Monrovia Gardens Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monrovia, California.
- Location
- 615 W. Duarte Rd., Monrovia, California 91016
- CMS Provider Number
- 055367
- Inspections on file
- 60
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Monrovia Gardens Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of stroke-related hemiplegia, hemiparesis, and DM experienced substantial unplanned weight loss over several months, dropping from 225 lbs to 178 lbs. Although an initial care plan for a 24-lb weight loss in one month was created with interventions to monitor weight loss and contact the physician and RD if decline persisted, the plan was not updated when the resident continued to lose an additional 19 lbs over a later period, and no care plan documented an intentional 47-lb loss. The resident, cognitively intact but dependent for ADLs, frequently ordered outside food, reported disliking facility meals, and was described by the RD as non-compliant with the diet while pursuing a personal weight-loss goal, yet the care plan was not revised in a timely manner to reflect these ongoing changes and continued weight loss.
A resident with DM, hemiplegia, and hemiparesis, dependent on staff for ADLs but cognitively intact, had a physician order for a podiatry consult and treatment that was placed on hold during a hospital stay and not reactivated on return. Nursing staff were aware of the resident’s long, thickened toenails but did not complete a change of condition report or notify the physician, citing that staff generally would not trim toenails for a diabetic resident at high risk for infection. The resident reported only concern about the pending podiatry appointment, and observation confirmed long, thickened toenails on both feet, while facility policies required physician notification for significant changes and resident participation in care planning.
A resident with ESRD and severely impaired cognition returned from hemodialysis with a right upper arm fistula and a pressure dressing in place, under a physician order directing removal of the dressing four hours after return. Nursing documentation showed the resident arrived back from dialysis in the afternoon with the fistula intact and no signs of infection, but the pressure dressing was not removed until the evening, several hours after the ordered timeframe, when an LVN noted scant bleeding and applied a new dressing. The LVN acknowledged awareness of the order and stated that prolonged use of the pressure dressing increased the risk of clotting, while facility policy required staff caring for ESRD residents to be trained in the care of grafts and fistulas.
A resident with intact cognition and a history of mental health conditions returned from the hospital with a right eye hematoma, which was identified as a potential sign of physical abuse. Despite facility policy requiring immediate reporting of such injuries, staff did not notify CDPH within the mandated timeframe after becoming aware of the injury.
A CNA failed to check and change a dependent resident after an episode of stool incontinence, leaving the resident in a soiled diaper for over five hours despite repeated requests for assistance. The resident, who communicated via an iPad, expressed frustration and helplessness, and the situation was confirmed by the resident's roommate and another CNA who later provided care.
Two residents did not receive appropriate ADL care according to facility policy, resulting in one being left with matted hair that was not brushed for several days and another being left soiled in a brief with urine and feces. Staff interviews and documentation confirmed that required hygiene tasks, such as hair brushing and regular incontinence care, were not consistently performed.
A resident with impaired mobility and incontinence was unable to access their call light, which was not connected to the wall or within reach, resulting in the resident being left soiled and unable to request assistance. Staff and nursing interviews confirmed the call light was not functioning or accessible, despite care plan and facility policy requirements for call light accessibility and prompt response.
A resident with severe dysphagia and a physician-ordered minced and moist diet was served toasted bread, contrary to their prescribed dietary requirements. Despite documentation and repeated notifications from the responsible party, bread continued to be provided. Staff interviews revealed that required checks of meal trays for correct diet and texture were not properly conducted, resulting in the resident being served inappropriate food items.
Two residents used swamp coolers in their rooms that had not been cleaned or had filters and water tanks changed since placement, with staff confirming there was no scheduled maintenance or cleaning for these devices, contrary to facility policy.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
A resident with a communication impairment did not have access to a communication board as outlined in their care plan. Staff were unable to locate the adaptive device during observation, despite facility policy requiring accommodation of such needs.
A resident with severe cognitive impairment and multiple medical conditions was found physically restrained in a wheelchair using a hospital gown tied around the waist, preventing free movement. The restraint was applied by a CNA to prevent falls, without a physician's order, care plan, or consent, and contrary to facility policy, which prohibits such use for staff convenience or fall prevention.
A resident with speech and neurological conditions did not have a physician-ordered MRI scheduled as required. The MRI order, documented after a neurology appointment, was not carried out, resulting in a delay in diagnostic testing. The DON confirmed the oversight during record review.
A resident with limited mobility and dependence on staff for toileting was found to have a non-functional call light, as the device was unplugged and out of reach. Staff did not check the call light during their rounds, and the issue was only discovered during an observation. Facility policy requires call lights to be plugged in and working at all times.
The facility did not ensure that its abuse prevention policy required or documented reference checks for new employees. Review of employee files showed that three CNAs lacked evidence of completed reference checks, and the policy did not specify the need to screen for abuse history with previous employers. Interviews confirmed that reference checks were expected but not documented for these staff members.
CNAs did not provide timely incontinent care to a resident with impaired mobility and inability to alert staff, despite care plan requirements for checks every two hours. The resident was repeatedly observed in a wet gown and adult brief, and communicated that care was not being provided. Staff interviews confirmed that care was delayed or not performed due to other priorities, in violation of facility policy.
Staff failed to perform proper hand hygiene and use required PPE when handling food trays and entering a room under respiratory precautions for two residents exposed to COVID-19 and another resident with significant care needs. CNAs handled dirty and clean food trays without sanitizing hands and did not wear gloves or use hand sanitizer as required by facility policy.
A resident with severe cognitive impairment and dependence on staff for daily activities was repeatedly observed not wearing a face mask or wearing it improperly during a COVID-19 outbreak. Despite known non-compliance and the need for frequent reminders, staff did not create or update a care plan with individualized, measurable interventions to address the resident's behavior, contrary to facility policy.
During a night shift, only two CNAs were available to care for 89 residents, far below the facility's usual staffing levels and policy requirements. As a result, a resident with diabetes, mobility issues, and frequent incontinence was not checked or changed throughout the night, despite their care plan requiring checks every two hours. Staff interviews confirmed the short staffing, with licensed staff having to assist with ADL care, leading to delays in care for residents.
A Social Services Director mistakenly emailed a resident's confidential medical and personal information, including insurance details and care needs, to another resident's family member instead of the intended medical provider. The resident involved had severe cognitive impairment and required significant assistance with daily activities. The incident was not reported to facility leadership as required by policy.
A resident dependent on staff for ADLs did not receive timely incontinence care, resulting in prolonged exposure to wet bedding and clothing. The delay was caused by confusion and late completion of CNA staffing assignments at the start of the shift, preventing prompt care as required by the resident's care plan and facility policy.
A resident with a history of fracture and cognitive impairment did not receive proper pain management when LNs failed to assess and document pain levels before and after administering oxycodone, as required by the care plan and facility policy. Additionally, when the resident reported new abdominal pain, staff did not document pain characteristics or provide pain medication as ordered. Interviews confirmed that staff did not follow expected pain assessment and documentation procedures.
A resident with significant communication and cognitive impairments did not receive their requested dinner meal due to a miscommunication between dietary staff and kitchen personnel. Although the resident had a documented menu of preferred foods and a weekly review process with the Dietary Services Supervisor, only a smoothie was provided for dinner because the kitchen was not informed of the full meal request.
A resident with significant cognitive and physical impairments was found with empty water containers and was not provided water according to their needs and preferences. Staff interviews confirmed that water pitchers should be filled and within reach, but the resident's hydration needs were not met as required by facility policy.
A resident with neurological and mobility impairments did not consistently receive ordered restorative nursing services, including active-assisted range of motion exercises, due to staff failing to provide the care as prescribed and falsifying documentation to indicate completion. Staff admitted to not performing or only partially performing the required exercises on several occasions, and documentation was completed on days when staff were not present.
A resident's medical record contained inaccurate documentation of restorative nursing services, as staff initialed flow sheets to indicate that range of motion exercises were provided even when they were not present or did not perform the ordered interventions. Review of staffing records and interviews confirmed that the required care was not always delivered or properly documented, resulting in incomplete and inaccurate medical records.
A resident's right hand resting splint, prescribed for contracture management, was not inventoried or tracked by staff after it was received. The device was subsequently lost, and staff did not document its disappearance or investigate as required by facility policy, leaving the resident without the necessary equipment.
A resident admitted with a generalized body rash did not have a care plan developed to address this condition, despite facility policy requiring such a plan within a specific timeframe. The resident had multiple diagnoses, including toxic encephalopathy and chronic kidney disease, and the rash was noted upon admission. The Infection Preventionist Nurse confirmed the absence of a care plan, which could lead to unmet needs and a break in continuity of care.
A resident at high risk for falls was left unsupervised in a conference room, leading to a fall and a fracture of the cervical spine. Despite a care plan requiring frequent visual checks and monitoring at the nursing station, staff failed to adhere to these measures. The resident had a history of falls and severely impaired cognition, necessitating close supervision, which was not provided.
The facility failed to provide timely assistance with ADLs for four residents, leading to deficiencies in care. A resident with spina bifida and diabetes experienced delays in changing incontinence briefs, while another with a spinal fracture faced long wait times for care after a bowel movement. A third resident with multiple health issues also encountered delays in receiving necessary care. Additionally, a resident with conversion disorder did not receive scheduled hair care due to communication lapses among staff. These failures highlight the facility's inability to adhere to its policy on supporting ADLs.
The facility failed to provide sufficient CNA staffing, resulting in delayed care for residents. Residents experienced long waits for call lights to be answered and incontinence care, with some CNAs responsible for up to 29 residents per shift. This staffing shortage led to inadequate care and delayed responses to residents' needs.
A non-verbal resident with conditions such as anarthria and aphonia attended a medical appointment without their communication device, contrary to their care plan. The resident, who relies on a tablet for communication, had to use a CNA's mobile phone to communicate during the appointment. Facility staff confirmed the expectation that the resident should have had their communication device, as per the facility's policy on resident rights.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident, at high risk for falls, was not adequately monitored and suffered a serious injury from an unwitnessed fall. Another resident did not receive medication administration as per their care plan, with a staff member failing to follow the requirement for dual staff presence during care.
A resident with conversion disorder, anarthria, and aphonia returned from a neurology appointment without an after visit summary (AVS), leading to a failure in obtaining a recommended MRI. The facility lacked a specific policy for obtaining records after outside appointments, resulting in the LVN not notifying the Medical Records Supervisor to acquire the necessary documentation.
Two residents experienced pain during care provision due to CNAs not using draw sheets for repositioning and handling them roughly and hurriedly. Despite training, CNAs failed to adhere to proper procedures, leading to deficiencies in care.
The facility failed to maintain sufficient nursing staff, resulting in delayed call light responses and rushed care for residents. One resident with a pressure ulcer experienced over an hour wait for assistance, while another with heart failure and diabetes reported longer wait times at night. Staffing records showed CNAs were responsible for up to 30 residents each, exceeding the facility's staffing ratio. The Director of Staff Development confirmed staffing shortages and the facility's policy for timely call light responses was not followed.
A resident felt embarrassed and disrespected when an RN publicly requested a urine sample in front of the resident's visitor. The resident, with no cognitive impairments and requiring supervision for personal care, was admitted with conditions including congestive heart failure and anxiety disorder. The incident was witnessed by an LVN, and the DON acknowledged the need for privacy in such matters to protect resident dignity.
A facility failed to monitor blood sugar levels for a resident with type 1 diabetes, despite transfer orders and facility policy requiring such monitoring. The resident, who had a history of using an insulin pump, was not checked for blood sugar levels, leading to a critical oversight. The resident's blood sugar level reached the 700s, necessitating transfer to an acute care hospital. The DON acknowledged the failure to monitor and the associated risks, yet no physician order was sought to address the issue.
A resident accused a CNA of rough handling, but the facility failed to remove the CNA from duties during the investigation. Despite the ongoing investigation, the CNA continued working, which was against the facility's policy to protect residents from further harm. The resident, with a history of osteomyelitis and osteoarthritis, reported the incident, and another CNA confirmed the resident's claims.
The facility failed to accommodate the needs of two residents, leading to discomfort and pain. One resident experienced shoulder pain due to the absence of a toilet paper dispenser, requiring them to reach awkwardly. Another resident was uncomfortable during wheelchair transport due to missing footrests, causing their feet to drag on the floor. Observations and interviews confirmed these deficiencies, highlighting a lack of adherence to facility policies on assistive devices and resident care.
The facility failed to inform two residents or their representatives of their right to formulate an advance directive, as required by policy. One resident had intact cognition with end-stage renal disease and diabetes, while the other had moderately impaired cognition with Alzheimer's and hypertension. The Social Services Director could not confirm that the required information was provided upon admission, with the first documented communication occurring later via email.
The facility failed to monitor a resident's change of condition after a fall and did not document it as required, while another resident received medication despite low blood pressure readings, contrary to physician orders. These deficiencies highlight lapses in following protocols for monitoring and medication administration.
Two residents developed skin issues due to inadequate care in preventing pressure ulcers. One resident, with conditions like hemiplegia and diabetes, was left in the same position for hours, leading to Moisture-Associated Skin Damage. Another resident, with severe cognitive impairment, was not repositioned or checked for incontinence, resulting in open areas and a fungal rash. The facility's policy on pressure ulcer prevention was not followed, contributing to these deficiencies.
Two residents in a facility developed Moisture Associated Skin Damage (MASD) due to inadequate incontinent care. Despite care plans requiring regular checks and changes of incontinence pads, a CNA failed to attend to the residents for several hours. This neglect resulted in open areas on the residents' buttocks and significant pain, highlighting a deficiency in the facility's adherence to its care protocols.
The facility experienced staffing shortages, particularly with CNAs, leading to delayed care and unmet needs for residents. Interviews revealed that residents faced long wait times for assistance, such as showering and call light responses, with some waiting up to an hour. The facility had contracts with registry companies for additional staffing, but these were not utilized due to last-minute call-offs and previous negative experiences with registry staff. The Director of Nursing acknowledged the shortage and its impact on resident care.
The facility failed to maintain sanitary conditions in food storage and sanitization, risking foodborne illnesses. Ice cream cups were stored past their use-by date, and a kitchen aide improperly tested the quaternary sanitizing solution, not following the manufacturer's instructions. The dietary supervisor confirmed the importance of discarding expired food and correctly testing sanitizing solutions.
The facility failed to implement proper infection control practices, including the storage of personal toiletries, adherence to Enhanced Barrier Precautions, and sanitary storage of oxygen tubing. An open and unlabeled toiletry was found in a shared restroom, and staff did not wear PPE while providing care to residents requiring EBP. Additionally, a resident's oxygen tubing was not stored properly, risking bacterial contamination.
A resident with severe cognitive impairment and a G-tube was not afforded full privacy during medication administration. An LVN partially drew the privacy curtain in a shared room, exposing the resident's abdomen, contrary to facility policies on dignity and privacy. The RN Supervisor confirmed that privacy should be fully ensured during such procedures.
A resident with severe cognitive impairment experienced difficulty eating due to broken dentures, which were not promptly reported to the physician by the facility staff. The delay in notification resulted in a delay in necessary care and services, violating the facility's policy requiring timely communication of changes in a resident's condition.
Failure to Revise Care Plan for Ongoing Significant Weight Loss
Penalty
Summary
The facility failed to timely revise and update the care plan for a resident who experienced significant unplanned weight loss. The resident was admitted with hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, as well as diabetes mellitus, and was cognitively intact but dependent on staff for ADLs. Weight records showed a decline from 225 lbs at admission to 178 lbs over approximately five months, including a 24-lb loss in one month and a subsequent 19-lb loss over a later two‑month period. A care plan for unplanned/unexpected weight loss of 24 lbs in one month was initiated and revised in October, with interventions to contact the physician and dietician if weight decline persisted and to monitor and evaluate any weight loss and determine percentage lost per facility protocol. Despite continued weight loss documented in the Weights and Vitals Summary, the care plan was not updated when the resident lost an additional 19 lbs between early November and early January, and there was no care plan indicating that the resident was intended to lose a total of 47 lbs in five months. The unplanned/unexpected weight loss care plan was not updated again until late January. Interviews revealed that the resident was very alert, initially on a puree diet with low intake, later on a regular diet, and frequently ordered food from outside the facility because the resident did not like facility food. The registered dietician reported that the resident had a personal goal weight of 170 lbs, had lost 19 lbs in three months before the dietician began working at the facility, then 1 lb in a month afterward, and was non‑compliant with the prescribed diet and ordering a lot of outside food. These findings showed that the care plan interventions were not revised in a timely manner in response to ongoing weight loss.
Failure to Resume and Act on Podiatry Order for Diabetic Resident
Penalty
Summary
The facility failed to provide podiatry care for a resident with diabetes, hemiplegia, and hemiparesis, who was dependent on staff for ADLs but had intact cognition for daily decision making. The resident had a physician’s order for a podiatry consult and treatment as needed, originally dated 11/2/25. After the resident was hospitalized, all physician orders were placed on hold. When the resident returned from the hospital, staff resumed all orders except the podiatry consult, which remained on hold and was not active. The resident reported that a staff member had recently indicated they would make a podiatry appointment, but the resident had not received any update on the status of that appointment. Nursing staff were aware of the resident’s foot condition but did not act on it. An LVN stated they observed the resident’s long and thickened toenails on 11/20/25 when completing a Change of Condition report for heel redness, but they did not complete a change of condition report related to the toenails and did not notify the physician about this issue. The LVN also stated that, because the resident was diabetic and at high risk for infection, facility staff generally would not trim the resident’s toenails. On observation, the resident’s toenails on both feet were noted to be long and thickened. Facility policies on resident rights and change in condition required that residents be informed of and participate in their care and that physicians be notified of significant changes in condition, but these processes were not followed for the resident’s podiatry needs.
Failure to Follow Physician Order for Timely Removal of Dialysis Pressure Dressing
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for timely removal of a hemodialysis pressure dressing for a resident with end-stage renal disease who was dependent on renal dialysis and had severely impaired cognition and dependence for ADLs. The resident’s admission record documented ESRD and dialysis dependence, and the MDS showed severely impaired cognition and total dependence on staff. A physician order dated 2/22/26 directed that the resident’s dialysis pressure dressing on the right upper arm be removed four hours after return from dialysis. Nursing documentation showed the resident returned from dialysis on 2/24/26 at approximately 2:15 pm with the right upper arm fistula intact, without swelling or signs of infection. The nursing progress note later that night, dated 2/24/26 at 10:50 pm, documented that the pressure dressing was removed and a new dressing applied. In interview, one LVN confirmed the resident returned from dialysis around 2:15 pm and that the fistula site was intact. Another LVN stated that on 2/24/26 they assessed the pressure dressing at about 4 pm after being informed the resident had returned from dialysis, found no leaking or signs of infection, and knew from the physician order that the pressure dressing should be removed four hours after return. This LVN stated they did not remove the pressure dressing until approximately 8 pm and then applied a new dressing due to scant bleeding at the fistula site, and documented the dressing change at 10:50 pm. The LVN also stated that leaving the pressure dressing on longer increased the risk of clotting. The facility’s ESRD policy stated that residents with ESRD would be cared for according to recognized standards of care and that staff would be trained in the care of grafts and fistulas.
Failure to Timely Report Suspected Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after becoming aware of a resident's injury. A resident, admitted with conversion disorder and major depressive disorder and assessed as having intact cognition and decision-making capacity, returned from the hospital with right eye discoloration. The injury was identified as a right periorbital hematoma, which is considered a potential sign of physical abuse according to the facility's own policies. The police initially informed an LVN about the resident's eye discoloration, and the Director of Nursing later confirmed that the facility became aware of the injury upon the resident's return from the hospital. Despite the facility's policy requiring immediate reporting of abuse allegations to state authorities, the incident was not reported to CDPH as mandated. Staff interviews and record reviews confirmed that the required notification did not occur. The facility's policies also specify that facial injuries such as black eyes and bruising are to be treated as potential abuse and reported accordingly, but this protocol was not followed in this case.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to maintain the dignity of a resident who was dependent on staff for dressing and toileting hygiene. The resident, who had diagnoses including conversion disorder, aphonia, and general anxiety disorder, was admitted as incontinent of bowel and bladder and required to be checked for incontinence at least every two hours per the care plan. On the day in question, the resident experienced an episode of stool incontinence in the morning and requested to be changed by CNA 1 starting at 8 AM. CNA 1 did not respond to the request or check on the resident for over five hours, leaving the resident in a soiled diaper until 12:30 PM, when another CNA took over care and found the resident soiled. The resident communicated feelings of frustration and helplessness due to being left in a soiled state. The resident's roommate confirmed the presence of a foul stool odor in the room starting around 10 AM. CNA 1 admitted to not checking or changing the resident during the assigned shift and was unaware of the reason for the resident's distress. Facility policy required care to be provided in a manner that promotes resident well-being and dignity, including identifying and addressing individual needs and preferences through assessment.
Failure to Provide Timely ADL Care and Hygiene
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care in accordance with its own policy and procedures for two residents. One resident, who had moderately impaired cognition and required assistance with personal hygiene, was observed with matted hair that had not been brushed for several days. The resident reported that the last time their hair was brushed was the previous week, and only the front was brushed. Staff interviews confirmed that hair brushing should occur daily and as needed, regardless of whether the resident refused showers. Documentation did not reflect consistent refusals of care, and staff acknowledged that personal hygiene tasks such as hair brushing should still be performed even if a shower is refused. Another resident, who was incontinent and dependent on staff for toileting and hygiene, was found soiled with urine and feces in their brief. The resident communicated that they had not been changed since the previous day. Observations confirmed that the resident's brief, bed sheet, and gown were wet and soiled, and staff confirmed the resident's condition. The care plan for this resident required staff to check and change the resident at least every two hours and as needed, but this was not followed, resulting in the resident being left unclean and uncomfortable. The Director of Nursing confirmed that hair brushing is part of ADL care and should be performed after showers, during morning care, and as needed. The DON also stated that residents' briefs should be checked and changed every two hours and as needed to prevent discomfort. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services to maintain good grooming and hygiene, which was not provided in these cases.
Failure to Ensure Call Light Accessibility and Timely Response to Resident Needs
Penalty
Summary
A deficiency occurred when a resident's call light was not fully connected to the wall and was not within the resident's reach, preventing the resident from requesting assistance as needed. Observations and interviews confirmed that the call light was not accessible, and staff acknowledged the issue, with one CNA stating that the call light was not working and not within reach. The resident, who was dependent on staff for toileting hygiene and had impaired mobility, was unable to alert staff and was left soiled in their briefs with urine and/or feces. The care plan for this resident specified that the call light should be placed within reach, hanging from the trapeze above the resident's head, and that staff should be educated on this preference. The care plan also required CNAs to check the resident for incontinence at least every two hours and to keep the call light accessible and answer it promptly. The resident had a history of conversion disorder, aphonia, generalized anxiety disorder, and neuropathy, and was at risk for infection and skin breakdown due to incontinence and immobility. The facility's policy required that call lights be plugged in, functioning, and accessible to residents at all times. Despite these requirements, the call light was observed to be disconnected and out of reach on multiple occasions, and maintenance had not yet completed securing the call light to the wall. The Director of Nursing confirmed that the issue with the call light's accessibility had been identified but not resolved prior to the incident.
Failure to Provide Prescribed Therapeutic Diet to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with severe dysphagia and a physician-ordered minced and moist diet received meals consistent with their prescribed dietary requirements. Despite clear documentation in the resident's records, including a speech therapy plan recommending pureed consistency food and a physician's order for a minced and moist texture diet, the resident was served toasted bread on their lunch tray. The responsible party reported repeated notifications to staff about the resident's inability to safely consume bread, yet bread continued to be provided. The dietary service supervisor acknowledged the error, stating the bread was likely placed on the tray by accident, and recognized the risk of choking associated with this mistake. Further review revealed that the facility's policies required both dietary and nursing staff to check trays for correct diet and texture before serving meals to residents. However, interviews with staff indicated that these checks were not properly conducted, resulting in the resident being served inappropriate food items. The director of nursing confirmed that failure to check trays could lead to residents receiving the wrong diet, which in this case, exposed the resident to potential harm due to their swallowing difficulties.
Failure to Maintain Swamp Coolers in Safe and Operable Condition
Penalty
Summary
The facility failed to maintain swamp coolers in a safe and operable manner for two of three sampled residents. Observations revealed that swamp coolers in use in residents' rooms did not have water in their tanks, and both residents reported that the facility had not cleaned or changed the filters or water tanks since the coolers were placed in their rooms. One resident stated the cooler had not been maintained for at least a month, while the other indicated no maintenance had occurred since admission. Interviews with facility staff, including the administrator, interim Maintenance Director, and Infection Preventionist, confirmed that there was no scheduled maintenance or cleaning time for the swamp coolers. Review of facility policy indicated that the maintenance director was responsible for developing and maintaining a schedule of maintenance service and that maintenance personnel should follow the manufacturer's recommended maintenance schedule. However, no such schedule or records existed for the swamp coolers, resulting in the deficient practice.
Failure to Assist Dependent Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for daily personal care tasks.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, review, and address quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Provide Communication Board for Nonverbal Resident
Penalty
Summary
Facility staff failed to provide a communication board for a resident who was unable to speak, as required by the resident's care plan. The care plan, dated 10/14/2024, identified the resident's communication problem and included interventions such as ensuring the availability and functioning of adaptive communication equipment, including a message board and alternative communication tools. During an observation, the resident was found sitting on the bed, unable to verbally communicate but able to nod and shake her head. When asked, the Certified Nurse Assistant present was unable to locate the communication board for the resident. A review of the facility's policy on accommodation of needs indicated that residents' individual needs and preferences, including access to assistive and adaptive devices, should be accommodated to the extent possible. Despite this policy and the care plan's directives, the communication board was not available for the resident's use, resulting in a failure to ensure continued communication for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 3 was immediately offered an alternative method of communication on July 9, 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On July 9th, 2025, the Director of Nursing (DON) / designee ensured that all non-verbal residents were provided with appropriate means of communication. This measure was implemented to prevent any lapses in communication between the facility and the affected residents. No additional findings were noted.
Resident Restrained with Gown Without Proper Authorization
Penalty
Summary
A deficiency occurred when a resident was found confined to a wheelchair using a hospital gown tied around their waist, which prevented the resident from moving freely. This action was discovered by a clinical team during routine rounds, and it was confirmed through interviews with the LVN/Treatment Nurse, the Director of Nursing (DON), and the Administrator. The staff involved acknowledged that using a gown in this manner constituted a physical restraint, and there was no physician's order or care plan authorizing the use of restraints for this resident. The resident involved had a history of dementia, cognitive impairment, hypertension, left lower leg contracture, lack of coordination, and a history of transient ischemic attack and cerebral infarction. The Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and required substantial to total assistance with most activities of daily living. Despite these needs, the MDS and facility records showed that restraints were not ordered or care planned for this resident at the time of the incident. Facility policy explicitly prohibits the use of restraints for staff convenience or fall prevention and requires that all less restrictive alternatives be attempted before considering restraint use. The Certified Nurse Assistant (CNA) who tied the resident to the wheelchair admitted to using the gown to prevent the resident from falling, without following proper protocol or obtaining the necessary orders and consents. The facility's investigation confirmed that the CNA did not comply with policy, resident rights, or standard care protocols, resulting in the resident being physically restrained without appropriate justification or documentation.
Plan Of Correction
What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? From July 10, 2025 to July 11, 2025, the Director of Staff Development (DSD) or designee conducted an in-service training for licensed nursing staff and Certified Nursing Assistants (CNAs). The training focused on the importance of ensuring that non-verbal residents are provided with an effective and reliable means of communication, in order to support continuous and timely interaction within the facility. Incoming admissions will be reviewed during the daily Interdisciplinary Team (IDT) Clinical Meeting to promptly identify non-verbal residents and ensure appropriate communication tools are made available. Any findings requiring additional follow-up will be reported to the Administrator for further review and action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: July 11th, 2025 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 1 was immediately released from the wheelchair and appropriately assessed for injury on June 26, 2025. CNA 1 was terminated following the substantiated allegation of abuse. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On June 27, 2025, department supervisors conducted room rounds with residents and/or their responsible parties (RPs) to ensure there were no similar concerns regarding interactions with facility staff and to assess residents' perceptions of their safety within the facility. No additional concerns were identified during the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From June 26, 2025 to June 27, 2025, the Director of Staff Development (DSD), designee conducted multiple in-service trainings for licensed nursing staff and Certified Nursing Assistants (CNAs). The trainings emphasized the importance of implementing appropriate fall prevention interventions. In-services also covered the recognition and prevention of abuse, reinforcing staff responsibilities in reporting and maintaining resident safety. Training also highlighted the proper use of restraints, stressing that restraints must only be applied when absolutely necessary and always with a valid physician's order obtained prior to utilization along with informed consent. This training aimed to ensure compliance with facility policies and regulatory standards while promoting the health, safety, and dignity of residents. Any negative findings identified throughout daily operations from staff will be reported to the Administrator for further review and action in accordance with our abuse policy. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: June 27th, 2025 All residents have the potential to be affected by this deficient practice. On June 27, 2025, department supervisors conducted room rounds with residents and/or their responsible parties (RPs) to ensure there were no similar concerns regarding interactions with facility staff and to assess residents' perceptions of their safety within the facility. No additional concerns were identified during the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From June 26, 2025 to June 27, 2025, the Director of Staff Development (DSD), designee conducted multiple in-service trainings for licensed nursing staff and Certified Nursing Assistants (CNAs). The trainings emphasized the importance of implementing appropriate fall prevention interventions. In-services also covered the recognition and prevention of abuse, reinforcing staff responsibilities in reporting and maintaining resident safety. Training also highlighted the proper use of restraints, stressing that restraints must only be applied when absolutely necessary and always with a valid physician's order obtained prior to utilization along with informed consent. This training aimed to ensure compliance with facility policies and regulatory standards while promoting the health, safety, and dignity of residents. Any negative findings identified throughout daily operations from staff will be reported to the Administrator for further review and action in accordance with our abuse policy. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: June 27th, 2025
Failure to Schedule Physician-Ordered MRI
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician-ordered MRI was scheduled and completed for a resident. The resident, who was admitted with diagnoses including aphonia, dysarthria, and anarthria, had intact cognitive skills and required supervision to extensive assistance with activities of daily living. The resident's neurology appointment resulted in an order for an MRI of the thoracic and lumbar spine, as documented in the After Visit Summary. Despite the physician's order, the MRI was not scheduled, which was confirmed during an interview and record review with the Director of Nursing. The facility's policy required that diagnostic service orders be promptly carried out as instructed by the physician, but this was not followed, resulting in a delay in the resident's diagnostic testing.
Plan Of Correction
F684 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On July 9, 2025, the Facility Case Manager promptly followed-up on MRI appointment for Resident 3 to prevent any further delays in diagnosis and treatment. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On July 10, 2025, the Medical Records Supervisor/designee conducted a review of all appointments within the previous 30 days to ensure appropriate follow-up was documented and completed, preventing any delays in diagnosis or treatment. No further concerns were reported or identified during this review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From July 10, 2025, to July 11, 2025, licensed nursing staff participated in an in-service training conducted by the Director of Nursing (DON)/designee. The training emphasized the importance of appropriate follow-up related to documentation and communication with outside providers after each resident appointment, ensuring continuity of care and timely interventions. A one-on-one in-service was conducted by the DON on July 9th, 2025, with the Facility Case Manager to reinforce the timely scheduling of resident appointments as required and the appropriate communication of follow-up appointments. Any negative findings or barriers will be reported to the Administrator for further review and appropriate action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any pattern of negative findings to QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until QAA committee determines compliance. Date of Compliance: July 11th, 2025
Call Light Not Plugged In and Non-Functional for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident's call light was found unplugged and non-functional during an observation. The resident, who had diagnoses including conversion disorder and aphonia, was dependent on staff for toileting hygiene and required maximal assistance. The call light button was observed hanging on the trapeze handle, with the plug disconnected from the wall outlet. The wall outlet was located on the head part of the bed and toward the right side, while the resident was unable to move the right side of their body, making it impossible for them to reconnect the call light independently. Staff interviews revealed that the LVN had been in the resident's room earlier in the day but did not check the call light plug at that time. The CNA noted that the resident typically called for assistance frequently and had wondered why there were no calls that day, but did not check the call light's functionality. The DON confirmed that the call light should be within reach and functioning. Review of facility policy indicated that call lights are to be plugged in and operational at all times.
Failure to Document Employee Reference Checks in Abuse Prevention Program
Penalty
Summary
The facility failed to ensure that its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy and procedure included requirements for screening potential employees through reference checks with previous or current employers. During a review of six employee files, it was found that three employees did not have documented reference checks. Specifically, one certified nursing assistant (CNA) had a blank Pre-Employment Reference Checklist (PRC), and two others had no PRC or reference check documentation in their files. Additional review of previous employee files did not reveal any evidence of completed reference checks for these individuals. Interviews with the Director of Staff Development (DSD) and the Administrator (ADM) confirmed that reference checks were expected to be conducted, including inquiries about prior allegations of abuse and rehire eligibility. However, there was no documentation to support that these checks were performed for the three employees in question. The facility's policy, dated April 2021, did not specify the requirement to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation by contacting previous or current employers.
Failure to Provide Timely Incontinent Care to Dependent Resident
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide timely incontinent care to a resident who was dependent on staff for toileting hygiene and had impaired mobility and inability to alert staff. The resident, admitted with conversion disorder and aphonia, was care planned to be checked for bladder incontinence at least every two hours and as needed. Observations revealed that the resident was left in a wet gown and adult brief, with a noticeable smell of urine, and communicated through gestures and writing that care was not being provided as required. Interviews with CNAs indicated that the assigned staff did not check or change the resident's adult brief during their rounds, prioritizing other tasks and residents instead. CNA 7 admitted to planning to provide care to the resident at the end of rounds and did not check the resident for incontinence care, despite knowing the risks of not doing so. CNA 8 also delayed providing care, stating that other duties, such as showering other residents, took precedence even after being notified by an LVN that the resident needed to be changed. Facility policy required staff to provide appropriate care and services for residents unable to perform activities of daily living independently, including hygiene and toileting, in accordance with the care plan. Despite this, the resident was observed multiple times to be wet and not changed in a timely manner, and staff interviews confirmed that care was not provided as required by policy and the resident's care plan.
Failure to Follow Infection Control Protocols During Food Tray Handling and PPE Use
Penalty
Summary
The facility failed to follow its infection prevention and control measures for three residents by not ensuring proper hand hygiene and use of personal protective equipment (PPE) by staff. Certified Nurse Assistant (CNA) 2 was observed exiting a resident's room after handling a dirty food tray without sanitizing hands and then proceeded to handle clean food trays for other residents without performing hand hygiene. Additionally, CNA 2 did not use alcohol-based hand rub before passing clean food trays to another CNA. CNA 1, who was responsible for setting up food trays in a room with a posted Novel Respiratory Precautions isolation sign, did not wear gloves or perform hand hygiene before accepting and setting up food trays for two residents who had been exposed to COVID-19. CNA 1 also failed to use hand sanitizer between setting up trays for the two residents. Both CNAs acknowledged during interviews that they did not follow proper hand hygiene protocols as required by facility policy. The residents involved had significant cognitive impairments and required assistance with activities of daily living, including eating. Facility policies reviewed indicated that staff were expected to adhere to hand hygiene and PPE protocols, especially when handling food trays and entering rooms with infection control precautions. The Infection Preventionist confirmed the importance of these measures during interviews.
Failure to Develop Comprehensive Care Plan for Mask Non-Compliance During COVID-19
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan with measurable objectives for a resident who was non-compliant with wearing a face mask during a COVID-19 outbreak. The resident, who had diagnoses including Alzheimer's disease, generalized muscle weakness, and a cervical vertebra fracture, was assessed as having severely impaired cognitive skills and was dependent on staff for activities of daily living and mobility. Despite being exposed to COVID-19, the care plan only included general interventions such as educating the resident on hand hygiene, mask use, and social distancing, without addressing the resident's specific non-compliance behavior or providing measurable objectives and individualized interventions. Observations showed the resident repeatedly in the hallway without a face mask or with the mask improperly worn, interacting with others. Staff interviews confirmed that the resident required frequent and constant reminders to stay in her room or wear a mask, and that a care plan addressing her non-compliance was not created when the behavior was first noted. Facility policy required ongoing assessment and revision of care plans as resident conditions changed, but this was not followed in the case of this resident's non-compliance with infection control measures.
Insufficient Night Shift Staffing Resulted in Delayed Incontinent Care
Penalty
Summary
The facility failed to provide sufficient nursing staff during one of two reviewed night shifts, specifically the 11 pm to 7 am shift, resulting in inadequate incontinent care for a resident. On the night in question, only two CNAs were on duty for a census of 89 residents, whereas the facility's policy and facility assessment indicated that four to six CNAs were typically required for this census, with an expected ratio of 12 to 16 residents per CNA. As a result, the two CNAs were assigned to care for 33 and 40 residents each, which was significantly above the usual assignment and made it difficult for them to provide timely care to all residents. A resident with a history of Type 2 diabetes mellitus with a foot ulcer, mobility issues, and frequent incontinence was not checked or changed throughout the night, contrary to their care plan, which required checks for bladder incontinence at least every two hours. The resident reported that staff did not check or change them during the night and attributed this to the reduced number of staff on duty. Staff interviews confirmed that the night shift was short-staffed, and licensed staff had to assist with ADL care, which was not typical and caused delays in their other duties. Facility records and staff interviews indicated that management was aware of the staffing shortage and attempted to find replacements but was unsuccessful. The facility's own policy and facility assessment required sufficient numbers of nursing staff to meet residents' needs, but this was not met on the night in question, leading to a delay in the provision of care and services for the affected resident and potentially others.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 3's needs were immediately addressed to ensure their care needs were adequately met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/28/25, department supervisors conducted rounds to ensure that no other individuals were impacted by this deficiency. No additional issues were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: A in-service training was conducted on 4/1/2025 with the DSD and DON by the Administrator, focusing on the importance of sufficient staffing and meeting staffing per patient day (PPD) requirements. On 10/29/24, QAPI centered on sufficient staffing created by Administrator/DON. The QAPI is ongoing. The facility will reinforce and ensure adherence to the 4-2 staffing ladder for CNAs. The Director of Staff Development (DSD) will be responsible for ensuring adequate CNA coverage for the AM, PM, and NOC shifts. The DSD will report any staffing shortages to the administrator daily (Monday-Friday) during morning stand-up meetings to ensure effective communication regarding CNA and licensed nurse staffing levels. The Administrator/designee will collaborate with the organization's HR Recruiter to ensure CNA hiring efforts remain a hyper-focus. The facility is working closely with a dedicated recruiter to prioritize the recruitment of qualified nursing staff. This partnership focuses on sourcing, screening, and hiring skilled nursing staff. The facility will also collaborate with sister facilities in an effort to meet staffing needs as needed. The facility will continue to implement a bonus incentive on an as-needed basis for licensed nurses/CNAs, effective January 27, 2025, to help maintain adequate staffing levels and effectively address staffing needs. The DSD/designee will continue to maintain a call log when staffing hours for CNAs are insufficient. The log will document all staff members contacted and the outcomes of those communications. The DSD/designee will report any pattern of findings related to staffing to the Administrator for further review and action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any pattern of findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QM committee determines compliance. Date of Compliance: April 1st, 2025
Unauthorized Disclosure of Resident PHI via Email
Penalty
Summary
A deficiency occurred when the Social Services Director (SSD) sent an email containing a resident's Face Sheet (Admission Record) and information regarding podiatry care needs to an unauthorized recipient, specifically another resident's family member. The email included protected health information (PHI) such as the resident's Medicaid, Medicare, and insurance policy numbers, home address, care providers, emergency contact, and financial representative. The SSD stated that the email was sent by mistake, confusing the intended recipient, a medical provider with the same first name as the family member who received the email. The resident whose information was disclosed had a history of anemia, chronic pain, and gout, and was noted to have severely impaired cognition, requiring substantial to maximal assistance with activities of daily living. The resident was able to make needs known but could not make medical decisions. The SSD recognized the error and attempted to recall the email but did not report the incident to facility leadership or follow the facility's policy for handling breaches of PHI. Interviews with the Administrator and Director of Nursing revealed that the facility's protocol required immediate reporting of any PHI breach to leadership, investigation of the incident, and notification of the resident or responsible party. The facility's policy also specified that access to resident records should be limited to authorized staff and business associates, which was not followed in this instance.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 8 was informed of the breach on March 26, 2025, and was assured that the facility would take all appropriate steps to mitigate any potential negative consequences resulting from the incident. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. Beginning on March 27, 2025, the Social Services Director conducted outreach to residents within the facility to identify any additional potential breaches and to ensure there were no further incidents or concerns related to the confidentiality of Protected Health Information (PHI). No additional findings were identified as a result of this review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and department supervisors participated in an in-service training conducted by the Administrator or designee. The training focused on the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in accordance with HIPAA regulations. On March 27, 2025, the Administrator conducted a one-on-one training with the Social Services Director, emphasizing the importance of secure communication practices and the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in compliance with HIPAA regulations. The Social Services Director will adhere to safe communication practices and will promptly report any potential breaches of confidentiality to the Administrator for further review and appropriate action. How the facility plans to monitor its performance to make sure that solutions are sustained: The ADMIN/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Failure to Provide Timely Incontinence Care Due to Staffing Assignment Delays
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs), including toileting and personal hygiene, did not receive timely incontinence care. The resident, who had diagnoses including conversion disorder, anarthria, and aphonia, was observed in bed with wet bedding, clothing, and sheets. The resident communicated to the surveyor that they had been wet for a long time and had not been changed. The care plan for this resident required staff to check for incontinence every two hours and as needed, and to provide peri-care after episodes. Staff interviews revealed that the assigned CNA had not changed the resident that morning, citing confusion over assignments at the start of the shift due to delays in finalizing the CNA staffing assignment. The Director of Staff Development confirmed that the assignment was not completed until after the shift began, which delayed care. The Director of Nursing stated that the staffing assignment should be ready before the shift so CNAs can provide immediate care. Facility policy required appropriate support and assistance with hygiene and toileting for residents unable to perform ADLs independently.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On March 27, 2025, Resident #1 was promptly provided with Activities of Daily Living (ADL) care by a facility CNA as soon as the deficient practice was identified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28th, 2025, Department supervisors conducted room rounds to follow up with residents to ensure there were no other concerns pertaining to ADL care. No additional findings were identified as a result. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and CNAs participated in an in-service training conducted by the Administrator/designee. The training focused on the importance of providing timely ADL care, with an emphasis on promptly responding to call lights to ensure residents' needs are consistently and adequately met. The Director of Staff Development (DSD)/Designee will conduct random daily rounds to ensure timely ADL care is being provided and that residents' needs are being consistently met. Any negative findings will be reported to the Director of Nursing (DON) for further review and appropriate follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Failure to Assess and Document Pain Management
Penalty
Summary
The facility failed to manage pain for one resident by not following its own pain assessment and management policy, as well as the resident's care plan. The care plan required licensed nurses to assess and document the resident's pain level on a 0-10 scale before and after administering pain medication, specifically oxycodone, for pain management. However, review of the medication administration records and progress notes showed that nurses did not document pain assessments before or after giving routine or as-needed pain medication. Additionally, when the resident complained of new abdominal pain, there was no documentation of the pain level, characteristics, or interventions provided to address the pain on the relevant dates. The resident involved had a history of a right femur fracture, was post-surgical for open reduction and internal fixation, and had other mobility issues. The resident was cognitively impaired and dependent on staff for most activities of daily living. Despite having physician orders for both scheduled and as-needed oxycodone for pain, there was no evidence that staff assessed or documented the resident's pain level or characteristics before or after medication administration, nor that pain medication was given in response to new complaints of abdominal pain. Interviews with nursing staff and the Director of Nursing confirmed that the expected practice was to assess and document pain levels before and after administering pain medication, and to address new onset pain as a change in condition. The facility's policy also required detailed pain assessments and documentation, including location, intensity, and characteristics of pain, as well as monitoring and reassessment after interventions. These practices were not followed, resulting in a failure to ensure proper pain management for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #2 was transferred to the hospital on January 14, 2025, and is no longer residing at the facility. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 27, 2025, the Medical Records Supervisor/designee reviewed pain level documentation for the 30 days prior, focusing on pre- and post-pain medication administration, to ensure no other residents were affected by this deficient practice. No additional findings were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 24 to March 28, 2025, licensed nurses received in-service training conducted by the Administrator/designee. The training focused on pain management, including proper procedures and protocols for pain assessment and timely intervention, to prevent physical, mental, and emotional distress. The Medical Records Supervisor will conduct bi-weekly reviews of the Medication Administration Record (MAR) to ensure pain level documentation is completed both prior to and following the administration of pain medication. Any negative findings will be reported to the Director of Nursing (DON) during the daily clinical stand-up meeting to ensure timely identification and resolution of concerns. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Failure to Honor Resident Food Preferences Due to Dietary Miscommunication
Penalty
Summary
A deficiency occurred when the dietary services department failed to honor a resident's documented food preferences for dinner on a specific date. The resident, who had conversion disorder, anarthria, and aphonia, was dependent on staff for several activities of daily living and communicated her meal preferences through a written list/menu, which was signed by the Dietary Services Supervisor (DSS). The care plan indicated that dietary staff were to review and provide food according to the resident's preferences, and the resident and DSS had agreed to review and update the menu weekly. On the day in question, the resident only received a strawberry smoothie for dinner, despite having a detailed menu of preferred foods for each meal. Interviews with the DSS and kitchen staff revealed a miscommunication: the cook believed only a smoothie was required, as the DSS had not informed the kitchen to prepare the resident's preferred dinner. The DSS acknowledged the need to provide meals according to the resident's written preferences, and the kitchen staff stated they had not received instructions to prepare anything beyond the smoothie and lemons. The facility's policy required staff to determine and honor resident food preferences and to offer a variety of foods at each meal. However, the failure to communicate and provide the resident's requested meal resulted in the resident's food choices not being honored, with the potential for unmet nutritional needs.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 was seen by the Dietary Supervisor on March 27, 2025, and the dietary preferences were updated to ensure there are no further concerns regarding the residents' meal schedule. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28, 2025, the Dietary Supervisor/designee reviewed resident preferences as documented on individual meal slips to ensure all preferences were current and being appropriately followed. No additional findings were identified as a result of the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 26 to March 27, 2025, the Dietary Supervisor or designee conducted in-service training for dietary staff on the importance of following resident preferences and adhering to the established meal slips. Licensed nurses will report any inconsistencies related to meal slips to the Dietary Supervisor for further review. The Dietary Supervisor will report any negative findings to the Administrator for appropriate follow-up and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. All residents had the potential to be affected by this deficient practice. On March 28, 2025, the Dietary Supervisor/designee reviewed resident preferences as documented on individual meal slips to ensure all preferences were current and being appropriately followed. No additional findings were identified as a result of the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 26 to March 27, 2025, the Dietary Supervisor or designee conducted in-service training for dietary staff on the importance of following resident preferences and adhering to the established meal slips. Licensed nurses will report any inconsistencies related to meal slips to the Dietary Supervisor for further review. The Dietary Supervisor will report any negative findings to the Administrator for appropriate follow-up and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 28th, 2025
Failure to Provide Water According to Resident Needs and Preferences
Penalty
Summary
A deficiency occurred when a resident, who was admitted with conversion disorder, anarthria, and aphonia, and who had moderate cognitive impairment and was dependent on staff for several activities of daily living, was not provided with water according to their needs and preferences. On the morning of the incident, the resident was observed lying in bed with empty water tumblers and cups. The resident, unable to speak, pointed to the empty tumblers, prompting a licensed vocational nurse to refill them. Staff interviews revealed that night shift nurses were responsible for distributing fresh water at the start of their shift, and morning CNAs were expected to refill pitchers if needed. Further interviews with staff, including the Director of Staff Development and the Director of Nursing, confirmed that water pitchers should be within reach, filled, and checked at least every two hours. The facility's policy emphasized the importance of providing adequate hydration and preventing dehydration. Despite these protocols, the resident's water pitchers were found empty and not refilled as required, resulting in a failure to meet the resident's hydration needs.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 1 was provided with immediate proper hydration on March 27th, 2025, to ensure residents' hydration needs are being met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28, 2025, department supervisors conducted room rounds to follow up with residents and ensure there were no additional concerns related to water hydration. No further issues were identified as a result of these rounds. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and CNAs participated in an in-service training conducted by the Director of Staff Development (DSD)/designee. The training focused on the importance of proper hydration to support residents' overall health and well-being. To reinforce this practice, department supervisors will conduct daily room rounds (Monday through Friday) to ensure water pitchers are filled and within reach of each resident. Any negative findings will be reported to the Director of Nursing (DON) during the daily clinical stand-up meeting for immediate and appropriate follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 28th, 2025
Failure to Provide and Accurately Document Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) as ordered for a resident with significant mobility and neurological impairments. The resident, admitted with diagnoses including conversion disorder, dysarthria, anarthria, and unspecified neuropathy, had physician orders and a care plan specifying active-assisted range of motion (AAROM) exercises for both lower extremities, to be performed daily, five days per week, with 20 repetitions and three sets per session or as tolerated. Despite these orders, documentation and interviews revealed that the resident did not consistently receive the prescribed RNS, and in some cases, the services were not provided at all. Record reviews and interviews indicated that restorative nurse assistants (RNAs) documented providing RNS on days when they were not present or working, and in some instances, initialed flow sheets to indicate completion of services that were not performed. One RNA admitted to only partially completing the ordered exercises and, on some days, not providing the treatment at all due to time constraints, yet still documented the services as completed. The resident also reported that RNAs either did not provide the RNS or only completed part of the ordered exercises on certain days. The facility's policy required that restorative nursing care be provided as needed to promote optimal safety and independence, but the failure to follow physician orders and accurately document care resulted in the resident not receiving the full extent of prescribed RNS. Staff interviews confirmed that documenting unprovided care was considered willful falsification of medical records, and the director of staffing development was unable to confirm whether the resident received RNS on multiple dates when documentation was falsified.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: RNA 1 and RNA 2 are no longer employed in the facility. Additionally, on March 5, 2025, the Administrator or designee held a one-on-one in-service session with RNA 5 along with a counseling, focusing on the importance of following RNA orders for Resident 2 and other residents in the program. This training emphasized essential steps for enhancing compliance and ensuring that residents' needs are effectively met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18th, 2025, the Director of Nursing (DON) or designee reviewed residents participating in the restorative nursing assistant (RNA) program to ensure that treatments were properly authenticated and administered, thereby preventing any further decline in range of motion (ROM). No additional findings were noted. 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's Director of Staff Development (DSD) resigned on March 7, 2025. A new DSD is scheduled to be onboarded on March 19, 2025, and appropriate policies and procedures will be followed to ensure the timely and accurate completion of Restorative Nursing flow sheets. On March 20th, 2025, facility restorative nursing assistants (RNAs) participated in an in-service training session conducted by the Administrator or designee. The training emphasized the importance of adhering to RNA orders for residents and the necessity of accurate charting related to RNA treatments. The Director of Nursing (DON)/designee will review RNA treatments on a weekly basis to ensure that orders are being properly implemented and accurately documented. The Director of Staff Development (DSD)/designee will conduct random rounds during RNA treatments to verify that orders are being executed as specified. Any negative findings will be reported to the Administrator for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until QAA committee determines compliance. Date of Compliance: March 20th, 2025
Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure accurate documentation of restorative nursing services (RNS) provided to a resident, as required by federal regulations and the facility's own policy. Specifically, restorative nursing assistants (RNAs) initialed the Restorative Nursing Flow Sheet (RNFS) to indicate that range of motion (ROM) exercises were provided to the resident on multiple dates, even though they were not present or did not perform the ordered interventions. Review of timecards and staffing sign-in sheets confirmed that on several dates, the RNAs who initialed the RNFS were not working, and the Director of Staff Development (DSD) could not verify whether the resident received the required RNS on those days. Further investigation revealed that on some occasions, an RNA documented that the full treatment was completed when, in fact, only a partial treatment or no treatment was provided. The RNA admitted to initialing the RNFS to indicate completion of the ordered exercises even when unable to perform them, citing lack of time as a reason. The resident also reported that RNAs sometimes did not provide the RNS as ordered or only completed part of the treatment. This resulted in the resident's medical record containing inaccurate information regarding the care and services provided. The facility's policy on charting and documentation requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be objectively, completely, and accurately documented in the medical record. Interviews with nursing staff confirmed that documenting care as completed when it was not is considered willful falsification of medical records. The inaccurate documentation and failure to provide ordered RNS could not be verified or corrected due to the lack of accurate records, directly impacting the integrity of the resident's medical record.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On February 27, 2025, licensed nursing staff and Rehab assessed Resident 2 for any adverse effects associated with missed restorative nursing assistant (RNA) orders. No ill effects were observed, and there was no decline in range of motion. RNA 1 and RNA 2 are no longer employed in the facility. Additionally, on March 5, 2025, the Administrator or designee held a one-on-one in-service session with RNA 5 along with a counseling, focusing on the importance of following RNA orders for Resident 2 and other residents in the program. This training emphasized essential steps for enhancing compliance and ensuring that residents' needs are effectively met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18th, 2025, the Director of Nursing (DON) or designee reviewed residents participating in the restorative nursing assistant (RNA) program to confirm that treatments were properly authenticated and administered, thereby preventing any further decline in range of motion (ROM). No additional concerns were identified. 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's Director of Staff Development (DSD) resigned on March 7, 2025. A new DSD is scheduled to be onboarded on March 19, 2025, and appropriate policies and procedures will be followed to ensure the timely and accurate completion of Restorative Nursing flow sheets. On March 20th, 2025, facility restorative nursing assistants (RNAs) participated in an in-service training conducted by the Administrator or designee. This training emphasized the importance of adhering to RNA orders for residents and the necessity of accurate charting related to RNA treatments. The Director of Nursing (DON)/designee will review RNA treatments on a weekly basis to ensure that orders are being properly implemented and documented. The DSD/designee will conduct random rounds during RNA treatments to verify that orders are being executed as specified. Any negative findings will be reported to the Administrator for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The Admin/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 20th, 2025.
Failure to Inventory and Protect Resident's Durable Medical Equipment
Penalty
Summary
Facility staff failed to protect a resident's property from loss by not properly inventorying a right hand resting splint (RHRS) on the resident's clothing and possession form when it was received. The RHRS, a piece of durable medical equipment prescribed to assist with the resident's contracture management, was not documented as received on the inventory form, and there was no record of its loss in the resident's progress notes. Despite physician orders for the resident to use the RHRS at night, staff did not update the inventory or document the device's whereabouts after it was last seen. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, reported that staff lost the RHRS shortly after it was received and did not respond to requests for its return or provide information about its location. Interviews with staff confirmed that the RHRS was last seen the day after it was received, and that staff were responsible for tracking and documenting the device in the resident's records. However, there was no evidence that staff reported the device missing or investigated its disappearance as required by facility policy. The facility's policy on personal property required that resident belongings be inventoried upon admission and updated as necessary, and that any complaints of missing property be promptly investigated. In this case, the lack of documentation and follow-up regarding the RHRS resulted in the resident being without the prescribed device, with no indication in the records that staff took steps to locate or account for the missing equipment.
Plan Of Correction
F584 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 2 was referred to the facility's rehabilitation department for a reassessment of their need for durable medical equipment (DME). If deemed necessary, an appointment with an external rehabilitation provider will be coordinated per resident preference. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18, 2025, the Director of Nursing (DON) or designee conducted a review of all residents with splints in the facility to ensure that the durable medical equipment (DME) was accurately accounted for and easily locatable. No additional findings were noted. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 17 to March 21, the Director of Nursing (DON) or designee conducted an in-service training for licensed nursing staff on the importance of accurately inventorying resident durable medical equipment (DME) and ensuring its proper placement. This training aims to meet resident needs effectively and eliminate barriers to care. Additionally, the Medical Records department or designee will audit admissions and readmissions to verify proper inventory logging of applicable DME. Any negative findings will be reported to the DON for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 21st, 2025 F 584
Failure to Develop Care Plan for Resident's Rash
Penalty
Summary
The facility failed to develop a care plan for a resident who was admitted with a generalized body rash. Upon admission, the resident had multiple diagnoses, including toxic encephalopathy and chronic kidney disease. The Admission/Readmission Data Tool noted the presence of a rash on the resident's arms, back, chest, and abdomen, described as spotted dark brownish red with itching. Despite this, a care plan addressing the rash was not created, which was confirmed during an interview with the Infection Preventionist Nurse. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the required Minimum Data Set assessment and no more than 21 days after admission. However, the care plan for the resident's rash was not developed, even though the hospital had ordered treatment for the rash to continue. This oversight had the potential to result in unmet individualized needs and a break in continuity of care for the resident's existing condition.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent a fall for Resident 12, who was assessed as being at high risk for falls. On December 28, 2024, Resident 12 was left unsupervised in the facility's conference room with the door closed, contrary to the care plan that required frequent visual checks and monitoring at the nursing station. This lack of supervision resulted in Resident 12 falling to the floor, sustaining a fracture of the dens of cervical spine 2 (C2). Resident 12 had a history of multiple falls and was identified as having severely impaired cognition, limited mobility, balance problems, and poor safety awareness. The resident's care plan, which was revised multiple times, included interventions such as frequent visual checks and keeping the resident at the nursing station for monitoring. Despite these measures, staff failed to follow the care plan, leading to the resident being left alone in the conference room, where the fall occurred. Interviews with staff, including CNA 4, LVN 6, and RN 2, revealed that the facility did not adhere to the established care plans and policies for fall prevention and resident supervision. The facility's policies emphasized the importance of resident safety supervision and the implementation of interventions to reduce accident risks. However, the staff did not effectively communicate or implement these interventions, resulting in the resident's fall and subsequent injury.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to deficiencies in care. Resident 3, who has spina bifida and diabetes, was not promptly changed after episodes of incontinence, despite being dependent on staff for toileting and hygiene. Resident 8, with a wedge compression fracture, also experienced delays in receiving care after reporting a bowel movement, resulting in a significant wait time before being cleaned and changed. Both residents expressed concerns about the timeliness of care, which was affected by the number of residents assigned to each CNA. Resident 18, who has myelodysplastic syndrome, type 2 diabetes, and chronic kidney disease, was similarly affected by delays in changing incontinence briefs. A family member reported that it took an hour for staff to respond to a request for a diaper change. The care plan for Resident 18 indicated a need for occupational therapy and assistance with various ADLs, yet the facility did not meet these needs in a timely manner. Resident 17, diagnosed with conversion disorder and anarthria, did not receive scheduled hair care, resulting in matted and hard hair. The care plan required hair washing and combing every Wednesday, but staff were not informed of the change from Saturday to Wednesday, leading to a lapse in care. Interviews with staff and family members highlighted the inconsistency in care and the lack of communication regarding care schedules. The facility's policy on supporting ADLs was not adhered to, as residents did not receive the necessary assistance to maintain their daily living activities.
Inadequate CNA Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient Certified Nursing Assistants (CNAs) were available to provide care and services to four of the 18 sampled residents, as per the facility's policy and procedure on staffing and the Facility Assessment Tool. This deficiency was observed on multiple dates, including 12/16/2024, 12/22/2024, 12/23/2024, 12/26/2024, 12/28/2024, 1/4/2025, and 1/7/2025. The lack of adequate staffing resulted in residents experiencing delays of up to an hour for call lights to be answered and for incontinence care to be provided, which could potentially lead to a decline in their physical and psychosocial well-being. Resident 3, who was admitted with spina bifida and diabetes mellitus, was dependent on others for toileting hygiene and was always incontinent of bladder and bowel. Despite having an intact cognition, Resident 3 reported waiting up to an hour for a diaper change, which was attributed to the number of residents assigned to each CNA. Similarly, Resident 8, who had a wedge compression fracture and required partial assistance, experienced delays in receiving care after a bowel movement, with a CNA taking nearly an hour to respond and provide care. Resident 8 also noted that some CNAs were rough due to being hurried. Interviews with staff and family members revealed that CNAs were often assigned more residents than they could adequately care for, with some shifts having CNAs responsible for up to 29 residents. This staffing shortage was corroborated by the facility's assignment sheets, which showed that the number of residents per CNA often exceeded the facility's own guidelines. The facility's policy indicated that staffing should be based on residents' needs, but the actual staffing levels fell short, leading to inadequate care and delayed responses to residents' needs.
Failure to Provide Communication Device for Non-Verbal Resident
Penalty
Summary
The facility failed to provide a communication device to a resident, identified as Resident 17, who was unable to speak due to conditions including conversion disorder, anarthria, and aphonia. This deficiency was observed when Resident 17 attended a medical appointment without their communication device, which was necessary for them to express their needs and communicate effectively. The resident's care plan specifically indicated the use of a tablet computer for communication, and staff were instructed to ensure the availability and functionality of this adaptive communication equipment. On the day of the appointment, a Certified Nursing Assistant (CNA) who accompanied Resident 17 confirmed that the resident did not have their communication device and had to use the CNA's mobile phone to communicate. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Social Services Director (SSD), highlighted the expectation that Resident 17 should always have a communication device during outside appointments. The facility's policy on resident rights also emphasized the importance of communication access, both inside and outside the facility.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement the care plan for two residents, leading to deficiencies in their care. Resident 12, who was at high risk for falls due to multiple medical conditions and cognitive impairment, was not adequately monitored as per their care plan. Despite being placed near the nursing station for supervision, Resident 12 was found unsupervised in a conference room, resulting in an unwitnessed fall that caused a serious injury. Interviews with staff revealed that the care plan's requirement for frequent visual checks was not followed, and the resident was left alone without supervision, contrary to the facility's policies. Resident 17, who had a conversion disorder and required assistance from two staff members for safety and care, did not receive medication administration as per their care plan. LVN 9 administered medication without the accompaniment of another staff member, as required by the care plan. This oversight was confirmed during interviews with both the resident and LVN 9, who admitted to forgetting the requirement for dual staff presence during care. The facility's policy on comprehensive, person-centered care plans was not adhered to, resulting in a failure to meet the resident's needs. The facility's policies and procedures, including those for safety supervision, fall risk management, and comprehensive care planning, were not effectively implemented for these residents. The lack of adherence to established care plans and protocols led to significant deficiencies in the care provided to Residents 12 and 17, highlighting a failure in communication and responsibility assignment among the staff.
Failure to Obtain After Visit Summary from Neurologist
Penalty
Summary
The facility failed to coordinate with an outside care provider to obtain necessary care records for a resident after a neurology appointment. The resident, who was admitted with diagnoses including conversion disorder, anarthria, and aphonia, attended a neurologist appointment but returned without an after visit summary (AVS). This document is crucial as it details the treatment plan and any new orders from the care provider. The absence of this record meant that the facility staff were unaware of the neurologist's recommendation for the resident to undergo an MRI. Interviews with facility staff revealed a lack of communication and follow-up procedures. The Licensed Vocational Nurse (LVN) who received the resident after the appointment did not notify the Medical Records Supervisor (MRS) to obtain the necessary records, as was the facility's practice. The Registered Nurse (RN) and MRS confirmed that there was no specific policy in place for obtaining records after outside appointments, relying instead on informal practices. This oversight resulted in the resident not receiving the recommended MRI, as there was no physician's order documented in the resident's medical record.
Improper Repositioning Techniques by CNAs
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) adhered to proper procedures when turning and caring for two residents, resulting in pain during care provision. Resident 7, who was admitted with a dislocation of an internal right hip prosthesis, reported that some CNAs did not use a draw sheet to turn them in bed, causing pain. Similarly, Resident 8, admitted with a wedge compression fracture of an unspecified thoracic vertebra, stated that CNAs pushed and held onto their skin roughly and hurriedly during repositioning, which was painful. Both residents had intact cognition and were capable of understanding and making decisions. The Director of Staff Development confirmed that CNAs were trained to use a draw sheet for turning residents and to handle them gently and unhurriedly. The facility's competency assessment and policy documents emphasized the use of a draw sheet to avoid shearing and the importance of providing care according to established procedures. Despite this training, the CNAs' failure to follow these protocols led to the deficiencies observed in the care of Residents 7 and 8.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to answer call lights timely and provide care and nursing-related services to two of three sampled residents. Resident 1, who was admitted with a Stage 4 pressure ulcer and malnutrition, experienced delays in call light responses, sometimes waiting over an hour for assistance with diaper changes. Resident 2, with heart failure and diabetes mellitus, also reported longer wait times for call light responses, particularly at night when staffing was insufficient. The facility's staffing records revealed that during several night shifts, the number of certified nursing assistants (CNAs) on duty was below the required level, leading to excessive workloads for the available staff. For instance, on certain nights, CNAs were responsible for up to 30 residents each, far exceeding the facility's stated staffing ratio of one CNA to 12 to 16 residents for the night shift. Interviews with CNAs confirmed that the high workload led to rushed care and delayed responses to residents' needs. The Director of Staff Development acknowledged the staffing shortages and indicated that the facility did not use registry staff to fill gaps. The facility's policy required timely responses to call lights and adequate staffing to meet residents' needs, but these were not adhered to, resulting in delayed care and dissatisfaction among residents. The facility's failure to maintain sufficient staffing levels directly contributed to the deficiency in care provided to the residents.
Resident's Dignity Compromised by Public Request for Urine Sample
Penalty
Summary
The facility failed to protect a resident's right to be treated with dignity and respect when a registered nurse (RN) requested a urine sample from the resident in the presence of the resident's visitor. This incident involved a resident who was admitted with diagnoses including congestive heart failure, amputation of both legs below the knee, and an anxiety disorder. The resident, who had no cognitive impairments and required supervision for personal care, felt embarrassed and disrespected by the RN's actions. The incident occurred when the RN entered the resident's room and, in front of the resident's friend, held up a urine cup and requested a urine sample. The resident expressed feeling mortified by the RN's behavior, which was witnessed by a licensed vocational nurse (LVN) who confirmed the resident's discomfort. The Director of Nursing acknowledged that such requests should be made privately to protect the resident's dignity, as outlined in the facility's policy on resident rights.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to monitor blood sugar levels for a resident with type 1 diabetes, which was a critical oversight given the resident's medical history. The resident was admitted to the facility with a history of using an insulin pump to manage her diabetes, as indicated in her transfer orders. However, the facility did not continue the order to check her blood sugar levels four times a day as directed. The Director of Nursing (DON) acknowledged that the facility staff did not monitor the resident's blood sugar levels, despite the transfer orders and the facility's policy requiring such monitoring. The resident's daughter reported that the resident's blood sugar level was in the 700s when she was transferred to an acute care hospital, indicating a severe lack of blood sugar management at the facility. The facility's policy stated that blood sugar levels should be monitored twice a day for residents on insulin, and more frequently for those on intensive insulin therapy. The DON admitted that not monitoring blood sugar levels in type 1 diabetic residents was dangerous, yet no discussion with the resident's physician occurred to obtain an order for monitoring, leading to a significant deficiency in care.
Failure to Remove CNA During Abuse Investigation
Penalty
Summary
The facility failed to immediately remove a Certified Nurse Assistant (CNA 1) from performing resident care duties after an allegation of rough handling was made by a resident (Resident 1). The incident was reported on 11/10/24, when Resident 1 accused CNA 1 of leaving her soaking wet and being rough while changing her. Despite the ongoing investigation, CNA 1 continued to work her regular schedule without suspension, which was acknowledged by the Director of Nursing (DON). The facility's policy and procedure for abuse prevention require protecting residents from further harm during investigations, which was not adhered to in this case. Resident 1, who was originally admitted on 10/12/23 and readmitted on 7/8/24, has a medical history that includes acute osteomyelitis, lack of coordination, bilateral primary osteoarthritis of the knee, and a Stage 3 pressure ulcer. The resident is capable of making her needs known but cannot make medical decisions. During interviews, Resident 1 expressed that CNA 1 was the only staff member who treated her roughly, and CNA 3 confirmed that Resident 1 reported mistreatment and neglect by CNA 1. The facility's investigation report indicated that the investigation was ongoing from 11/10/24 to 11/11/24, but CNA 1 was not suspended during this period, contrary to the facility's policy to protect residents from further harm during investigations.
Facility Fails to Provide Necessary Accommodations for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents, leading to discomfort and pain. For one resident, the absence of a toilet paper dispenser in the restroom required the resident to reach behind to access toilet paper placed on the toilet tank, causing shoulder pain. This resident had intact cognition and required moderate assistance for toileting hygiene and transferring, as indicated in their Minimum Data Set (MDS). Observations and interviews with the resident, a Certified Nursing Assistant (CNA), and the Maintenance Supervisor confirmed the lack of a toilet paper holder and the resulting difficulty for the resident. Another resident experienced discomfort during wheelchair transport due to the absence of footrests. This resident, with a diagnosis of unspecified dementia and a history of falling, required substantial assistance for activities of daily living and used a manual wheelchair. During an observation, the resident's feet were seen dragging on the floor, and the resident expressed discomfort from having to lift their feet. A CNA acknowledged the issue and intended to report it, while a Registered Nurse Supervisor confirmed that wheelchairs should have footrests for comfort and safety. The facility's policy on assistive devices indicated that mobility devices should be maintained and supervised for resident safety and independence.
Failure to Inform Residents of Advance Directive Rights
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 14 and Resident 40, or their representatives, were informed of their right to formulate an advance directive, as required by the facility's policy and procedure on Advanced Directives. Resident 14, who had intact cognition, was admitted with diagnoses including end-stage renal disease and type 2 diabetes. Resident 40, who had moderately impaired cognition, was admitted with Alzheimer's disease and hypertension. During a review of their records, it was found that neither resident had an advanced healthcare directive, and there was no documentation indicating that they or their representatives had received written information about their rights to formulate such a directive. The Social Services Director (SSD) confirmed that the facility's policy required residents or their representatives to be provided with written information about their rights to accept or refuse medical treatment and to formulate an advance directive upon admission. However, the SSD could not confirm that this had been done for Residents 14 and 40. The first documented proof of communication regarding these rights was an email sent to the residents' responsible parties, which occurred after the residents' admission. This oversight had the potential to affect the care of the residents, as their representatives might not be informed of their rights to make medical decisions if the residents became incapacitated.
Deficiencies in Monitoring and Medication Administration
Penalty
Summary
The facility failed to provide appropriate care and treatment for three residents, leading to deficiencies in meeting their physical, mental, and psychosocial needs. Resident 79 experienced a change of condition when they fell asleep and hit their forehead against a table, resulting in a bruise and a scab. Despite the physician's order for continued monitoring, the facility did not initiate a 72-hour monitoring period or document the change of condition, as required by their policy. This lack of documentation and monitoring could have hindered the ability to track further changes in Resident 79's condition. Resident 34's care was compromised when the facility did not adhere to the physician's order regarding the administration of Doxazosin, a medication used to treat high blood pressure. The medication was administered even when Resident 34's blood pressure readings were below the specified parameters, which could have led to a further drop in blood pressure. The facility's policy on medication administration was not followed, as the medication was given despite the resident's blood pressure being too low, and the administration was incorrectly documented in the Medication Administration Record. The facility's failure to follow its own policies and procedures for monitoring changes in condition and administering medication as prescribed resulted in deficiencies in the care provided to Residents 34 and 79. These actions and inactions highlight lapses in the facility's adherence to established protocols, potentially impacting the residents' health and safety.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to provide adequate care and services to prevent pressure ulcers for two residents, leading to the development of skin issues. Resident 47, who was admitted with conditions including hemiplegia and diabetes, was at moderate risk for pressure ulcers due to immobility and incontinence. Despite having a care plan in place, the interventions did not adequately address the prevention of pressure ulcers. Observations revealed that Resident 47 was left in the same position for extended periods without repositioning, and the incontinence pad was not changed promptly, resulting in a recurrence of Moisture-Associated Skin Damage (MASD) with open areas on the buttocks. Resident 79, who had severe cognitive impairment and was always incontinent, was also at risk for pressure ulcers. The resident was left sitting in a wheelchair for long hours without being checked for incontinence or repositioned. This neglect led to the development of open areas and a fungal skin rash on the scrotum and buttocks. The facility's policy required repositioning and prompt incontinence care, but these were not followed, contributing to the skin issues observed in Resident 79. The observations and interviews with staff highlighted a lack of adherence to the facility's policy on pressure ulcer prevention. Certified Nursing Assistant 1 (CNA 1) failed to reposition and provide timely incontinence care to both residents, despite being aware of the facility's practice to check and reposition residents every two hours. The Treatment Nurse and Registered Nurse Supervisor acknowledged the role of moisture and pressure in skin breakdown, yet the necessary preventive measures were not implemented, resulting in the deficiencies noted in the report.
Inadequate Incontinent Care Leads to Skin Damage
Penalty
Summary
The facility failed to provide adequate incontinent care for two residents, resulting in Moisture Associated Skin Damage (MASD). Resident 47, who was admitted with diagnoses including hemiplegia and type 2 diabetes, was observed to be always incontinent and dependent on staff for toileting hygiene. Despite the care plan indicating the need for regular checks and changes of incontinence pads, observations revealed that the assigned Certified Nursing Assistant (CNA 1) did not attend to Resident 47 for several hours. This neglect led to the resident developing MASD, with open areas on the buttocks and significant pain reported by the resident. Similarly, Resident 79, who had severe cognitive impairment and was always incontinent, did not receive timely incontinent care. The care plan for Resident 79 also required frequent checks and changes of incontinence pads. However, observations showed that CNA 1 did not bring Resident 79 back to their room for necessary care, leaving the resident in a wheelchair for extended periods. This lack of care resulted in open areas on the resident's buttocks and scrotum, identified as excoriated skin by the Registered Nurse Supervisor. The facility's policy on Activities of Daily Living, which mandates providing necessary services to maintain residents' hygiene and prevent skin breakdown, was not adhered to. The failure to follow these protocols for both residents led to the development of MASD, highlighting a significant deficiency in the care provided by the facility.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing aides were available to meet the basic needs of residents, specifically affecting two sampled residents. Interviews with staff and residents revealed that the facility experienced staffing shortages, particularly with CNAs, which led to delays in care and unmet needs. Residents expressed frustration over long wait times for assistance, such as showering and response to call lights, with some residents waiting up to an hour. The issue was raised in Resident Council Meetings, indicating it was an ongoing problem. Staff interviews confirmed the shortage, with CNAs responsible for an average of ten residents per shift. The facility had contracts with registry companies for additional staffing, but these were not utilized due to last-minute call-offs and previous negative experiences with registry staff. The Director of Nursing acknowledged the shortage and its impact on resident care, noting that ten CNAs had left in the past two months, leaving the facility short by six CNAs. The facility's policy stated that sufficient and competent nursing staff should be provided, but this was not achieved.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed under sanitary conditions, which placed residents at risk for foodborne illnesses. During an observation, it was found that ice cream cups stored in Freezer 1 were past their use-by date. The kitchen staff, including the cook and dietary supervisor, acknowledged that food past its use-by date should not be stored and should be discarded to prevent potential foodborne illnesses. The facility's policy and procedure on food receiving and storage, revised in November 2022, indicated that foods should be labeled, dated, and monitored to ensure they are used by their use-by date, frozen, or discarded. Additionally, the facility failed to properly check the concentration of the quaternary sanitizing solution used for sanitizing surfaces. A kitchen aide was observed using a quaternary test strip incorrectly by not immersing it for the required ten seconds as per the manufacturer's instructions. The test results showed varying concentrations of 150 ppm and 300 ppm, which were not verified for accuracy. The dietary supervisor confirmed that the test strip should be immersed for at least ten seconds to ensure the sanitizing solution is at the correct concentration for effective disinfection. The facility's policy on sanitization, also revised in November 2022, stated that chemical sanitizing solutions should be used according to the manufacturer's instructions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices for six residents, leading to potential cross-contamination and the spread of pathogens. In the shared restroom of three residents, an open and unlabeled personal toiletry was found, which was against the facility's infection control protocols. The toiletry was supposed to be kept at each resident's bedside to prevent cross-contamination, as confirmed by a Certified Nursing Assistant and the Infection Preventionist. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for two residents who required such measures due to their medical conditions. A Licensed Vocational Nurse failed to don personal protective equipment (PPE) while providing care to a resident with a G-tube, and a Treatment Nurse improperly donned a gown and did not wear gloves while providing pressure ulcer care to another resident. These lapses in protocol were acknowledged by the Infection Preventionist, who emphasized the importance of PPE in preventing the spread of multidrug-resistant organisms. Furthermore, the facility did not ensure the sanitary storage of a resident's oxygen nasal cannula tubing, which was found resting over the oxygen concentrator instead of being stored in a clean, dry plastic bag. This oversight was noted by the Infection Preventionist, who highlighted the risk of bacterial contamination, especially given the resident's existing pneumonia diagnosis. The facility's infection control policies, intended to maintain a safe and sanitary environment, were not followed in these instances.
Failure to Ensure Resident Privacy During G-tube Medication Administration
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident during medication administration involving a G-tube. The incident involved a resident who was dependent on others for all activities of daily living and had a feeding tube. During a medication administration session, a Licensed Vocational Nurse (LVN) partially drew the privacy curtain in a multi-bed room, exposing the resident's abdomen while accessing the G-tube. This action did not fully respect the resident's right to privacy as the curtain was not completely closed, leaving the resident exposed to potential view by roommates and passersby. The resident's medical history included severe cognitive impairment and dependency on a feeding tube, which necessitated careful handling to maintain dignity and privacy. The facility's policies on dignity and resident rights, as well as the procedure for administering medication via a feeding tube, emphasized the importance of ensuring privacy. However, the LVN's failure to fully draw the privacy curtain during the procedure was contrary to these policies, as confirmed by the Registered Nurse Supervisor, who stated that privacy should be ensured 100% during such procedures.
Failure to Notify Physician of Broken Dentures
Penalty
Summary
The facility staff failed to promptly notify the physician about a resident's broken bottom dentures, which caused difficulty with eating. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported that her dentures were broken by a CNA during cleaning. The incident was reported to the Director of Nursing (DON) but not to the resident's physician in a timely manner, as required by the facility's policy. The delay in notifying the physician resulted in a delay in the provision of necessary care and services, such as adjusting the resident's diet to accommodate the broken dentures. The facility's policy mandates that changes in a resident's condition be reported to the physician within 24 hours, but this was not adhered to in this case, leading to a deficiency in care.
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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