Monrovia Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Duarte, California.
- Location
- 1220 E. Huntington Drive, Duarte, California 91010
- CMS Provider Number
- 055259
- Inspections on file
- 45
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Monrovia Post Acute during CMS and state inspections, most recent first.
The facility failed to immediately report an influenza outbreak to the county DPH after three residents with multiple comorbidities developed respiratory symptoms and subsequently tested positive for influenza within a short time frame. According to the IP, one resident with a hip fracture and acute cholecystitis, another with osteomyelitis and type 2 DM with a foot ulcer, and a third with hemiplegia, hemiparesis, and type 2 DM with neuropathy all developed cough or cough with wheezing and were confirmed influenza-positive, meeting outbreak criteria under the Influenza and other Respiratory Virus Diseases Outbreak Toolkit, yet the required notification to public health was not made immediately.
Two residents who were dependent on staff for bathing and toileting hygiene were left exposed during bed baths when CNAs failed to maintain privacy curtains and adequate covering. In one case, a cognitively impaired resident with mental illness and dementia had their blanket, gown, and brief removed, and the CNA opened the privacy curtain while the room door was open, leaving the resident’s body visible from the hallway. In another case, a resident with epilepsy and a history of falls was fully exposed during perineal care when a roommate opened the privacy curtain and the CNA did not re-cover the resident or close the curtain, continuing care despite the resident feeling upset and requesting privacy. These actions conflicted with facility policies requiring residents to be covered during bed baths and afforded privacy and dignity.
Staff failed to follow infection control and bed bath procedures during incontinence and bathing care for three residents. One CNA did not change gloves after transferring a resident and before handling clean linens, body wash, and a clean brief, and then used the same contaminated gloves to access a drawer and retrieve a sheet. In separate observations, two CNAs provided bed baths to two residents using a single basin or bucket of water and the same washcloth to cleanse multiple body areas, including the perineal and buttocks areas, without changing the bathwater as required by facility policy.
A resident with multiple chronic conditions and documented decision-making capacity repeatedly requested copies of her medical records through authorization forms and email. Facility policy required access to records within 24 hours and copies within two business days, but staff delayed fulfilling several requests well beyond this timeframe and did not honor at least one email request. The ADM and Director of Medical Records stated that response times depended on the volume of records and acknowledged that medical records staff did not document their interactions in the resident’s chart, resulting in the resident not receiving timely copies of her records as required by facility policy.
During a prolonged power outage, the facility did not ensure that the call light system remained operational for several high-risk residents with significant medical needs. Multiple residents, all requiring substantial assistance and at risk for falls, were left without a functioning call system or adequate alternative devices to request help. Staff confirmed the outage and the lack of sufficient temporary bells, and facility policies required a functional call system at all times.
Licensed staff did not sign, date, or time the receipt of pharmacy-delivered medications for three residents with complex medical needs, as required by facility policy. Review of records and staff interviews confirmed the absence of proper documentation for medication receipt.
A resident with diabetes, cognitive impairment, and other conditions repeatedly refused blood glucose checks and insulin injections, but nursing staff did not notify the physician as required by facility policy. Both the resident's physician and care coordinator confirmed they were not informed of these refusals, despite documentation and staff interviews verifying the missed notifications.
A resident with cognitive impairment and multiple medical conditions reported being verbally and physically abused by a CNA during a night shift. The CNA did not report the allegation to the charge nurse, administrator, or authorities as required. Staff interviews and record review confirmed that the facility failed to notify the Department, Ombudsman, and law enforcement within the mandated two-hour timeframe, resulting in a delay in reporting the abuse allegation.
Residents lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that declines in ADL performance were clinically unavoidable, as required, and records lacked evidence of a medical justification for the loss of function.
A resident did not receive treatment and care in accordance with physician orders and their own stated preferences and goals, as evidenced by surveyor findings and record review.
A resident with multiple pressure injuries and MASD, who was dependent on staff for care, did not have a weekly skin check documented over a two-week period. The responsible nurse confirmed missing the required wound note, which was mandated by facility policy for monitoring skin conditions.
A resident with multiple chronic conditions and moderate cognitive impairment did not receive three scheduled doses of Morphine Sulfate for pain management because the medication supply ran out and was not reordered in accordance with facility policy. The DON confirmed the lapse was due to a delay in obtaining the physician's signature, and the pharmacy did not process the refill request until after the supply was depleted.
A resident did not receive the specialized rehabilitative services that were required for their care, as the facility failed to provide or arrange for these necessary interventions.
A resident with significant cognitive and physical impairments did not have an Orthopedic consultation note available in the electronic medical record following a specialty appointment, despite a physician's order and documentation of the visit in progress notes. Both nursing staff and the DON were unable to locate the note, which was required to be accessible under facility policy as the facility transitioned to paperless charting.
A resident with diabetes and ESRD was not properly informed of a significant kidney mass found on an ultrasound, and the physician was not promptly notified for further evaluation. Documentation was lacking regarding communication of the results, and the nephrology provider did not receive the test information until the day of the resident's appointment, resulting in delayed follow-up.
A resident with a documented diagnosis of Parkinson's disease and ongoing treatment with Sinemet was not accurately coded for this condition in the MDS assessment. Despite clear evidence in medical records, physician orders, and direct observation of symptoms, the diagnosis was omitted from the MDS, and the responsible LVN could not explain the discrepancy. This failure resulted in an inaccurate assessment entry, contrary to facility policy requiring consistency between assessments and clinical documentation.
A resident receiving Sinemet for Parkinson's disease did not have a comprehensive care plan addressing the medication or its potential side effects. The resident's diagnosis was not reflected in the MDS, and staff were unaware of the omission. Despite physician orders and neurologist instructions to monitor for adverse reactions, the facility failed to document and communicate these needs as required by policy.
A consultant pharmacist did not identify or report irregularities related to Sinemet use for a resident with multiple diagnoses, including dementia and a history of Parkinsonism, during monthly medication regimen reviews. The resident's MDS did not reflect a Parkinson's diagnosis, and there was no documented monitoring or follow-up after a Levodopa trial was initiated by a neurologist. Despite facility policy requiring thorough review and reporting of medication issues, the pharmacist found no concerns and made no recommendations regarding Sinemet use or monitoring.
A resident was administered Sinemet without adequate documentation of a Parkinson's diagnosis or proper monitoring for effectiveness and adverse effects. The MDS did not reflect the neurological diagnosis, and staff acknowledged the inaccuracy and lack of follow-up. The consultant pharmacist did not identify irregularities, and facility policies for assessment and medication review were not followed.
A resident reported missing two cord holders to a CNA, who failed to report the issue to supervisors, contrary to facility policy. The resident, with no cognitive impairments and requiring substantial assistance, felt unheard as the facility's Theft and Loss Report Log showed no record of the incident, highlighting a lapse in the reporting process.
A facility failed to accurately document staff attendance at a resident's care conference, leading to inaccurate medical records. The resident, with conditions including acute embolism and morbid obesity, required substantial assistance for daily activities. The Activities Assistant was incorrectly recorded as present at the meeting, contrary to the facility's documentation policy.
The facility failed to manage pain effectively for two residents. One resident's request to change pain medication from as-needed to scheduled was not documented or followed up, leading to unmanaged pain. Another resident was given Tylenol for severe pain without proper assessment, resulting in prolonged suffering. The facility did not adhere to its pain management protocols.
A resident did not receive prescribed medications on time due to a failure by an LVN to administer them as ordered. The medications, including glipizide and metoprolol, were given after meals instead of before or with food, contrary to the facility's policy. The DON confirmed the importance of timely medication administration to ensure effectiveness and prevent health issues.
The facility failed to follow its infection control policies, as two CNAs did not perform hand hygiene before and after providing care to residents, despite signs indicating the need for Enhanced Barrier Precautions. One resident had chronic kidney disease and a diabetic foot ulcer, while another had cervical disc degeneration and hypertensive heart disease. Both CNAs acknowledged the importance of hand hygiene but did not adhere to the protocols.
A facility failed to accurately document a resident's active diagnoses on the MDS, listing an active cancer diagnosis despite the resident's history indicating past skin cancer. The resident expressed concern, and staff interviews confirmed the error, highlighting the importance of accurate MDS documentation for proper care and billing.
A resident with severe pain was inadequately assessed and documented by an LVN, who administered Tylenol without verifying the resident's pain level, leading to inappropriate pain management. The resident, with conditions including diabetes and chronic kidney disease, reported a pain level of 9 out of 10, but the LVN documented it as 3 out of 10. The DON confirmed the necessity of accurate pain assessment and documentation as per facility policy.
A resident felt singled out and belittled when a Maintenance Supervisor reprimanded him in a raised and condescending tone for charging his phone at an emergency outlet during a power outage. Despite other residents also using the outlets, only this resident was addressed, leading to feelings of embarrassment and emotional distress. The Director of Nursing emphasized the importance of treating residents with dignity and respect, as outlined in the facility's policy on Resident Rights.
A facility failed to maintain a homelike environment for a resident due to a cracked window in the resident's room, which was covered with peeling tape and had been present since the resident's last admission. The resident, who had chronic obstructive pulmonary disease and depression, felt neglected by the facility's inaction. Interviews revealed that the issue was not reported by staff, and the facility's policy on maintaining a homelike environment was not followed.
A facility failed to develop a care plan for a resident in the bowel and bladder program, despite the resident requiring maximal assistance for toileting. The resident, admitted with cellulitis and depression, had intact cognition. The facility's policy mandated a care plan for the 14-day retraining program, which was not created, potentially leading to unmet continence needs.
A resident in isolation due to COVID-19 did not receive adequate sensory stimulating activities, as the facility failed to provide sufficient reading materials despite the resident's expressed preferences. The Activities Director admitted to not closely monitoring staff to ensure isolated residents received their preferred materials, leading to the resident experiencing boredom and loneliness.
A facility failed to follow its Bladder and Bowel Program policy for a resident requiring maximal assistance for toileting. Despite a physician order for retraining, the necessary 72-hour diary form was not completed, leaving CNAs without specific toileting instructions. This oversight could hinder the resident's ability to regain continence and prevent complications like skin breakdown and UTIs.
A facility failed to document a code status for a resident with acute respiratory failure, dementia, and failure to thrive. The absence of this documentation was confirmed during record reviews and interviews with staff, including an RN and the DON, who acknowledged the importance of having the code status documented to ensure timely and respectful care. The facility's policy requires complete and accurate documentation to facilitate communication among the care team.
A resident with a history of falls and severe cognitive impairment experienced two falls in one night due to inadequate supervision and failure to update the care plan. Despite being assessed as high risk for falls, the resident was not provided with increased monitoring during periods of agitation and confusion, leading to a fracture and head laceration.
A resident with a history of falls and severe cognitive impairment experienced two falls in one night, resulting in a head injury. Despite being at high risk for falls, the care plan was not updated with new interventions after the first fall. Staff interviews indicated a lack of increased supervision or medication administration to address the resident's confusion and agitation.
A facility failed to ensure a resident with Parkinsonism and dementia was free from physical restraints. A CNA tied a fitted sheet to the grab bars of the resident's bed, restricting the resident's arm movements to prevent the resident from pulling out a Foley catheter. The incident was discovered by other CNAs and a Charge Nurse, who immediately removed the sheet and reported the situation. The responsible CNA admitted to the action and was suspended.
A facility failed to provide a low air loss (LAL) mattress as ordered by a physician for a resident with severe pressure ulcers. Despite the resident's critical need and multiple staff acknowledgments of the order, the LAL mattress was delayed due to unavailability and poor communication, resulting in the resident lying on a regular mattress for two days.
Failure to Promptly Report Influenza Outbreak to Public Health Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an influenza outbreak to the Los Angeles County Department of Public Health (DPH) as required by the Influenza and other Respiratory Virus Diseases Outbreak Toolkit. The Infection Preventionist (IP) stated that one resident first presented with influenza symptoms, including cough, on 2/1/2026 and later tested positive for influenza on 2/7/2026. A second resident developed cough and wheezing on 2/2/2026 and tested positive for influenza on 2/5/2026. A third resident began having cough on 2/4/2026 and tested positive for influenza on 2/7/2026. Despite these three confirmed influenza cases, the facility did not immediately report the outbreak to LAC DPH as required. The residents involved had multiple medical conditions documented in their admission records and Minimum Data Set (MDS) assessments. One resident had a displaced fracture of the base of the neck of the left femur and acute cholecystitis, with intact cognition and a need for partial to moderate assistance with bathing and toileting hygiene. Another resident had osteomyelitis of the right ankle and foot and type 2 diabetes mellitus with a foot ulcer, also with intact cognition and requiring partial to moderate assistance for bathing and toileting hygiene. The third resident had hemiplegia and hemiparesis affecting the left non-dominant side and type 2 diabetes mellitus with diabetic neuropathy, with impaired cognition and dependence for activities of daily living. These findings, along with the IP’s interviews and the positive influenza test results, established that an outbreak had occurred but was not promptly reported to public health authorities.
Failure to Maintain Privacy and Dignity During Bed Baths
Penalty
Summary
The deficiency involves failure to maintain resident privacy and dignity during personal care for two residents who were dependent on staff for bathing and hygiene. One resident, admitted with schizophrenia and dementia and assessed as moderately cognitively impaired and dependent for shower/bath, toileting, and personal hygiene, was observed receiving a bed bath. The CNA removed the resident’s blanket, gown, and diaper, leaving the resident’s whole body exposed while washing various body parts. During this care, the CNA opened the privacy curtain around the bed while the room door remained wide open, allowing the resident’s exposed body to be visible from the hallway. The CNA later acknowledged that residents must be covered during a bed bath and stated they forgot to cover this resident, contrary to facility policy requiring residents to be kept covered as much as possible during bed baths. A second resident, admitted with epilepsy and a history of falls, had no cognitive impairment and was also dependent on staff for shower/bath and toileting hygiene. During a bed bath, the CNA initially closed the privacy curtain, removed the resident’s blanket and gown, and cleansed multiple body areas including the perineal area and buttocks while the resident’s whole body was exposed. The resident’s roommate then opened the privacy curtain, and the CNA did not re-cover the resident or close the curtain, continuing care, applying powder to the groin, and fastening the diaper while the resident remained exposed. In a concurrent interview, the resident stated feeling upset due to the lack of privacy and reported asking the CNA to close the privacy curtain. Facility policies on bed baths and resident rights required that residents not be exposed, be covered with a bath blanket, and be afforded privacy and a dignified existence.
Inadequate Infection Control During Incontinence and Bathing Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices during personal care and incontinence care for multiple residents. For one resident admitted with obstructive and reflux uropathy and diabetes mellitus, who was dependent on staff for ADLs, surveyors observed two CNAs transfer the resident from a geriatric chair to the bed after performing hand hygiene and donning gloves. After the transfer, one CNA, without changing gloves, retrieved towels from a cabinet, placed them on a table, checked the resident’s diaper, then accessed a body wash bottle from a drawer at the foot of the roommate’s bed. Using the same gloves, the CNA applied body wash to a wet towel, cleansed the resident’s perineal area and buttocks, applied a new diaper, and then, still without changing gloves, opened the same drawer again, touched items inside, and removed a sheet to cover the resident. A second component of the deficiency involved bathing practices for two other residents who were dependent on staff for shower/bath, toileting, and personal hygiene. For one resident with mental illness and dementia, a CNA donned PPE and brought a single basin of water mixed with body wash into the room. The CNA used one towel and the same basin of water to wash the resident’s face, chest, armpits, arms, neck, legs, perineal area, back, and buttocks, rinsing the towel in the same water between body areas, without changing the bathwater prior to providing perineal care. This sequence of care did not follow the facility’s written procedure for a bed bath, which required changing the bathwater at specified intervals, including before washing the perineal area. For another resident with epilepsy, a history of falls, and dependence on staff for shower/bath and toileting hygiene, a CNA prepared supplies, donned gloves, and brought a bucket of water into the room. The CNA used one small wet towel to clean the resident’s face, armpits, and arms, rinsing the towel in the same water between areas. The CNA then used the same water to rinse the towel, applied body wash, and cleansed the perineal area, followed by pouring water from the basin over the perineal area and drying it with a towel, and then washing the buttocks with body wash. These observed practices did not align with the facility’s bed bath policy, which directed staff to change bathwater before washing the perineal area and to wash the anal area last to avoid contamination, and also differed from referenced guidance that called for clean water or new cloths when cleaning the genital area.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident timely access to and copies of her medical records as required by facility policy. The resident was admitted with multiple diagnoses including obesity, acute respiratory failure without hypoxia, basal cell carcinoma of the right upper limb/shoulder, unilateral primary osteoarthritis of the left hip, and muscle wasting and atrophy. An initial history and physical documented that the resident had capacity to understand and make decisions. The facility’s written policy, revised in May 2017, stated that residents must be provided access to their personal and medical records within 24 hours (excluding weekends and holidays) of request, and copies of records within two business days of an oral or written request. Record review showed that the facility received written Authorization for Use or Disclosure of Protected Health Information forms from the resident on multiple occasions. Requests dated 3/6/2025 and 4/4/2025 were fulfilled by the facility on 3/26/2025 and 4/14/2025 respectively, which exceeded the two-business-day timeframe in the policy. An email from the resident dated 6/23/2025 requested release of medical records, but the facility did not release the records in response to that request. Another authorization form dated 7/1/2025 was received without the resident’s signature, and the facility did not provide copies of the records at that time. The administrator later acknowledged that the 6/23/2025 request was not honored. During interviews, the administrator and Director of Medical Records described a practice of varying response times based on the volume of records requested, stating that small requests could be completed the same day, while large requests could take several days. The administrator stated that on 3/6/2025 and 4/4/2025 the resident requested a large volume of records and that the medical records department might need more than two days, and would tell residents they needed more than the 48 hours indicated in the policy. The Director of Medical Records stated that staff visit residents to help complete consent forms, that residents are informed how long it may take and asked about preferred format, but also stated that medical records staff do not document these visits in the resident’s record. The resident reported having requested records multiple times by email and phone without success, refused to sign the release form because it released the facility from liability, and stated that the medical records staff member never told her how long it would take to receive the records. The surveyors concluded that the facility failed to provide copies of requested medical records within two business days as required by its own policy, thereby violating the resident’s right to obtain records in a timely manner.
Failure to Maintain Functional Call Light System During Power Outage
Penalty
Summary
During an 11-hour power outage, the facility failed to ensure that the call light system, which allows residents to signal for assistance, remained functional for four sampled residents. These residents had significant medical conditions, including morbid obesity, history of falls, hemiplegia, hemiparesis, osteoarthritis, epilepsy, cerebral palsy, hypertension, acute respiratory failure, end stage renal disease, and cerebral infarction. All four residents were assessed as high risk for falls and required varying levels of assistance with activities of daily living such as toileting, bathing, and dressing. Their care plans specifically required that call lights be within reach and functional to ensure prompt staff response to requests for help. Interviews with the residents confirmed that the call light system was not operational during the power outage, and none of them received an alternative means to request assistance, such as a temporary bell or device. One resident reported having to yell for help when assistance was needed. Staff interviews corroborated that the call light system was nonfunctional during the outage, and although the facility had some temporary bells, there were not enough for every resident. Maintenance records confirmed the duration of the power outage, and staff acknowledged the lack of sufficient alternative signaling devices. A review of the facility's policies and procedures indicated that each resident should have a means to call staff for assistance at all times, and that the call system must remain functional. The maintenance department is responsible for ensuring that all building systems, including the call light system, are maintained in a safe and operable manner. The failure to provide a functioning call system or adequate alternatives during the power outage was inconsistent with these policies and directly affected residents who were dependent on staff for their care and safety.
Failure to Document Receipt of Pharmacy-Delivered Medications by Licensed Staff
Penalty
Summary
The facility failed to follow its own Policy and Procedure regarding the receipt and documentation of medications delivered by the pharmacy for three sampled residents. Specifically, licensed staff did not check, sign, date, or time the receipt of medications for these residents as required by the facility's policy. This was confirmed through interviews with nursing staff and a review of the Prescription Delivery Receipt records, which showed missing signatures, dates, and times for the medications received. The residents involved had significant medical histories, including morbid obesity, history of falls, acute respiratory failure, end stage renal disease, chronic obstructive pulmonary disease, osteoarthritis, and major depressive disorder. Each resident had active medication orders, such as topical antifungals, inhalation solutions, and oral antibiotics, which were not properly documented upon receipt. Staff interviews confirmed that the expected process was not followed, and the required documentation was absent from the records for these residents.
Failure to Notify Physician of Repeated Refusals of Diabetes Care
Penalty
Summary
Facility staff failed to notify a resident's physician of multiple refusals of blood glucose monitoring (accuchecks) and insulin injections on two consecutive days. The resident, who had diagnoses including Parkinson's disease, dementia, and type 2 diabetes mellitus, was moderately impaired in cognitive skills and dependent on staff for daily care. Physician orders required blood glucose checks and administration of insulin as per a sliding scale, as well as scheduled long-acting insulin injections. Documentation showed that the resident refused accuchecks and an insulin injection on several occasions, but these refusals were not communicated to the resident's physician as required by facility policy. Interviews with nursing staff confirmed that the refusals were not reported to the physician, and both the resident's primary physician and care coordinator stated they were not notified of the missed treatments. Facility policy specified that the attending physician should be notified after two or more consecutive refusals of treatment or medication, but this procedure was not followed in this case.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required two-hour timeframe to the California Department of Public Health, the Ombudsman, and local law enforcement, as mandated by the facility's policy. The incident involved a resident with diagnoses including type 2 diabetes mellitus, chronic pulmonary edema, and toxic encephalopathy, who was mildly impaired in cognitive skills and required substantial to moderate assistance with daily activities. The resident reported to the Social Service Director that a CNA told them to 'shut up' and hit them on the mouth during a night shift. The CNA involved did not report the resident's allegation to the charge nurse, administrator, or authorities as required. Interviews with facility staff, including the CNA, DON, and Administrator, confirmed that the allegation was not reported in accordance with the facility's Abuse Investigation and Reporting policy, which requires immediate reporting, but not later than two hours, for alleged violations involving abuse. Review of the resident's records and staff interviews substantiated that the required notifications were not made in a timely manner, resulting in a delay in notifying the appropriate authorities about the abuse allegation.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Document Weekly Skin Checks for Resident with Pressure Injuries
Penalty
Summary
Facility staff failed to document a weekly skin check for one resident over a two-week period, despite the resident being dependent on staff for all activities of daily living and having multiple pressure injuries and Moisture-Associated Skin Damage (MASD) upon readmission. The resident's medical record and progress notes confirmed the absence of a weekly wound note from 7/5/2025 to 7/18/2025, which was required by facility policy for tracking the progress or decline of skin conditions. The treatment nurse, who was responsible for completing the weekly wound note, acknowledged missing the documentation during this period. The facility's policy and procedure specified that weekly skin checks must be conducted by a licensed nurse and documented in the electronic medical record, but this was not done for the resident in question.
Failure to Timely Reorder and Administer Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's supply of Morphine Sulfate, a medication prescribed for pain management, was restocked and available when needed. The resident, who had diagnoses including Parkinson's disease, dementia, and type 2 diabetes mellitus, was dependent on staff for daily care and had moderate cognitive impairment. The medication order required Morphine Sulfate 15 mg to be administered every 12 hours. According to the Medication Administration Record, the resident did not receive three scheduled doses because the medication supply ran out. The Director of Nursing confirmed that the supply was depleted due to the ordering physician not signing for the refill in time. The contracted pharmacist stated that the refill request was not processed until after the supply had already run out, and that the pharmacy did not begin the refill process until the day after the medication was depleted. Facility policy required that medications, especially Schedule II controlled substances like Morphine, be reordered when a three to five-day supply remained, and specifically that the pharmacy be notified when a five-day supply remained. The failure to follow these procedures resulted in the resident missing multiple doses of prescribed pain medication.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which were necessary to meet the resident's assessed needs. This deficiency was identified during the survey based on the lack of evidence that the required rehabilitative interventions were implemented for the resident.
Failure to Maintain Readily Accessible Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were readily accessible, specifically by not having the resident's Orthopedic consultation note from a follow-up appointment available in the electronic medical record. The resident, who had a history of right-sided hemiplegia and hemiparesis following a cerebral infarction, aphasia, and osteoarthritis of the left hip and knee, had a physician's order for an Orthopedic consult due to left hip and knee pain. Progress notes indicated that the resident attended the Orthopedic appointment and received a recommendation for a cortisone injection, but the actual consultation note documenting this visit was missing from the electronic records. During the review, both a registered nurse and the DON confirmed that they were unable to locate the Orthopedic note in the electronic system, which was being used as the facility transitioned to paperless charting. The absence of this record meant that staff could not verify the most current recommendations for the resident's care. The facility's policy required that all current medical records be maintained and safeguarded, but the Orthopedic note was not accessible as required.
Failure to Notify Resident and Physician of Significant Diagnostic Test Result
Penalty
Summary
The facility failed to ensure that a resident was properly notified of a significant diagnostic test result and that appropriate follow-up was completed by the resident's physician. Specifically, a retroperitoneal ultrasound identified a 3.4 cm mass on the resident's right kidney, with recommendations for further imaging to differentiate the mass. Although progress notes indicated the resident was informed of the results and a nephrology referral was made, the resident later stated he was unaware of the kidney issue until a nephrology appointment months later. The nephrology nurse practitioner also reported not receiving the ultrasound results until the day of the appointment, due to the facility's delay in faxing the information. The resident had a history of diabetes mellitus and end stage renal disease, with cognitive skills intact and independence in activities of daily living. Documentation did not show that the resident was given a copy of the test results or that the physician was informed of the need for further imaging. The facility's policy required timely review, communication, and documentation of diagnostic results, but there was no evidence that these steps were followed, resulting in a delay in medical treatment and communication to both the resident and the physician.
Failure to Accurately Document Parkinson's Disease in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's active diagnosis of Parkinson's disease. Despite documentation in the resident's admission record, physician orders, and neurology consultation notes indicating a diagnosis of Parkinson's disease and ongoing treatment with Sinemet, the MDS did not include Parkinson's disease under the active diagnoses section. The resident was observed to have symptoms consistent with Parkinson's, such as noticeable tremors, and was able to verbally confirm the diagnosis. A review of medication administration records further confirmed that the resident was receiving Sinemet for Parkinson's disease, with periods of discontinuation and restart as ordered by the neurologist. During interviews, the LVN responsible for the MDS assessment was unable to explain why Parkinson's disease was omitted from the MDS and acknowledged the inaccuracy. The neurologist who evaluated the resident noted that follow-up was not conducted by the facility after initiating a Levodopa trial, despite instructions to monitor for adverse reactions. The facility's policy requires that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not followed in this case, resulting in an inaccurate assessment entry for the resident.
Failure to Develop Comprehensive Care Plan for Sinemet Administration
Penalty
Summary
The facility failed to develop a comprehensive care plan to address medication administration and monitoring for side effects related to Sinemet for a resident who was receiving the medication for Parkinson's disease. The resident, who was cognitively severely impaired and unable to make her own decisions, had a physician's order for Sinemet administered via G-tube, but there was no care plan in place addressing the diagnosis of Parkinson's disease or the use of Sinemet. Additionally, the resident's Minimum Data Set (MDS) did not reflect the diagnosis of Parkinson's disease, and the medication administration records showed periods where Sinemet was both discontinued and restarted without corresponding updates to the care plan or MDS documentation. During interviews and record reviews, it was revealed that staff were unaware of why the Parkinson's diagnosis was not coded in the MDS, and the neurologist's consultation had specifically instructed staff to monitor for adverse reactions to Levodopa, a component of Sinemet. Facility policies required that all services, progress toward care plan goals, and changes in the resident's condition be documented and communicated among the interdisciplinary team, but these requirements were not met in this case. As a result, the resident's medication regimen and potential side effects were not adequately addressed through care planning or interdisciplinary communication.
Failure to Identify and Report Medication Irregularities in Pharmacist Review
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified medication irregularities related to the use of Sinemet for a resident during the monthly medication regimen review. The resident, who had a complex medical history including urinary tract infection, type 2 diabetes, atrial fibrillation, iron deficiency anemia, unspecified dementia, hypothyroidism, bipolar disorder, acute embolism and thrombosis, and hypotension, was prescribed Sinemet for Parkinson's disease. However, the resident's Minimum Data Set (MDS) did not reflect a diagnosis of Parkinson's disease, and the medication administration records showed periods where Sinemet was both discontinued and restarted. Observations revealed that the resident exhibited noticeable tremors, and interviews with nursing staff indicated uncertainty about the accuracy of the resident's documented diagnoses. The neurologist's consultation noted that the findings were atypical for idiopathic Parkinson's disease and that a trial of Levodopa (Sinemet) was initiated, with instructions to monitor for adverse reactions. Despite this, there was no evidence that the pharmacist identified or reported any irregularities or made recommendations regarding the use or monitoring of Sinemet during the medication regimen reviews from January to April. The pharmacist also stated there were no concerns and that no adverse effects had been reported by staff. A review of facility policy confirmed that the consultant pharmacist is responsible for thoroughly reviewing each resident's medical record to identify and report medication-related problems, including inadequate monitoring or use of medications without proper indication. In this case, the lack of identification and reporting of irregularities related to Sinemet use constituted a deficiency, as the pharmacist did not follow established guidelines for medication regimen review and irregularity reporting.
Failure to Document Indication and Monitor Sinemet Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not documenting an adequate indication for the use of Sinemet, a medication used to manage symptoms of Parkinson's disease. The resident in question had multiple diagnoses, including unspecified dementia, diabetes, atrial fibrillation, and a history of tremors, but the Minimum Data Set (MDS) did not reflect a diagnosis of Parkinson's disease, despite a physician order for Sinemet. The neurologist's consultation noted that the findings were atypical for idiopathic Parkinson's disease and that a trial of Levodopa (Sinemet) was initiated, with instructions to monitor for adverse reactions. However, there was no documentation of follow-up or monitoring for effectiveness or side effects after the medication was started. Observations revealed that the resident exhibited noticeable tremors, and interviews with nursing staff confirmed that the MDS was inaccurate and did not include the Parkinson's diagnosis. The staff member acknowledged the importance of accurate diagnosis coding and proper monitoring of Sinemet due to its potential for adverse effects. The neurologist also stated that follow-up could have occurred shortly after starting the medication, but no such follow-up was documented or communicated by the facility. Additionally, the facility's consultant pharmacist did not identify any irregularities or make recommendations regarding the use of Sinemet during medication regimen reviews from January to April. Facility policies required comprehensive assessments and medication regimen reviews to ensure appropriate use and monitoring of medications, but these were not followed in this case, resulting in the resident receiving Sinemet without adequate documentation of indication or monitoring for effectiveness and adverse effects.
Failure to Assist Resident in Locating Missing Personal Belongings
Penalty
Summary
The facility failed to assist a resident in locating her missing personal belongings, specifically two cord holders. The resident, who was admitted with diagnoses including acute embolism, thrombosis, morbid obesity, and a history of falls, reported the missing items to a Certified Nursing Assistant (CNA). Despite the resident having no cognitive impairments and requiring substantial assistance for daily activities, the CNA did not report the missing items to their supervisors, as required by the facility's policy. The Director of Nursing (DON) confirmed that the facility's Theft and Loss Report Log did not list any reports of missing items for the relevant months, indicating a failure in the reporting process. The facility's policy on personal property, which emphasizes treating resident belongings with respect, was not followed. This oversight had the potential to make the resident feel unheard and disrespected, as the facility did not take appropriate action to address the resident's concerns about her missing belongings.
Inaccurate Documentation of Care Conference Attendance
Penalty
Summary
The facility failed to accurately document the attendance of staff members at a quarterly care conference for one of the residents. The resident, who was admitted with diagnoses including acute embolism, thrombosis, morbid obesity, and a history of falls, had no cognitive impairments and required substantial assistance for certain activities of daily living. During the care conference, it was inaccurately documented that the Activities Assistant (AA) was present, although the AA confirmed they did not attend the meeting. The Director of Nursing (DON) reviewed the documentation and confirmed the expectation that all relevant disciplines should meet together to ensure consistency in the care plan. The facility's policy on charting and documentation, which requires records to be objective, complete, and accurate, was not adhered to in this instance, resulting in inaccurate information being recorded in the resident's medical records.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide effective pain management for two residents, Resident 2 and Resident 3, as per the facility's policies and procedures. Resident 2 requested that their pain medications, ibuprofen and Tylenol, be changed from as-needed to scheduled doses to better manage their pain. This request was communicated by LVN 5 to the physician via text but was not documented in the medical record, nor was it followed up on, resulting in Resident 2's pain not being effectively managed. Resident 3 experienced severe pain that was not appropriately addressed by the facility. On a specific day, LVN 4 administered Tylenol to Resident 3 for a pain score of three out of ten, without assessing the actual pain level, which was later revealed to be nine out of ten. This inappropriate administration of medication led to Resident 3 experiencing severe pain for several hours until they were given Norco. LVN 4 admitted to not asking Resident 3 about their pain level before administering the medication and incorrectly documenting the pain score. The Director of Nursing confirmed that the facility's protocol requires licensed nurses to notify physicians of medication change requests and to assess pain levels before administering medication. The failure to adhere to these protocols resulted in inadequate pain management for both residents, potentially causing psychosocial harm and a decline in health. The facility's policies on pain management and changes in resident condition were not followed, leading to these deficiencies.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received prescribed medications in accordance with the facility's policy and procedure. The deficiency involved a Licensed Vocational Nurse (LVN) who did not administer medications to a resident as ordered by the physician. The medications involved included calcium, Freshkote ophthalmic solution, glipizide, metoprolol, and muro 128 ophthalmic solution. These medications were not given on time, which was contrary to the facility's policy that required medications to be administered within one hour of their prescribed time unless specified otherwise. The resident, who had been admitted with diagnoses including type II diabetes mellitus, hypertensive heart disease, and ischemic cardiomyopathy, was supposed to receive glipizide before meals and metoprolol with food or a snack. However, the LVN administered these medications after the resident's meal, which could potentially affect the medications' effectiveness and the resident's health. The LVN acknowledged that the medications were due at specific times and that administering them late could lead to issues such as high blood sugar and stomach upset. The Director of Nursing (DON) confirmed that medications should be given according to the order they are due and not by room number. The DON emphasized the importance of following medication orders, especially those that specify administration before meals or with food, to ensure proper absorption and effectiveness. The facility's policy on administering medications highlighted the need for timely administration to enhance therapeutic effects and prevent interactions, which was not adhered to in this case.
Failure to Follow Hand Hygiene and EBP Protocols
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding hand hygiene and Enhanced Barrier Precautions (EBP). Certified Nurse Assistant (CNA) 2 did not perform hand hygiene before and after providing care to a resident with chronic kidney disease and type II diabetes mellitus, who also had a diabetic foot ulcer. Despite a sign indicating the need for hand hygiene before entering and upon exiting the resident's room, CNA 2 entered and exited without performing the required hand hygiene. During an interview, CNA 2 acknowledged the importance of hand hygiene but incorrectly believed it was unnecessary in this instance. Similarly, CNA 3 failed to perform hand hygiene before and after entering the room of another resident with cervical disc degeneration, hypertensive heart disease, and hyperlipidemia. Despite the presence of a sign indicating the need for hand hygiene, CNA 3 entered the room, repositioned the resident's bedside table, and exited without sanitizing hands. CNA 3 admitted to not following the policy despite being in-serviced on the importance of hand hygiene. The Director of Nursing confirmed that staff were expected to perform hand hygiene to prevent the spread of infections.
Inaccurate Documentation of Active Diagnoses on MDS
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's active diagnoses on the Minimum Data Set (MDS), which is a critical resident assessment tool. This deficiency was identified for one resident who was admitted with a history of squamous cell carcinoma, among other conditions. The MDS inaccurately reflected an active diagnosis of cancer, despite the resident's medical records and personal statements indicating a past history of skin cancer, with no current active cancer diagnosis. The resident expressed concern about the incorrect active cancer diagnosis, which was confirmed by interviews with facility staff, including the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON). The MDSN and DON both acknowledged that the active diagnoses were typically derived from hospital records upon admission, and the DON confirmed that the resident did not have active cancer. The facility's policy and procedure for resident assessments require that all portions of the MDS be completed accurately and signed by the responsible staff, attesting to the accuracy of the information. The inaccurate documentation on the MDS had the potential to negatively impact the resident's plan of care and the delivery of necessary services, as the MDS is used for monitoring and billing purposes.
Inaccurate Pain Assessment and Documentation
Penalty
Summary
The facility failed to ensure accurate documentation on the medication administration record (MAR) for a resident, identified as Resident 3, according to the facility's policy and procedure titled, Charting and Documentation. Licensed Vocational Nurse (LVN) 4 did not accurately document Resident 3's pain score when administering Tylenol, a medication used to treat mild pain. Instead of assessing the resident's pain level, LVN 4 documented a pain score of 3 out of 10, despite the resident experiencing severe pain rated at 9 out of 10. Resident 3, who had been admitted with diagnoses including type II diabetes mellitus, chronic kidney disease, and hydronephrosis, was observed to have severely impaired cognition and frequently experienced pain. On the day of the incident, Resident 3 reported being in significant pain, stating a pain level of 9 out of 10, and expressed distress over the inadequacy of the pain management. LVN 4 administered Tylenol without assessing the resident's pain level, as the resident could not receive more Norco until later due to dosage timing restrictions. The Director of Nursing (DON) confirmed that licensed nurses are required to assess residents' pain scores before administering medication to ensure appropriate treatment. The facility's policy mandates that all services provided, including pain management, be documented accurately and objectively. The failure to assess and document the resident's pain level accurately led to inappropriate pain management, potentially exacerbating the resident's condition.
Resident Dignity Compromised During Power Outage
Penalty
Summary
The facility failed to ensure that a staff member treated a resident, identified as Resident 44, with respect and dignity. During a power outage caused by California wildfires, Resident 44 was charging his cell phone at an emergency outlet near the facility entrance. The Maintenance Supervisor (MS) approached Resident 44 and, in a raised and condescending tone, instructed him not to use the emergency outlet for charging his phone, stating it was only for emergency purposes. This interaction made Resident 44 feel singled out, embarrassed, emotionally distressed, angry, and belittled, as he was the only resident reprimanded despite others also using the emergency outlets. Resident 44's roommate, identified as Resident 41, corroborated the incident, stating that the MS yelled at Resident 44 in a rude and impolite manner, while not addressing other residents who were also charging their phones. Resident 41 expressed feeling awful and embarrassed for Resident 44, noting that the situation could have been handled more calmly and respectfully. Both residents were cognitively intact and required supervision or touching assistance with activities of daily living and mobility. The Director of Nursing (DON) emphasized that staff are expected to uphold a standard of care that includes dignity, respect, and effective communication. The facility's policy on Resident Rights guarantees residents the right to a dignified existence and to be treated with respect, kindness, and dignity. The incident highlights a failure to adhere to these standards, resulting in a deficiency in treating Resident 44 with the respect and dignity he is entitled to.
Failure to Maintain Homelike Environment Due to Unreported Cracked Window
Penalty
Summary
The facility failed to ensure a homelike environment for a resident, identified as Resident 21, due to a cracked window in the resident's room. The resident, who had been readmitted to the facility with chronic obstructive pulmonary disease and depression, expressed feelings of neglect regarding the appearance of their living space, describing it as 'ghetto and tacky.' The cracked window, covered with peeling blue tape, had been present since the resident's last admission in October 2024, but had not been reported to maintenance by the resident or noticed by staff. Interviews with facility staff revealed a lack of communication and reporting regarding the maintenance issue. The Housekeeping Supervisor stated that no reports of a cracked window had been made, and the Maintenance Supervisor was unaware of the damage until it was pointed out during the survey. The housekeeper responsible for cleaning the windows admitted that windows were only cleaned when visibly dirty or upon request, and had not noticed the crack. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unreported and unrepaired window damage in the resident's room.
Failure to Develop Care Plan for Bowel and Bladder Program
Penalty
Summary
The facility failed to develop a care plan for a resident participating in the bowel and bladder program. This deficiency was identified during an interview and record review, where it was found that the resident, who required maximal assistance for toileting hygiene and transfers, did not have a care plan addressing their participation in the bowel and bladder retraining program. The absence of a care plan meant that staff lacked guidance on the interventions needed for the resident and did not have a clear goal, such as achieving continence by discharge. The resident in question was admitted with multiple diagnoses, including cellulitis of the left lower limb and depression, and had intact cognition. The facility's policy required the initiation of a 14-day bowel and bladder retraining program and the development of a corresponding care plan, which was not done. This oversight had the potential to result in unmet bowel and bladder continence needs for the resident.
Failure to Provide Adequate Activities for Isolated Resident
Penalty
Summary
The facility failed to provide an ongoing sensory stimulating activities program tailored to meet the interests of a resident, identified as Resident 226. This resident was admitted with diagnoses including a periprosthetic left hip joint fracture, a fracture of the left radial styloid process, and dysphagia. The resident's activity preferences, as documented in the Activity Interview for Daily and Activity Preferences, included reading mystery books and doing word search puzzles. Despite being cognitively intact and able to communicate effectively, the resident was dependent on staff for emotional, intellectual, and social needs, as outlined in the care plan. During an observation, it was noted that the resident was in isolation due to COVID-19 and expressed feelings of boredom and loneliness, having only received one mystery book despite requests for more reading materials. The Activities Director acknowledged that the resident liked to read and do crossword puzzles and admitted to not closely monitoring staff to ensure that residents in isolation received their preferred materials. The facility's policy indicated that activity programs should be designed to meet the interests and support the well-being of each resident, but this was not adequately implemented for the resident in question.
Failure to Follow Bladder and Bowel Program Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure for the Bladder and Bowel Program for a resident who was placed in the program. The resident, who had intact cognition and required maximal assistance for toileting hygiene and transfers, was admitted with multiple diagnoses, including cellulitis and depression. A physician order was in place for bowel and bladder retraining for 14 days, starting on a specified date, per family request. However, the facility did not complete the necessary 72-hour diary form, which was crucial for identifying the optimal times to toilet the resident. During interviews, it was revealed that the Certified Nursing Assistant (CNA) assisting the resident did not have specific toileting instructions and attempted to assist the resident every two hours. The lack of specific instructions and the absence of the 72-hour diary form meant that the CNAs were not informed of the precise hours to toilet the resident, as required by the facility's policy. This oversight had the potential to prevent the resident from regaining bowel and bladder continence and could lead to issues such as skin breakdown and urinary tract infections.
Failure to Document Code Status for Resident
Penalty
Summary
The facility failed to document a code status for a resident, identified as Resident 27, on the Admission Record, Electronic Health Record (EHR) dashboard banner, and the physical medical record. This deficiency was identified during a review of Resident 27's records, which revealed that the resident was admitted with serious medical conditions, including acute respiratory failure with hypoxia, dementia, and failure to thrive. The Minimum Data Set (MDS) indicated that the resident was dependent on others for activities of daily living and had limited mobility due to medical conditions. Furthermore, a follow-up visit confirmed that Resident 27 lacked the capacity to make decisions independently. During interviews and record reviews, Registered Nurse (RN) 2 confirmed the absence of a documented code status in all relevant records for Resident 27. The RN emphasized the importance of having the code status documented to promote patient-centered care, enhance communication, and ensure timely and respectful care in accordance with the resident's wishes. The Director of Nursing (DON) also acknowledged the potential serious consequences of failing to document the code status, highlighting the importance of accurate and accessible documentation to protect residents' rights and ensure appropriate care delivery. The facility's policy on charting and documentation requires that all services and changes in a resident's condition be documented to facilitate communication among the interdisciplinary team.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent falls for a resident who was assessed as high risk for falls. The resident, who had a history of traumatic subarachnoid hemorrhage, COVID-19, and gait abnormalities, was admitted to the facility and was noted to have severely impaired cognition and required substantial assistance for daily activities. Despite these assessments, the facility did not ensure that the resident received the necessary supervision, especially during periods of increased agitation and confusion. On the night of the incident, the resident experienced increased confusion and repeatedly attempted to get out of bed unassisted. The Certified Nursing Assistant (CNA) on duty noted the resident's agitation and attempted to monitor the situation by sitting near the resident's room. However, the CNA was unable to provide continuous supervision, and the resident experienced two falls within a short period. After the first fall, which was unwitnessed, the resident was found sitting on the floor without injuries. Despite this incident, no new interventions were implemented to prevent further falls. The second fall occurred shortly after the first, resulting in a laceration on the resident's head and a fracture of the left femur. The Licensed Vocational Nurse (LVN) on duty did not revise the resident's care plan or increase supervision following the first fall, as required by the facility's policies. The Director of Nursing later confirmed that supervision should have been increased, and the care plan should have been updated to prevent further incidents. The facility's failure to implement timely interventions and provide adequate supervision directly contributed to the resident's injuries.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan and implement new interventions for a resident after the resident experienced a fall. The resident, who was admitted with a history of traumatic subarachnoid hemorrhage, COVID-19, and gait abnormalities, was identified as being at high risk for falls. Despite this, after the resident's first fall, the care plan was not updated to include new interventions to prevent further falls. The resident's Minimum Data Set indicated severely impaired cognition and a need for substantial assistance with daily activities. On the night of the incident, the resident was confused and restless, repeatedly getting out of bed unassisted. The resident experienced two falls within a short period, the second resulting in a head laceration. Despite these events, there was no documented evidence of increased supervision or medication administration to address the resident's agitation and confusion. Interviews with staff revealed that the resident required frequent cueing and supervision, yet the care plan was not adjusted to reflect these needs. The facility's policies on safety and fall risk management emphasize the importance of revising care plans based on changes in a resident's condition, but this was not done in this case, leading to the deficiency.
Failure to Ensure Resident was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which led to a violation of the resident's rights and potential harm. The incident involved a resident with diagnoses of Parkinsonism, dementia, and a history of falling. The resident required substantial assistance for daily activities and had severely impaired cognition. Despite these needs, a Certified Nurse Assistant (CNA) tied a fitted sheet to the grab bars of the resident's bed, restricting the resident's arm movements to prevent the resident from pulling out a Foley catheter. This action was taken without proper authorization and was not in the resident's best interest. The incident was discovered when other CNAs and a Charge Nurse found the resident with limited mobility due to the fitted sheet being tied to the grab bars. The fitted sheet was immediately removed, and the situation was reported to the appropriate nursing staff. Interviews with the involved CNAs and Licensed Vocational Nurses (LVNs) confirmed that the resident's arms were restricted under the fitted sheet, which was tied in a knot on one side and wrapped around the grab bars on the other side. The resident was covered with additional blankets, further limiting movement. The CNA responsible for tying the fitted sheet admitted to doing so to prevent the resident from harming himself by pulling out the catheter. The CNA acknowledged that it was a busy period and that the action was taken to manage the resident's restlessness. The facility's policies on abuse prevention and the use of restraints clearly state that residents have the right to be free from physical restraints not required to treat their symptoms. The CNA was suspended immediately following the incident, and the facility's administration was made aware of the situation.
Failure to Provide Ordered Low Air Loss Mattress
Penalty
Summary
The facility failed to provide a low air loss (LAL) mattress as per the physician's order for a resident who was readmitted with severe pressure ulcers. The resident had diagnoses including acute kidney failure, pressure ulcer of the sacral region, and muscle wasting and atrophy. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and dependence on assistance for various activities, including rolling in bed. Despite the physician's order and care plan specifying the need for a LAL mattress, the resident was observed lying on a regular mattress multiple times over two days. Licensed Vocational Nurses (LVNs) and a Registered Nurse (RN) acknowledged the physician's order for the LAL mattress but cited unavailability as the reason for the delay. The facility had no available LAL mattresses in storage, and the staff were waiting for one to become available. The importance of the LAL mattress for wound management and pressure relief was recognized by the staff, but the communication and coordination to obtain the mattress were lacking. Observations and interviews revealed that the LAL mattress was eventually brought to the facility but remained in the hallway without being set up for the resident. The facility's job description for the LVN Treatment Nurse emphasized the responsibility to provide treatment per physician orders and ensure appropriate prophylaxis and treatment for residents with pressure ulcers. However, the failure to promptly provide the LAL mattress as ordered led to a deficiency in the resident's 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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