Montebello Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montebello, California.
- Location
- 1035 W Beverly Blvd, Montebello, California 90640
- CMS Provider Number
- 055153
- Inspections on file
- 47
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Montebello Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with severe cognitive impairment and dependence on staff for ADLs was found with untrimmed, sharp fingernails, a bruise near the eye, and scratches on the forehead. Staff confirmed nail care was their responsibility, but there was no care plan or specific policy addressing nail care or self-scratching behavior, resulting in inadequate hygiene and risk of injury.
A resident with severe cognitive impairment and total dependence on staff did not have a comprehensive care plan developed or implemented for Foley catheter care, despite physician orders and facility policy requiring such planning. Staff interviews and record reviews confirmed the absence of a care plan addressing catheter care and urine output monitoring.
A resident with multiple pressure injuries and significant cognitive and physical impairments was incorrectly documented as having no skin issues on a weekly summary, despite other clinical records and wound assessments confirming the presence of wounds. The LVN responsible acknowledged the documentation error, and the DON confirmed the inconsistency with facility policy and other records.
A resident with an indwelling catheter was not consistently monitored or documented for signs and symptoms of UTI, as required by their care plan and facility policy. Staff failed to observe and record changes in urine appearance, sediment, and discomfort, and did not consistently follow interventions for catheter care, resulting in a deficiency related to appropriate catheter management and infection prevention.
Two residents with indwelling urinary catheters were observed with uncovered urine collection bags, despite facility policy and care plans requiring privacy bags to maintain dignity. Nursing staff and the DON confirmed that the bags should have been covered, and the facility's policy prohibits practices that compromise resident dignity, such as exposing catheter bags.
Two residents were placed at risk when a razor blade was found on the floor in the room of a cognitively impaired resident and medication was left unattended on the bedside table of another resident with moderate cognitive impairment and multiple medical conditions. Staff confirmed that both the presence of the razor blade and the unattended medication violated facility policy and could have resulted in harm.
Surveyors found expired medications, including insulin, suppositories, ointments, enemas, and vitamins, in medication carts and storage rooms, as well as eye drops not discarded within the labeled timeframe and insulin not properly refrigerated. Nursing staff and the DON confirmed these medications were expired or improperly stored and should have been discarded or stored according to policy.
Three residents with complex medical needs did not receive advance meal menus, were not served meals according to prescribed portions or preferences, and were not informed of available meal options. One resident waited over two hours for a required fortified meal and could not take medications, while others reported persistent hunger, lack of menu access, and limited substitution choices. Staff confirmed that menus were only posted in common areas and not distributed to residents, contrary to facility policy.
Surveyors found that food items in the kitchen, including pre-filled orange juice cups and pitchers, were not labeled with expiration dates, and staff confirmed this was not in line with facility policy. The conventional oven lacked temperature settings, requiring staff to guess cooking temperatures, and the gas department had previously adjusted the oven due to improper heating. Eighteen baking trays had grease build-up, two food pans were dented, and a blender used for mechanical soft diets was cracked and dirty. The dishwashing machine showed signs of calcification and corrosion, with staff acknowledging potential hazards and sanitation concerns. Facility policies required proper labeling, equipment maintenance, and safe food handling, which were not followed.
Staff failed to follow infection control protocols during care and equipment handling for multiple residents, including not changing gloves or performing hand hygiene after peri-care and wound care, not wearing required PPE, allowing a Foley catheter bag to rest on the floor, and improperly storing respiratory equipment. These actions did not comply with facility infection prevention policies.
A resident with blindness and muscle weakness was not provided with an accessible call light, as required by their care plan and facility policy. The standard push button call light was left out of reach and was not appropriate for the resident's condition, with staff confirming the resident could not use it due to visual impairment.
A resident with severe cognitive impairment and multiple physical diagnoses was inaccurately assessed on the MDS as needing only partial/moderate assistance with personal hygiene, despite consistent documentation and staff reports indicating a need for substantial/maximal assistance. This discrepancy was confirmed through record review, staff interviews, and direct observation, with facility leadership acknowledging the error and its potential impact on care planning.
Two residents did not have required care plans in place: one resident with severe cognitive impairment and dependence in daily activities lacked a care plan addressing smoking safety and refusal to use a protective apron, while another resident with chronic kidney disease, diabetes, and heart failure did not have a care plan reflecting a physician-ordered fluid restriction. Staff interviews and record reviews confirmed the absence of these care plans, despite facility policy and physician orders requiring them.
A resident with multiple pressure ulcers and severe cognitive impairment had their low air loss mattress (LALM) set at a weight much higher than their actual weight, contrary to physician orders and facility policy. Staff confirmed that this incorrect setting could make the mattress too hard and negatively affect wound healing.
A resident with a history of malnutrition, muscle weakness, and diabetes mellitus was observed receiving enteral feeding through a gastrostomy tube without the required label indicating feeding rate, date, or time hung. Staff and the DON confirmed that the facility's policy mandates labeling of enteral feeding, but this was not followed, resulting in noncompliance with established procedures.
A resident with chronic kidney disease, diabetes, and heart failure was not properly monitored for fluid intake despite a physician-ordered fluid restriction. Staff provided additional fluids without verification and did not document actual intake, failing to follow facility policy and physician orders.
A resident with severe cognitive impairment and a feeding tube did not receive the full prescribed doses of Acetazolamide and Oyster Shell Calcium/Vitamin D when an LVN failed to completely administer the medications, leaving significant residue in the medication cup. This action was not in accordance with facility policy, as confirmed by the DON.
A resident with multiple medical conditions did not receive a required monthly medication regimen review by the consulting pharmacist, as confirmed by record review and staff interviews. The resident's name was missing from the MRR list for the month, and facility policy requiring monthly reviews was not followed.
A resident with severe cognitive impairment and a feeding tube did not receive the full prescribed doses of Acetazolamide and Oyster Shell Calcium/Vitamin D when an LVN failed to fully administer the medications, leaving significant residue in the medication cup. This resulted in a medication error rate of eight percent, exceeding the required threshold.
Surveyors found that two large trash bins in the parking lot were repeatedly left uncovered and overfilled, with trash scattered around them. Multiple staff, including dietary, maintenance, and infection prevention, confirmed that the bins should be kept closed at all times per facility policy to prevent contamination and pest infestation. Review of facility policies showed clear requirements for covered, well-maintained waste containers, but these were not followed, resulting in improper waste containment.
A resident experienced significant weight loss and poor meal intake, but the facility failed to notify the primary physician and RD or develop a care plan. This led to the resident's hospitalization for dehydration, anorexia, and general weakness. Staff interviews revealed lapses in following facility policies for documenting and addressing changes in the resident's condition.
The facility failed to maintain a sanitary environment in the laundry room, where old cockroach traps with dead insects were found behind dryer machines, covered in dust and lint. Staff were unaware of when to dispose of the traps, and the facility's policies lacked clear instructions. The infection preventionist nurse highlighted the potential health risks, as cockroaches could contaminate clean linen carts.
A resident with dementia and a history of wandering accessed a bottle of cleaning solution left unattended in a shower area. The resident, who requires moderate assistance and supervision, was found tilting the bottle towards their mouth, posing a risk of ingestion. Facility staff interviews revealed that cleaning solutions should be stored securely, but a housekeeper left the bottle in the shower, and the door was left open, allowing the resident access.
The facility failed to observe infection control measures and did not fully implement its Legionella Water Management Program. A CNA provided care without proper PPE, and the Maintenance Director admitted to inadequate water testing and monitoring. The facility's policies on infection prevention and water management were not followed, potentially compromising resident safety.
The facility failed to ensure the call light was within reach for two residents, leading to potential delays in necessary care. One resident with hemiplegia and muscle weakness could not reach the call light placed beside her right shoulder, while another resident with a history of falls and muscle weakness had the call light placed on the floor, out of reach. This was a deviation from the facility's policy on call light accessibility.
The facility failed to ensure the MDS accurately reflected the status of two residents, leading to potential negative impacts on their care plans. One resident's history of falls was not documented, and another resident's restorative nursing services were not recorded in the MDS, despite being provided.
The facility failed to provide necessary care and services for two residents at risk for falls. One resident experienced multiple falls due to inadequate supervision and an unmodified care plan, while another resident's fall mat was not properly placed as required. The facility's policies for fall management and care plans were not followed, putting both residents at risk for injury.
The facility failed to provide pharmaceutical services to meet the needs of two residents. An LVN did not administer one resident's medications within the required 60 minutes of the scheduled time and failed to check another resident's blood glucose and administer insulin before a meal. These actions were not in accordance with the facility's medication administration policy.
The facility failed to maintain a medication error rate below 5%, resulting in a 30.3% error rate. An LVN administered medications late to a resident with asthma, dysphagia, and hypertension, and failed to check another resident's blood glucose and administer insulin before a meal, as required. These actions were inconsistent with the facility's policies.
The facility failed to label foods in the kitchen with item names and 'use by' dates, and did not discard expired food as per the facility's policy. Several food items in the kitchen's refrigerators and freezer were not properly labeled or had expired dates. The ACM and RD Consultant acknowledged the importance of labeling and discarding expired food to prevent serving expired food to residents.
The facility failed to maintain a safe environment by not fixing broken tiles around two uncovered sewer drains in the hallway near the rehabilitation room and the kitchen/activity/dining room. The Maintenance Director acknowledged the issue but had not received any repair reports, while the Housekeeping Supervisor confirmed that the problem had been reported to maintenance.
The facility staff failed to ensure a resident was cared for in a dignified manner by not sitting and being at eye level while feeding. The resident, who had severe cognitive impairment and difficulty swallowing, was fed by a CNA who was standing and leaning in front of them. This practice was against the facility's policy on promoting residents' well-being and dignity.
The facility failed to ensure a resident was given information to formulate an advance directive. Despite the resident's cognitive capacity to make decisions, there was no advance directive noted in the chart, and the POLST form was incomplete. The facility's policy requires staff to inquire about advance directives at admission, but there was no documented evidence that this was done.
The facility failed to notify the physician when a resident's discharge was delayed and after the resident experienced a fall. The resident was scheduled to be discharged but was delayed by a day without informing the physician, who only learned of the delay and fall after the resident had already been discharged. This oversight compromised the resident's safety and care.
The facility failed to revise the care plan for a resident with multiple falls, despite the resident's diagnoses of muscle weakness and dementia. The care plan lacked structured monitoring or supervision interventions, which the DON acknowledged should have been included. Interviews revealed that the resident was not supervised at the time of the falls, and the care plan was not individualized to prevent further incidents.
A resident with multiple medical conditions, including dysphagia and dementia, was found with food crumbs and drool on their gown and face after breakfast. The facility's staff acknowledged that the resident required assistance for eating and personal hygiene, and that the CNA should have provided the necessary care to maintain the resident's dignity.
The facility failed to follow the care plan for a resident with a penile wound, as a physician's order to replace a condom catheter with a foley catheter was not implemented. Observations and interviews confirmed the resident continued to use a condom catheter, contrary to the care plan, potentially worsening the wound.
The facility failed to change a resident's nasal cannula tubing weekly as per policy, leading to the use of undated tubing for 27 days. This was confirmed through observations and interviews with staff, who acknowledged the tubing should be labeled and changed weekly to prevent infection.
The facility failed to ensure a resident was free from significant medication errors by not checking blood sugar and administering insulin before meals as per the physician's order. The resident's blood sugar was checked after insulin was administered and after the resident had already consumed a portion of his lunch meal, compromising the accuracy of the blood sugar reading and the effectiveness of the insulin administration.
The facility failed to maintain accurate narcotic drug records for three residents, leading to discrepancies in medication administration and documentation. The ADON confirmed that these inaccuracies are not acceptable and could lead to potential harm.
The facility failed to ensure a call light was within reach for a resident with hemiplegia and hemiparesis, potentially resulting in the resident not receiving timely assistance. The call light was found on the floor, and both the LVN and DON confirmed it should be accessible at all times.
The facility failed to post daily staffing information, including the number of RNs, LVNs, and CNAs responsible for resident care, on multiple days. The DSD admitted to not posting the required information, and the DON was unaware of the lapse. This failure was observed and confirmed during interviews and a review of facility policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Nail Care and Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, autism, and dementia, who was dependent on staff for most activities of daily living (ADLs), was not provided adequate care and services to maintain good grooming and personal hygiene. The resident was observed with untrimmed fingernails that had sharp edges, a pea-sized bruise near the left eye, and scratches on the right forehead. Staff interviews confirmed that nail care was part of their responsibilities and that the resident's fingernails should have been assessed and trimmed regularly to prevent self-injury. Further review revealed that there was no care plan addressing the resident's behavior of self-scratching or specific interventions for nail care. The facility's Director of Nursing confirmed the absence of a care plan for these issues and acknowledged that the facility did not have a policy and procedure specific to nail care, relying instead on a general ADL policy. The lack of individualized care planning and oversight led to the resident being at risk for skin injuries from untrimmed nails.
Failure to Develop and Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's Foley catheter care as ordered by the physician. The resident, who had a history of left femur fracture, left artificial hip joint, and unspecified fall, was admitted and readmitted to the facility. The Minimum Data Set assessment indicated the resident had severely impaired cognitive skills and was dependent on staff for all activities of daily living. Despite physician orders for Foley catheter care and monitoring of urine output, there was no corresponding care plan documented or implemented in the resident's records. Interviews with facility staff, including an LVN, medical records staff, and the Director of Nursing, confirmed that no care plan was developed or updated to address the Foley catheter care and urine output monitoring. The facility's own policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan for each resident, incorporating measurable objectives and timetables, and to update the plan with any new physician orders or changes in the resident's condition. This policy was not followed in the case of this resident.
Inaccurate Documentation of Pressure Injuries on Weekly Summary
Penalty
Summary
The facility failed to ensure accurate and concise documentation of a resident's skin condition on the Weekly Summary Documentation (WSD) dated 4/17/2025. Despite the resident having multiple documented pressure injuries—including a stage 3 pressure injury on the left buttock and deep tissue injuries (DTIs) on both heels, as confirmed by the Treatment Administration Record (TAR) and the wound care doctor's Weekly Wound Assessment (WWA)—the WSD incorrectly indicated that the resident had no skin issues. This error was acknowledged by the LVN who completed the WSD, stating that the section for skin integrity was checked incorrectly and should have reflected the presence of skin problems. The resident involved had a complex medical history, including a hip fracture, left artificial hip joint, and a history of falls, and was assessed as severely cognitively impaired and fully dependent for all activities of daily living. The discrepancy in documentation was identified during interviews and record reviews, with the Director of Nursing (DON) confirming that the WSD was inconsistent with other clinical records. Facility policy requires nursing documentation to be clear, accurate, and reflective of the resident's condition, but this was not followed in this instance, potentially impacting the monitoring and care of the resident's wounds.
Failure to Monitor and Document Catheter Care and UTI Signs
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter by not consistently monitoring for signs and symptoms of urinary tract infection (UTI) as required by the resident's care plan and facility policy. The resident, who was admitted with diagnoses including urine retention, hemiplegia, hemiparesis, and muscle weakness, had a care plan that specified monitoring for infection, urine characteristics, and discomfort, with documentation and prompt reporting to the physician if abnormalities were observed. Despite these directives, there were multiple instances where staff did not document or monitor the resident's urine for sediment, color changes, or pain, particularly during shifts when changes in the resident's condition were noted, such as the presence of white sediments, pinkish urine, and lower abdominal pain. Observations and interviews revealed that staff, including the DON, LVNs, and CNAs, acknowledged lapses in documentation and monitoring. The DON confirmed that there was no documentation of urine monitoring for several shifts when the resident had documented changes in urine appearance and discomfort. Staff interviews indicated that some did not check for sediments or document findings, and there was inconsistency in following the care plan interventions. The facility's policy required observation and documentation of urine characteristics and signs of UTI, but these procedures were not followed. Record reviews further showed that the required monitoring and documentation were missing during critical periods when the resident exhibited symptoms such as sediment in the catheter tubing, pinkish urine, and bladder pain. The DON stated that the facility lacked a clear policy on documenting changes of condition every shift for 72 hours, and staff were not consistently addressing or documenting the resident's change of condition. This failure to adhere to care plan interventions and facility policy resulted in a deficiency related to catheter care and UTI prevention.
Failure to Cover Urinary Collection Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents by not ensuring their urinary collection bags were covered with privacy bags, as required by facility policy and care plans. For one resident with end stage renal disease and chronic kidney disease, documentation showed the need for an indwelling Foley catheter and a care plan intervention to provide a privacy bag. During observation, the resident's Foley catheter bag was found uncovered and hanging on the side of the bed. Interviews with nursing staff and the DON confirmed that the catheter bag should have been covered to promote privacy and dignity. Another resident, admitted with kidney and ureter disorders and dehydration, was also observed with an uncovered urine collection bag. This resident was severely cognitively impaired and dependent on staff for all activities of daily living, including toileting and hygiene. Staff interviews again confirmed that the urine collection bag should not have been exposed, as this compromises the resident's dignity. A review of the facility's policy on dignity emphasized that residents must be cared for in a manner that promotes well-being and self-esteem, specifically prohibiting practices that compromise dignity, such as leaving urinary catheter bags uncovered. The failure to follow these policies and care plan interventions resulted in a deficiency related to the residents' right to privacy and dignity.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
A deficiency was identified when a razor blade was found on the floor in the room of a resident with severe cognitive impairment and significant physical limitations. The resident required partial or moderate assistance with eating and hygiene, and was fully dependent for toileting, dressing, repositioning, and transfers. The razor blade was observed by staff during a room check, and it was confirmed that razor blades are not permitted in resident rooms due to the risk of injury. Staff interviews indicated that the razor blade was likely left behind by a CNA after assisting the resident with shaving, and both the Infection Preventionist Nurse and Registered Nurse Supervisor acknowledged that this was a violation of facility policy and posed a hazard to the resident and staff. Another deficiency was observed when medication was left unattended on the bedside table of a resident with moderate cognitive impairment and multiple medical conditions, including diabetes, end stage renal disease, and dysphagia. The medication, identified as Tums, was left by a nurse for the resident to take at their convenience. Staff interviews confirmed that medication should not be left at the bedside, regardless of whether it is over-the-counter, as it could be accessed by the resident or others, potentially leading to harm. The nurse responsible acknowledged the error and stated that it was a mistake not to check the room during rounds. Facility policy review indicated that environmental hazards include unattended equipment and sharp objects accessible to vulnerable residents. Both incidents involved a failure to maintain an environment free from accident hazards, as required by facility policy, and were confirmed through staff interviews and direct observation.
Expired and Improperly Stored Medications Found During Survey
Penalty
Summary
Surveyors observed that the facility failed to ensure the safe provision of pharmaceutical services by not removing and discarding expired medications and by not storing certain medications according to manufacturer requirements and facility policy. Specifically, expired insulin vials, suppositories, topical ointments, enemas, and vitamin bottles were found in medication carts and storage rooms. Additionally, eye drops were not discarded within the labeled 28-day period after opening, and unopened insulin vials were not refrigerated as required. These findings were confirmed through interviews with nursing staff, who acknowledged that the medications were expired or improperly stored and should have been discarded or stored according to policy. The Director of Nursing confirmed that medications should be stored and discarded per manufacturer instructions and facility policy, including the use of multi-dose vials within 28 days and proper refrigeration of insulin. The facility's policy and procedure also require that discontinued, outdated, or deteriorated medications be returned or destroyed as directed by the dispensing pharmacy, and that medications for external use be clearly marked and stored separately. The observed deficiencies were based on direct observation, staff interviews, and review of facility policy.
Failure to Provide Menus and Follow Prescribed Diets for Residents
Penalty
Summary
The facility failed to provide menus and ensure nutritional adequacy for three residents by not supplying meal menus in advance, not following prescribed meal portions, and not honoring food preferences as documented in care plans and physician orders. For one resident with multiple diagnoses including diabetes, end stage renal disease, and chronic kidney disease, the facility did not provide the ordered double portion and fortified oatmeal for breakfast, resulting in the resident waiting over two hours for the correct meal and being unable to take morning medications due to an empty stomach. Observations and interviews confirmed that the resident's meal ticket specified double portions and oatmeal, but these were not delivered as ordered. Another resident, dependent on staff for most activities of daily living and at nutritional risk due to wound healing needs, reported never receiving a menu and not being informed about meal options. This resident expressed dissatisfaction with the food, was not offered substitutions, and often ate less than 25% of meals, leading to persistent hunger. Staff interviews confirmed that menus were not distributed to residents and that communication about meal options was lacking, especially for those who were bedbound or did not attend the activity room. A third resident, with significant medical history including diabetes with neuropathy and multiple amputations, also did not receive a menu and was not informed about meal options. This resident frequently found the meals unappetizing and insufficient in portion size, often resorting to limited substitution options such as a cold turkey sandwich. Staff and dietitian interviews corroborated that menus were only posted in common areas and not provided individually, making it difficult for residents, especially those confined to their rooms, to make informed meal choices or request timely substitutions. Facility policies required that food preferences be honored and menus be reviewed with residents, but these practices were not followed.
Deficient Food Storage, Equipment Maintenance, and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and equipment maintenance within the facility's kitchen. Seventeen pre-filled orange juice cups and two orange juice pitchers were found in a refrigerator without any use by or expiration dates. Dietary staff confirmed these items should have been labeled to ensure expired food is not served to residents. Additionally, the conventional oven's temperature knobs had no visible settings, requiring staff to guess the temperature during cooking. Staff acknowledged that this could result in food not being cooked to the required temperature, with the gas department previously noting the oven was not heating properly and had since been adjusted, possibly leading to overheating. Further observations revealed that eighteen large metal baking trays had visible grease build-up, and two large food pans were dented. Staff indicated that using trays with caked-on grease could pose a fire hazard. A blender used for preparing mechanical soft diets was found to have small cracks at the bottom and was dirty and dusty, despite being relatively new. Staff stated the importance of having equipment in good condition to ensure proper food preparation for residents requiring pureed diets. The dishwashing machine was observed to have visible calcification, corrosion, and discoloration. Staff reported that the machine is serviced annually and tested daily, but acknowledged that the corrosion could present electrical hazards and impact the machine's ability to properly sanitize dishes. Facility policies and procedures reviewed by surveyors required proper labeling and dating of refrigerated foods, maintenance of clean and undamaged equipment, and safe food handling practices, all of which were not followed as observed during the survey.
Failure to Follow Infection Control Practices During Resident Care and Equipment Handling
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices for four of five sampled residents, as observed through direct care activities and interviews. For one resident with a history of sepsis, cellulitis, and dementia, a CNA did not wear a gown while providing incontinent care, used the same gloves to touch the resident and room surfaces after care, and did not perform hand hygiene. During wound care for the same resident, a treatment nurse failed to change gloves and perform hand hygiene between removing a soiled dressing and applying a clean one, contrary to facility policy and the resident's care plan for enhanced standard precautions due to MDRO risk. Another resident with a urinary tract infection and dementia was subject to similar lapses. A CNA touched surfaces belonging to another resident and then handled the resident's cup and straw without performing hand hygiene. The same CNA also failed to change gloves and perform hand hygiene after providing peri-care, subsequently touching the resident's hand and bed rail. Interviews with the Infection Prevention Nurse confirmed that these actions did not comply with facility policy and increased the risk of infection transmission. Additional deficiencies included improper management of medical equipment. One resident with an indwelling Foley catheter was observed with the catheter bag resting on the floor, which was confirmed by nursing staff as a violation of policy intended to prevent infection. Another resident receiving respiratory treatments had their mask and nasal cannula stored on top of an undated and unlabeled plastic bag, rather than inside a clean, dated, and labeled bag as required. Staff interviews corroborated that these storage practices did not meet infection control standards outlined in facility policies.
Failure to Provide Accessible Call Light for Visually Impaired Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident with significant visual impairment and muscle weakness by not ensuring the call light was within reach and by not providing an appropriate touch pad call light. The resident, who was blind and dependent on staff for most activities of daily living, was observed with a standard push button call light that was not accessible. Staff interviews confirmed that the call light was not within reach and was not suitable for the resident's condition, as the resident would not know where or how to use it due to blindness. The resident's care plan specifically indicated that the call light should be placed within reach, and facility policy required accessible call systems or alternative communication methods for residents with disabilities. Despite these directives, observations showed the call light was left in the middle of the bed while the resident was in a wheelchair against the wall, making it inaccessible. Staff acknowledged the oversight and the need for a more appropriate call light device for the resident's needs.
Inaccurate MDS Assessment of Resident's Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's functional ability for personal hygiene on the Minimum Data Set (MDS), as required by facility policy. The resident in question was admitted with diagnoses including osteoarthritis, contracture, muscle weakness, and dementia, and was documented as severely impaired in cognitive skills for daily decision making. Multiple reviews of the resident's MDS indicated inconsistencies: while the MDS at one point recorded the resident as requiring only partial/moderate assistance with personal hygiene, other documentation, including care conference notes and subsequent MDS assessments, indicated the resident actually required substantial/maximal assistance. Observations of care and interviews with staff confirmed that the resident had consistently needed maximal assistance for personal hygiene for at least a year. Interviews with the DON and MDS Nurse revealed that the MDS had been inaccurately completed, listing a lower level of assistance than was actually required. Both acknowledged the importance of accurate MDS assessments for care planning. The facility's policy assigns responsibility for ensuring accurate and timely MDS submissions to the assessment coordinator or designee, in accordance with federal and state guidelines. The inaccurate assessment had the potential to impact the development and implementation of a resident-centered care plan tailored to the resident's actual needs.
Failure to Develop and Implement Required Care Plans for Smoking Safety and Fluid Restriction
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by facility policy and physician orders. For one resident with severe cognitive impairment and dependence in daily activities, there was no care plan addressing the resident's smoking behavior and consistent refusal to wear a protective smoker's apron. Observations confirmed the resident's refusal, and staff interviews acknowledged the absence of a care plan to address this risk, despite facility policy requiring such issues to be documented and communicated to all personnel. For another resident with stage 4 chronic kidney disease, type 2 diabetes, and acute systolic heart failure, the facility did not create a care plan reflecting a physician-ordered fluid restriction. The order specified detailed fluid limits for both nursing and dietary staff, but review of the care plan and staff interviews confirmed that no care plan was in place to guide staff in monitoring and implementing the fluid restriction. Facility policy required care plans to be updated with new physician orders or changes in condition, but this was not done for the resident. Both deficiencies were identified through observation, record review, and staff interviews. The facility's own policies outlined the need for individualized, measurable care plans that incorporate physician orders and address identified risks, but these were not followed for the two residents in question.
Incorrect LALM Setting for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to set a low air loss mattress (LALM) at the correct setting for a resident with multiple pressure ulcers, as required by the facility's policy and physician's order. The resident, who was admitted with a Stage 4 sacral pressure ulcer, five unstageable pressure ulcers, and a history of diabetes mellitus, was dependent on staff for all activities of daily living and had severe cognitive impairment. According to the resident's care plan and physician's order, the LALM was to be set based on the resident's weight, which was documented as 94 lbs. During an observation, the LALM was found set at 160 lbs, significantly higher than the resident's actual weight. Both the LVN and DON confirmed that setting the LALM above the resident's weight would make the mattress too hard, potentially worsening the resident's wounds. The facility's policy on skin integrity management required staff to implement pressure ulcer prevention measures and to provide care in accordance with physician orders, which was not followed in this instance.
Failure to Label Enteral Feeding Formula
Penalty
Summary
A deficiency was identified when a resident receiving enteral feeding was observed to have an unlabeled feeding formula infusing through a gastrostomy tube. The resident, who had diagnoses including malnutrition, muscle weakness, and diabetes mellitus, required tube feeding as ordered by the physician and as documented in the care plan. The care plan specified that the registered dietitian should monitor caloric intake and that staff should administer tube feeding as ordered. However, during multiple observations, the enteral feeding in the resident's room was found to be infusing without a label indicating the feeding rate, date, or time hung. Interviews with staff, including an LVN and the DON, confirmed that the enteral feeding should have been labeled according to the facility's policy and procedure, which requires labeling the formula with the date and time it was hung. The DON emphasized the importance of labeling to ensure the correct resident receives the correct formula and rate of feed, as this directly impacts the resident's nutritional status. The failure to label the enteral feeding was not in compliance with the facility's established policy and procedure.
Failure to Monitor and Record Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to accurately monitor and record the fluid intake for a resident with a physician-ordered fluid restriction of 1200 ml per 24 hours, divided between nursing and dietary staff. The resident, who had diagnoses including stage 4 chronic kidney disease, type 2 diabetes, and acute systolic heart failure, was observed consuming coffee in addition to milk during lunch. The certified nursing assistant (CNA) who provided the coffee acknowledged knowing about the fluid restriction but did not verify with a nurse before giving the additional fluid. Further interviews revealed that the actual fluid intake for the resident was not being recorded by nursing staff, and there was no documentation of fluid intake for each shift in the resident's medical record. The facility's policies required accurate recording and division of fluids for residents on restriction, but these procedures were not followed, resulting in a failure to implement the physician's order for fluid restriction.
Incomplete Administration of Medications via G-Tube
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to fully administer two prescribed medications, Acetazolamide and Oyster Shell Calcium/Vitamin D, to a resident with severe cognitive impairment and total dependence for daily activities, who was receiving medications via a gastrostomy tube. The LVN prepared the medications by crushing and mixing them in water, but did not ensure the entire dose was delivered, leaving approximately 70% of the Oyster Shell Calcium and 50% of the Acetazolamide in the medication cup. This resulted in the resident not receiving the full prescribed doses as ordered by the physician. The resident involved had a history of urinary tract infection and congestive heart failure, and was dependent on a feeding tube for medication administration. The facility's policy and procedure required that medications be administered in accordance with prescriber's orders and tailored to resident needs. Both the LVN and the Director of Nursing confirmed that the medications were not completely administered, which was not in accordance with the facility's policy.
Missed Monthly Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to conduct a required monthly Medication/Drug Regimen Review (MRR) for one of five sampled residents during the month of February 2025. Specifically, a resident with diagnoses including cerebral infarction, unspecified psychosis, and diabetes mellitus did not have their medication regimen reviewed by the consulting pharmacist as required by the facility's policy and procedure. The resident's admission record and Minimum Data Set (MDS) indicated various care needs and intact cognitive skills, but there was no documented evidence that their medications were reviewed during the specified month. Interviews with the Director of Nursing (DON) and the Pharmacy Consultant confirmed that the resident's name was not included in the MRR list for the month in question, and therefore, the review was not performed. The facility's policy requires that the consultant pharmacist review each resident's medication regimen at least monthly, including upon admission, to ensure appropriate medication management. The absence of the MRR was verified through record review and staff interviews, confirming non-compliance with established procedures.
Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 25 observed opportunities, resulting in an eight percent error rate. During medication administration for a resident with severe cognitive impairment, dependent on a feeding tube, a Licensed Vocational Nurse (LVN) prepared and administered medications using the same G-tube syringe for all crushed medications. The LVN did not fully administer Acetazolamide and Oyster Shell Calcium/Vitamin D as prescribed, leaving significant residue in the medication cup. The LVN acknowledged that only 30% of the Oyster Shell Calcium and 50% of the Acetazolamide were administered, with the remainder left in the cup and not given to the resident. The Director of Nursing confirmed that the medications were not administered in accordance with the physician's orders. Facility policy requires medications to be administered as prescribed, but this was not followed in this instance.
Failure to Properly Contain and Cover Waste Bins
Penalty
Summary
Surveyors observed that two large trash bins located in the facility parking lot were repeatedly left uncovered, with their lids open and visible trash scattered on the ground around them. These observations were made on multiple occasions, and staff interviews confirmed that the bins were not being kept closed as required by facility policy. Dietary staff, the DON, the Maintenance Supervisor, and the Infection Preventionist all acknowledged that the trash bin lids should remain closed at all times to prevent contamination and pest infestation. The bins were also noted to be overfilled, further preventing the lids from being closed properly. A review of the facility's policies and procedures revealed clear requirements for garbage and refuse containers to be kept in good condition, covered with tight-fitting lids, and free of surrounding litter. The policies also specified that garbage areas should be maintained to prevent pests and that food-related waste should be stored in a manner inaccessible to pests. Despite these policies, the facility failed to ensure proper containment and coverage of waste, as evidenced by the open bins and littered area.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care services for a resident experiencing impaired nutrition. The resident experienced a significant weight loss of six pounds, which was noted on July 3, 2024. However, the facility did not notify the resident's primary physician or the Registered Dietician (RD) about this change of condition. Additionally, the resident's meal intake was consistently 50% or less over several days, yet there was no communication to the primary physician or RD regarding this poor intake. The facility also failed to initiate a resident-centered care plan to address the resident's weight loss and poor meal intake. Despite the resident's declining condition, including general weakness and poor meal intake, no care plan was developed to address these issues. The lack of a care plan and failure to notify the appropriate medical staff placed the resident at risk for further health complications, leading to a hospital admission with diagnoses of dehydration, anorexia, and general weakness. Interviews with facility staff revealed that the Registered Dietician and primary physician were not informed of the resident's condition changes in a timely manner. The facility's policies and procedures for documenting changes in condition and notifying medical staff were not followed. The Director of Nursing acknowledged the absence of a care plan and the lack of an Interdisciplinary Team meeting to address the resident's nutritional needs, which contributed to the resident's deteriorating health condition.
Sanitation Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the laundry room, as observed during a survey. Two cockroach traps were found behind the dryer machines, covered with dust and lint, and containing dead insects. The maintenance assistant (MA) acknowledged that the traps appeared old and were not dated, and he was unaware of when they were placed or when to dispose of the dead insects. The laundry staff also confirmed the presence of dead cockroaches in the traps for several days but did not know who was responsible for discarding them. The infection preventionist nurse (IPN) expressed concerns about the unsanitary conditions, noting that cockroaches could potentially contaminate clean linen carts and pose a health risk to residents. The assistant administrator (AA) stated that the traps were placed by a pest control company to monitor cockroach activity, but there were no instructions on when to dispose of them. The facility's policy and procedure (P&P) on pest control, last revised in 2008, did not specify when to change or dispose of cockroach traps. The director of nursing (DON) confirmed that the P&P lacked necessary instructions and emphasized the potential health risks posed by cockroaches. Additionally, the facility's Environmental Services Operations Manual, revised in 2017, indicated the importance of keeping equipment clean to prevent germ breeding.
Resident Access to Hazardous Cleaning Solution Due to Inadequate Supervision
Penalty
Summary
The facility staff failed to ensure a safe environment for Resident 4, who was found holding a bottle of cleaning solution in the shower area. Resident 4, who has a history of wandering and impaired cognitive skills due to dementia, was left unsupervised, allowing access to the cleaning solution. The resident was observed tilting the bottle towards their mouth, which posed a significant risk of ingestion and potential harm. Resident 4's medical history includes hypercalcemia, dementia, and dysphagia, and they require moderate assistance with daily activities. The care plan for Resident 4 highlighted the risk of wandering due to impaired cognition and safety awareness, with interventions to redirect the resident to safe areas. However, on the day of the incident, the resident was not adequately monitored, leading to the exposure to the cleaning solution. Interviews with facility staff, including the Housekeeping Supervisor, Licensed Vocational Nurse, and Certified Nursing Assistants, revealed that cleaning solutions are supposed to be stored securely in locked carts or closets. However, a housekeeper left the bottle in the shower, and the shower door was left open, allowing Resident 4 to access the area. The Director of Nursing confirmed that the facility's policies require cleaning solutions to be stored safely to prevent resident access and potential poisoning.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to observe infection control measures as indicated in their policy. Specifically, a Certified Nursing Assistant (CNA) was observed providing care to a resident in an Enhanced Standard Precaution room while only wearing gloves and not a gown. The CNA acknowledged that she should have worn a gown to prevent the spread of infection. The Infection Preventionist Nurse confirmed that CNAs are required to wear gowns and gloves while providing close contact care in such rooms. The facility's policy mandates the use of appropriate precautions and personal protective equipment to prevent the transmission of communicable diseases and infections. Additionally, the facility did not fully implement its Legionella Water Management Program policy and procedure. The Maintenance Director admitted to not using any toolkit to test the water for Legionella since 2018 and only conducted visual inspections and random hot water temperature checks. The data was recorded in a building management platform that did not log information on weekends, and there was no monitoring of cold-water temperatures or comprehensive documentation of water system inspections. The Infection Preventionist and Administrator confirmed that the water management monitoring was not performed daily as required by the policy. The facility's policy on water management emphasizes the importance of proactive steps to prevent Legionella growth and spread. The policy outlines the need for a water management program team, control measures, and regular monitoring to ensure the program's effectiveness. However, the facility failed to adhere to these guidelines, potentially compromising the safety and health of residents, staff, and visitors by not ensuring a safe and sanitary water supply.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, Resident 94 and Resident 24, which had the potential to delay necessary care and services. Resident 94, who was admitted with hemiplegia affecting the right side and muscle weakness, was observed with a call light placed on the bed beside the resident's right shoulder, despite being unable to move her right arm. Interviews with the Director of Staff Development (DSD) and Physical Therapy (PT) confirmed that Resident 94's right elbow could only move 45 degrees actively, making it impossible for the resident to reach the call light. The Director of Nursing (DON) also acknowledged that the call light was not within reach, which could prevent the resident from calling for help in an emergency. The facility's policy on answering call lights, revised in September 2022, indicated that call lights should be accessible to residents when in bed, from the toilet, shower, or floor, which was not adhered to in this case. Resident 24, who had a history of falls, transient ischemic attack, generalized muscle weakness, and lack of coordination, was also found to have the call light out of reach. During an observation, Resident 24 was seen trying to get up from bed and asking for help, with the call light device placed on the floor near the middle of the headboard, out of the resident's reach. Interviews with the assigned Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) confirmed that the call light should have been placed on the bed close to the resident for easy reach to ensure timely assistance and prevent falls. The facility's policy on answering call lights, revised in September 2022, was again not followed, as it required the call light to be accessible to the resident in various situations. The failure to ensure the call light was within reach for both residents was a clear deviation from the facility's policy and had the potential to delay necessary care and services. Both residents had significant impairments that required them to have easy access to the call light to call for assistance, which was not provided. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of two residents, leading to potential negative impacts on their care plans. Resident 77, who was admitted with muscle weakness and dementia, had a fall incident that was not accurately documented in the MDS. Despite having a history of falls and a change of condition related to falls, the MDS did not reflect these incidents, which the Director of Nursing acknowledged should have been included to ensure an accurate care plan for the resident's needs. Resident 31, who had diagnoses including abnormal posture and contractures of the knees, did not have an accurate assessment for the restorative nursing program in the MDS. Although the resident received various restorative nursing services, such as passive range of motion exercises and the use of a cervical collar, these were not documented in the MDS. The MDS Coordinator admitted that the restorative nursing program section was not completed, which should have reflected the services provided to the resident. The facility's policy and procedure on resident assessments, revised in October 2023, indicated that MDS assessments should consistently reflect information in progress notes, care plans, and resident observations/interviews. However, the discrepancies in the MDS for both residents 77 and 31 indicate a failure to adhere to this policy, potentially affecting the development and implementation of individualized care plans for these residents.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to provide necessary care and services for two residents at risk for falls. Resident 77 experienced multiple falls, and the facility did not modify the fall/injury care plan after these episodes. The resident, who has muscle weakness and dementia, was not provided with adequate supervision, as evidenced by several incidents where the resident fell from a wheelchair or was found on the floor. The Director of Nursing (DON) acknowledged that the care plan was not revised to include structured monitoring or supervision interventions, and the resident was not supervised as required, leading to repeated falls. Resident 82, who has a history of falls, lack of coordination, and dementia, was also not provided with the necessary care as indicated in the care plan. The care plan required a fall mat to be placed on the left side of the bed to prevent injury in case of a fall. However, during an observation, the fall mat was found folded and not placed on the floor as required. Licensed Vocational Nurse 4 (LVN 4) confirmed that the fall mat was not properly placed, and the resident was at risk for falls due to improper positioning in bed. The facility's policies and procedures for fall management and comprehensive person-centered care plans were not followed. The DON and other staff members acknowledged that the care plans were not individualized or revised as needed to prevent further falls. The lack of supervision and failure to implement the required interventions put both residents at risk for injury, hospitalization, or death.
Failure to Administer Medications Timely and Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, Resident 16 and Resident 48, as per the facility's policy. During a medication pass observation, Licensed Vocational Nurse 7 (LVN 7) did not administer Resident 16's medications within the required 60 minutes of the scheduled time of 9 AM. This delay was confirmed by LVN 7, who acknowledged administering the medications after 10 AM. Resident 16's medical history includes asthma, dysphagia, and hypertension, and the resident requires various levels of assistance for daily activities. The medications scheduled for 9 AM included Advair Diskus, Ascorbic Acid, Enoxaparin sodium, Irbesartan, Isosorbide Mononitrate, Lactulose, Lorazepam, Ferrous sulfate, and Colace. The failure to administer these medications on time could potentially affect the resident's health and well-being, as noted by LVN 7 during the interview. The facility's policy mandates that medications be administered within one hour of their prescribed time unless otherwise specified, which was not adhered to in this case. In another instance, LVN 7 failed to check Resident 48's blood glucose and administer insulin before the lunch meal. Resident 48 has a medical history that includes type 2 diabetes, muscle weakness, and dementia. The physician's order required a blood sugar check and insulin administration per sliding scale before meals and at bedtime. During the observation, it was noted that Resident 48 had already started eating before the blood sugar check was performed, resulting in a blood sugar reading of 245 mg/dL. The Assistant Director of Nursing (ADON) confirmed that the blood sugar result was unreliable since it was checked after the resident had started eating. LVN 3 emphasized the importance of checking blood sugar levels and administering insulin as ordered to prevent hyperglycemia. The facility's policy on administering medications specifies that medications should be administered in a safe and timely manner, which was not followed in this case. The facility's failure to adhere to its medication administration policy for both Resident 16 and Resident 48 was observed and confirmed through interviews and record reviews. The deficiencies in medication administration timing and procedure could potentially lead to adverse health outcomes for the residents. The facility's policy clearly states that medications should be administered within one hour of their prescribed time and in accordance with prescriber orders, which was not done in these instances.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that its medication error rate was less than five percent, resulting in a 30.3% error rate. This was observed during a medication pass where a Licensed Vocational Nurse (LVN) did not administer medications within the required time frame. Specifically, Resident 16's medications were administered more than an hour late, which could potentially affect the resident's condition, especially given their diagnoses of asthma, dysphagia, and hypertension. The LVN acknowledged the delay and its potential impact on the resident's health during an interview. Additionally, the facility failed to check Resident 48's blood glucose and administer insulin before a meal, as required by the physician's order. Resident 48, who has type 2 diabetes and dementia, had their blood sugar checked after starting their meal, rendering the result unreliable. The LVN and Assistant Director of Nursing (ADON) confirmed that the blood sugar should have been checked before the meal to ensure proper insulin administration. This failure could lead to uncontrolled blood sugar levels, which is critical for diabetic patients. The facility's policies and procedures were reviewed and indicated that medications should be administered within one hour of their prescribed time. The LVN's actions were inconsistent with these policies, leading to the observed deficiencies. The ADON emphasized the importance of timely medication administration to prevent complications and ensure the effectiveness of the treatment.
Failure to Label and Discard Expired Food
Penalty
Summary
The facility failed to label foods in the kitchen with item names and 'use by' dates, and did not discard expired food as per the facility's policy and procedure. During an observation and interview with the Accounts Manager (ACM), it was found that several food items in the kitchen's refrigerators and freezer were not labeled with item names, dates opened, or 'use by' dates. Specifically, an open bag of fries, an open bag of chicken tenders, a clear bag of hash browns, two packs of raw meat, a metal container of beans, a zip lock bag containing deli turkey, and an open loaf of bread were not properly labeled or had expired dates. The ACM acknowledged that these items should have been labeled and expired items should have been discarded to prevent serving expired food to residents. In a follow-up interview, the ACM reiterated the importance of labeling food items with expiration dates to prevent serving expired food. The Registered Dietician (RD) Consultant confirmed that there was no specific policy for discarding food items but stated that the facility followed FDA guidelines for discarding food. A review of the facility's policy and procedure indicated that all foods should be stored, wrapped, labeled, and dated to prevent cross-contamination. Additionally, the 2022 FDA Food Code requires that time/temperature control safety refrigerated foods must be consumed, sold, or discarded by the expiration date.
Failure to Maintain Safe Environment Due to Uncovered Sewer Drains and Broken Tiles
Penalty
Summary
The facility failed to maintain a safe environment by not fixing broken tiles around two uncovered sewer drains on the floor in the hallway. This issue was observed in the hallway near the rehabilitation room and the hallway in front of the kitchen and activity/dining room. The Maintenance Director (MED) acknowledged the problem, stating that all sewer drains should be covered and broken tiles should be repaired to prevent falls. However, the MED mentioned that he had not received any reports for floor repairs. The Housekeeping Supervisor (HS) confirmed that housekeeping had cleaned the hallway the previous night and had reported the uncovered sewer drains and broken tiles to the maintenance department for fixing. The facility's Policy and Procedure (P&P) on Maintenance Service, Physical Environment, revised in December 2009, indicates that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. This includes maintaining the building in good repair and free from hazards, as well as providing routinely scheduled maintenance services. Despite these guidelines, the facility failed to address the reported issues, posing a risk of falls and injuries to residents, visitors, and staff.
Failure to Ensure Dignified Feeding Practices
Penalty
Summary
The facility staff failed to ensure that Resident 18 was cared for in a dignified manner by not sitting and being at eye level while feeding the resident. On 4/22/2024, a Certified Nursing Assistant (CNA1) was observed standing and leaning in front of Resident 18, who was in a wheelchair, while feeding the resident. This observation was made in the presence of the Infection Preventionist Nurse (IPN), who stated the importance of sitting while feeding to ensure nothing is pushed down the resident's mouth and to be at eye level. Resident 18 had been admitted with diagnoses including Parkinson's disease and dementia, and was dependent on staff for feeding due to severe cognitive impairment and difficulty swallowing (dysphagia). The resident's care plan indicated the need for a regular dysphagia puree texture and thick liquids of nectar consistency, with double portions as ordered by the physician on 3/30/2023. Further interviews with the Restorative Nursing Assistant (RNA) and the Director of Nursing (DON) confirmed that staff should sit while feeding residents to provide dignity and respect. The facility's policy on Quality of Life-Dignity, revised in February 2020, emphasized that each resident should be cared for in a manner that promotes their sense of well-being, self-worth, and self-esteem. The failure to adhere to this policy and procedure had the potential to negatively affect Resident 18's dignity and self-worth.
Failure to Provide Information for Advance Directive
Penalty
Summary
The facility failed to ensure that Resident 107 was given information to formulate an advance directive. Resident 107 was admitted with diagnoses of arthritis and sciatica and had the cognitive capacity to understand and make decisions, as indicated by the Minimum Data Set (MDS) and History and Physical (H&P) records. Despite this, a review of Resident 107's records on 4/23/2024 revealed no advance directive noted in the chart, and the Physician Orders for Life Sustaining Treatment (POLST) form had the advance directive box unchecked. During an interview and record review on 4/24/2024, the Administrator and Assistant Administrator confirmed that the Social Services Director (SSD) had not confirmed whether Resident 107 had an advance directive before marking the POLST form. The facility's policy, dated 3/23/2022, requires admission staff to inquire about the existence of an advance directive at the time of admission and provide the resident with an opportunity to complete one if it does not exist. There was no documented evidence that Resident 107 was given this option, leading to the deficiency noted in the report.
Failure to Notify Physician of Discharge Delay and Fall Incident
Penalty
Summary
The facility failed to notify the resident's physician when there was a delay in discharging a resident to home. Resident 108 was admitted with diagnoses of generalized osteoarthritis, syncope, and a history of falling. The resident was scheduled to be discharged on 3/8/2024, but the discharge was delayed to 3/9/2024 without notifying the physician. The resident had a fall on 3/7/2024, and the physician was not informed about the delay in discharge or the fall incident. The physician only became aware of the fall and the discharge delay when they came to see the resident on 3/9/2024, after the resident had already been discharged. This lack of communication could have resulted in an unsafe discharge for the resident. Interviews with the nursing staff and the Director of Nursing confirmed that the physician was not notified about the delay in discharge. The facility's policies and procedures require that physicians be informed of changes in the resident's condition and discharge plans. However, in this case, the staff did not follow the protocol, leading to a deficiency in the care provided to Resident 108. The facility's failure to notify the physician of the discharge delay and the resident's fall was a significant oversight that compromised the resident's safety and care.
Failure to Revise Care Plan for Resident with Multiple Falls
Penalty
Summary
The facility failed to revise the care plan for one resident who had multiple falls. The resident, who was admitted with diagnoses of muscle weakness and dementia, experienced several falls over a period of time. Despite these incidents, the care plan was not updated to include structured monitoring or supervision interventions to prevent further falls. The Director of Nursing (DON) acknowledged that the care plan should have included monitoring or supervision at least every two hours to prevent further falls. The resident's care plan, dated 10/03/2023, included various interventions such as assessing for changes in medical status, keeping the bed in a low position, and utilizing bilateral floor mats for safety. However, it lacked a structured monitoring or supervision intervention. The DON confirmed that the care plan should have been revised to include such interventions. Additionally, the care plan dated 4/18/2024 also did not include structured monitoring or supervision interventions, despite the resident having multiple falls. Interviews with the DON and a Licensed Vocational Nurse (LVN) revealed that the resident was not supervised at the time of the falls. The DON stated that all the fall incidents were due to a lack of supervision and that the care plan should have been individualized to prevent further falls. The facility's policy indicated that care plans should be revised as the resident's condition changes, but this was not done in the case of this resident.
Failure to Maintain Resident's Dignity After Meal
Penalty
Summary
The facility failed to clean a resident's face and gown after breakfast, compromising the resident's dignity. The resident, who has diagnoses including dysphagia, hemiplegia, hemiparesis, and dementia, was observed with food crumbs on their gown and around their mouth, as well as drool marks and a wet mark on their gown. The resident's Minimum Data Set (MDS) indicated they required partial to moderate assistance for eating and personal hygiene, and substantial to maximal assistance for other activities of daily living (ADLs). During interviews, both the Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged that the resident's condition was not acceptable and that the Certified Nursing Assistant (CNA) should have provided hygiene care and changed the resident's gown. The facility's policies and procedures emphasize the importance of maintaining residents' dignity and providing appropriate care to ensure their ADLs do not diminish unless clinically unavoidable. The failure to clean the resident after breakfast was a clear deviation from these policies.
Failure to Implement Care Plan for Wound Management
Penalty
Summary
The facility failed to implement the care plan for Resident 39, who was admitted with diagnoses of a pressure ulcer and muscle weakness. Despite a physician's order on 4/14/2024 to replace the resident's condom catheter with an indwelling foley catheter for wound management, the care plan was not followed. Observations on 4/24/2024 revealed that Resident 39 still had a penile wound and was using a condom catheter instead of the prescribed foley catheter. Treatment Nurse 1 confirmed that the care plan was not implemented, which could have prevented the resident's wound from worsening. Resident 39's medical records indicated that the resident had a skin tear on the penile shaft, which was noted on 4/14/2024. The wound assessment on 4/18/2024 documented an open wound at the base of the penis. Despite the care plan's directive to use a foley catheter until the wound healed, the resident continued to use a condom catheter. This oversight was confirmed during an interview with Treatment Nurse 1, who acknowledged that the care plan should have been implemented to prevent further deterioration of the wound.
Failure to Change Nasal Cannula Tubing Weekly
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not ensuring the nasal cannula tubing was changed weekly as per the facility's policy. Resident 17, who had severe cognitive impairment and required oxygen therapy, was observed using nasal cannula tubing that had not been changed for 27 days. The tubing was not dated, and the bag containing the tubing was dated 3/27/2024. This was confirmed through observations and interviews with the resident, LVN, Infection Prevention Nurse, and the Director of Nursing, all of whom acknowledged that the tubing should be labeled and changed weekly to prevent infection. The Director of Nursing admitted that the facility did not have a policy requiring the dating of oxygen tubing to ensure it was changed every seven days, despite it being the best standard of practice. The facility's undated policy indicated that nasal cannula and oxygen tubing should be changed weekly and as needed if visibly soiled or damaged. The failure to adhere to this policy had the potential to expose Resident 17 to respiratory infections due to the prolonged use of undated and potentially contaminated oxygen tubing.
Failure to Administer Insulin Before Meals
Penalty
Summary
The facility failed to ensure that Resident 48 was free from significant medication errors by not checking blood sugar and administering insulin before meals as per the physician's order. On the specified date, Resident 48's blood sugar was checked after insulin was administered and after the resident had already consumed a portion of his lunch meal. This practice was observed during a medication pass, where the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN) noted that the blood sugar check was due at 11:30 AM, but was performed at 12:07 PM, resulting in a blood sugar reading of 245 mg/dL. The ADON stated that this reading was unreliable since it was taken after the resident had eaten, and per the physician's order, Resident 48 should have received 1 unit of insulin Lispro based on the sliding scale. Resident 48, who has diagnoses including type 2 diabetes, muscle weakness, and dementia, was admitted with severely impaired cognitive skills and required assistance with various activities of daily living. The facility's policy and procedure for administering medications, revised in April 2019, indicated that medications should be administered in a safe and timely manner as prescribed. However, the failure to check blood sugar and administer insulin before meals as ordered compromised the resident's health and safety, as confirmed by interviews with the ADON and LVN. The ADON emphasized the importance of timely medication administration to control blood sugar levels and prevent complications such as uncontrolled high blood sugar.
Inaccurate Narcotic Drug Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for three residents. For Resident 18, the narcotic drug record for amoxicillin and lorazepam was found to be inaccurate. The record did not indicate the correct number of tablets taken out from the bubble pack, and the licensed nurse mistakenly signed under the wrong medication record. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an investigation and observation of the medication cart. For Resident 41, the narcotic drug record for nitrofurantoin mono MCR was not signed off correctly. The Licensed Vocational Nurse (LVN) stated that although the medication was administered, she forgot to sign it off in the narcotic drug record. This was observed during an inspection of the medication cart, where the bubble packet was found to be empty despite the record indicating one medication left. For Resident 78, the narcotic drug record for morphine sulfate was also found to be inaccurate. The LVN admitted to administering the medication but failing to sign it off in the narcotic drug record. The bubble packet contained fewer tablets than recorded. The ADON confirmed that it is not acceptable for the narcotic count record to be unsigned, as it could lead to potential harm if the medication falls into the wrong hands. The facility's policy on controlled substances emphasizes the importance of accurate inventory monitoring and reconciliation to prevent loss or diversion.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of the sampled residents, Resident 80. Resident 80 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side. The Minimum Data Set (MDS) indicated that Resident 80 had impairments on one side of the upper and lower extremities and required moderate to maximal assistance from staff for activities of daily living. During an observation and interview, it was noted that the call light was on the floor, out of reach for Resident 80, who confirmed the inability to reach it when assistance was needed. Licensed Vocational Nurse 4 acknowledged that the call light should be within the resident's reach at all times. The Director of Nursing (DON) confirmed that the call light should be accessible to the resident while in bed for easy access, especially for assistance with toileting, hygiene, repositioning, and emergencies. The facility's policy and procedure titled 'Answering the Call Light' also indicated that the call light should be accessible to the resident from the bed, toilet, shower, or bathing facility. The failure to ensure the call light was within reach had the potential to result in Resident 80 not receiving timely assistance from the staff.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information, including the total number of staff and the actual hours worked by the staff, was posted in a visible and prominent place on 4/22/2024. During an observation on 4/22/2024 at 7:45 AM, no visible daily staffing information was found in the facility lobby. The Director of Staff Development (DSD) confirmed during an interview on 4/24/2024 that she did not post the number of licensed nurses (RNs and LVNs) and the number of unlicensed nursing personnel (CNAs) responsible for resident care on 4/22/2024, 4/23/2024, and 4/24/2024. The DSD could not recall the exact date when she stopped posting this information. The Director of Nursing (DON) stated during an interview on 4/24/2024 that she was unaware that the facility was not posting the shift staffing information, which includes the census and the total number of RNs, LVNs, and CNAs working each shift. The DON emphasized the importance of this posting for residents, visitors, and staff to ensure that the facility is staffed with the required number of nurses to deliver care in accordance with regulations. A review of the facility's policy and procedure titled 'Posting Direct Care Daily Staffing Numbers,' revised in August 2022, indicated that the facility is required to post nurse staffing data daily for each shift.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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