greater or equal to 90%, as required by the physician's order. Licensed Nurse (LN) 9 confirmed the absence of such documentation and stated that the physician's orders should always be followed. The Director of Nursing (DON) acknowledged that the physician's order for oxygen therapy should have been followed and that any changes in oxygen settings should be thoroughly documented and assessed. The facility's policy and procedures for oxygen administration also emphasized the importance of adhering to physician's orders and documenting any changes in the resident's condition. The failure to follow the physician's order for oxygen therapy had the potential to result in unsafe delivery of oxygen to Resident 18, which could lead to respiratory problems.
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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