Montrose Springs Skilled Nursing & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montrose, California.
- Location
- 2635 Honolulu Ave, Montrose, California 91020
- CMS Provider Number
- 056322
- Inspections on file
- 40
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Montrose Springs Skilled Nursing & Wellness Center during CMS and state inspections, most recent first.
A resident with hepatic encephalopathy, dysphagia, and moderate cognitive impairment experienced a fall resulting in a forehead laceration; EMS was called and the wound was treated, but there was no documentation that the physician or family were notified of the fall and injury. Subsequently, a physician ordered ROM and ambulation with a front wheel walker three times weekly, yet the restorative treatment record showed no treatments provided over several consecutive days. The RNA stated the resident had not been feeling well and refused the exercises, but there was no documentation that the physician was informed of these refusals.
Two residents with limited English proficiency and documented preferences for interpreter services did not have person-centered care plans addressing their communication needs, despite MDS assessments and facility policies requiring identification and care planning for communication requirements. One resident with DM, muscle weakness, and colorectal cancer reported not being fluent in English and needing help to communicate needs, while another resident with hepatic encephalopathy, dysphagia, and cognitive communication deficit could not effectively express concerns, including that his television was not working and available programming was not in a language he understood. The MDS coordinator confirmed that no communication-focused care plans were developed for either resident.
A resident with DM and cognitive impairment had physician orders for Glipizide and Metformin, with fasting blood sugar checks required before breakfast and at bedtime, and instructions to notify the physician if levels were below 70 or above 400. On one morning, the ordered fasting blood sugar was not obtained or documented before the resident received the scheduled oral hypoglycemic medications. The DON confirmed the blood sugar should have been checked prior to administration and that lack of documentation indicated it was not done. This failure was inconsistent with the resident’s diabetes care plan and the facility’s medication administration policy requiring completion and recording of ordered testing, such as point-of-care blood glucose, before giving medications dependent on such results.
A resident with multiple cardiac conditions and diabetes was ordered numerous oral medications and a clonidine patch but persistently refused all medications except the patch over an extended period. The existing care plan for medication refusal contained only basic interventions such as assessing reasons for refusal, documenting refusals, encouraging compliance, and notifying the MD for complications, and it was not updated with new, specific, or measurable interventions despite continued noncompliance. IDT meetings did not reassess or address the ongoing refusals, nursing staff limited their response to repeated education and documentation, the RN supervisor did not involve the pharmacist and had minimal documented MD communication, and the administrator was unaware of the persistent refusals, contrary to the facility’s own person-centered care planning policy.
A nurse administered seven scheduled morning medications, including an antiepileptic, antihypertensive, antidepressant, vitamin D, iron supplement, stool softener, and multivitamin, to a resident more than one hour after the ordered 9:00 AM time, outside the facility’s 8:00–10:00 AM administration window. The RN supervisor reported that nurses typically have about 30 residents and roughly 5 minutes per resident for the morning med pass, which can extend beyond the 2-hour window, and the LVN involved acknowledged the medications were late due to unforeseen events on the unit, contrary to the facility’s policy requiring adherence to the “Right Time” for medication administration.
Surveyors observed that several opened dry food items in the kitchen, including powdered cheese, gelatin mix, cake mix, breadcrumbs, and coconut flakes, were not labeled with opened dates or were stored beyond recommended timeframes. The Registered Dietitian confirmed that facility policy requires labeling and timely disposal of such items, but these procedures were not followed, resulting in improper food storage practices.
A resident with significant physical and cognitive impairments was assisted with feeding by a CNA who stood over the resident instead of sitting at eye level, as required by facility policy. The CNA reported not using a chair due to its unavailability, and both the CNA and an RN confirmed that proper feeding assistance should be provided while seated to maintain resident dignity and comfort.
A resident with dementia and anxiety disorder was prescribed Ativan, a psychotropic medication, without documented informed consent as required by facility policy. Despite the resident's capacity to make decisions, staff confirmed that no signed consent form was present in either the paper or electronic health records, constituting a violation of resident rights and facility procedures.
A resident with multiple medical conditions and intact cognition repeatedly raised concerns about poor Wi-Fi connectivity affecting personal device use. Despite facility acknowledgment and some steps toward resolution, there was a lack of timely follow-up and communication with the resident, and no clear explanation for the delay in installing Wi-Fi extenders. This resulted in the resident's grievance remaining unresolved and affected their quality of life.
A resident with severe cognitive impairment and fluctuating decision-making capacity did not have an Advance Directives Acknowledgement Form or POLST present in their hard copy medical record. Multiple staff, including the SSD, RN Supervisor, and DON, confirmed the absence of these documents, despite facility policy requiring their provision and accessibility.
Two residents did not receive comprehensive, person-centered care plans following significant changes in their conditions and medication regimens. One resident with abdominal pain and moderate cognitive impairment was not provided a care plan after a change in condition, and another resident prescribed Depakote for behavioral issues did not have a care plan addressing medication use, monitoring, or side effects. Staff and leadership confirmed these omissions, which were not in accordance with facility policy.
A resident with quadriplegia and severe cognitive impairment was left without required supportive devices, such as pillows or wedges, after morning care. The resident was observed in an uncomfortable position, and staff interviews confirmed that proper positioning and support were not provided as outlined in the care plan and facility policy.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These failures resulted in a deficiency related to resident care.
A resident with severe cognitive impairment, dysphagia, and malnutrition, who required moderate assistance with eating, did not receive proper mealtime support from a CNA. The resident was left to manage a mechanical soft diet tray without necessary help, such as cutting food or ensuring items were within reach, contrary to care plan and facility policy requirements. Staff interviews and observations confirmed the lack of appropriate assistance.
The facility did not provide necessary medically-related social services to a resident, resulting in the resident not achieving the highest possible quality of life.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A deficiency was cited when it was found that a working call system was not available in each resident's bathroom and bathing area, preventing residents from being able to request assistance as needed.
Two residents experienced deficiencies in fall prevention when staff failed to follow established care plan interventions and facility policies. One resident with severe cognitive impairment was left unattended during toileting, resulting in an unwitnessed fall and injury requiring hospital treatment. In another case, after a resident's fall and readmission, there was no documentation of an IDT review as required by policy. These failures led to inadequate supervision and lack of proper post-fall evaluation.
Surveyors found that several rooms in the facility housed more than four residents per room, with some rooms containing five or six beds and being fully occupied. Although residents reported no concerns about space and rooms were equipped with necessary furniture and equipment, the facility did not comply with federal regulations limiting room occupancy.
Eighteen resident rooms were found to be below the required 80 square feet per resident in multiple occupancy rooms, as confirmed by the ADM and documented in facility records. Despite the deficiency, no concerns were raised by residents or observed by surveyors, and the facility continues to seek a waiver for these rooms.
A resident with adult failure to thrive and Alzheimer's disease was admitted with an NPO order due to inability to swallow, but the care plan did not reflect this dietary restriction. Both an RN and the DON confirmed the omission, despite facility policy requiring care plans to include physician and dietary orders within 48 hours of admission.
A resident with severe cognitive impairment and total dependence for care was subjected to rough perineal care by a CNA, resulting in pain and distress. Despite reports from the responsible party and a roommate who witnessed and heard the resident in distress, facility staff did not immediately remove the CNA from the assignment or report the incident as potential abuse. The resident's care plan interventions were not followed, and mandated reporting procedures were not implemented, leading to further distress for the resident and fear for another resident.
A resident with severe cognitive impairment and multiple medical conditions was allegedly treated roughly by a CNA during peri care, as witnessed by the responsible party and corroborated by a roommate. Despite the allegation being reported to facility staff, required notifications to CDPH, the Ombudsman, and Law Enforcement were not made within the mandated timeframe, and the CNA continued to provide care to the resident. Staff failed to recognize and escalate the incident as abuse, and the facility did not initiate an investigation or remove the CNA from duty until after law enforcement was contacted.
A resident with severe contractures and arthritis was roughly handled by a CNA during care, resulting in a fracture and hospitalization. Despite the resident's complaints and visible injuries, the facility failed to promptly report the abuse allegation or suspend the CNA. The DON initiated an investigation but did not interview the CNA or follow the facility's abuse prevention and reporting policies.
A facility failed to ensure proper discharge planning for a resident with Parkinson's Disease and Dementia, resulting in the resident not receiving necessary home health services and durable medical equipment after discharge. The Social Service Director and Case Manager did not coordinate effectively, leading to a lack of follow-up on required services and equipment.
The facility failed to complete and document the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC) for eight CNAs. The DON admitted there was no system to track performance evaluations, and CNAs could not recall their last skills assessment. A review of employee files showed no ACCC documentation, and only partial skills competencies were evidenced, contrary to facility policy.
A facility failed to inform a resident about medications before administration, violating their rights. An LVN administered medications, including laxatives, without informing the resident, who had expressed a preference against laxatives. Additionally, the facility failed to account for six doses of controlled substances for four residents, with discrepancies found in medication records. The LVN admitted to administering these medications but did not document them, violating facility policy and increasing the risk of medication errors.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.71% due to two errors affecting two residents. One resident received the wrong form of calcium, and another received a multivitamin with minerals instead of the prescribed type. LVNs acknowledged the errors, and the DON confirmed the medications were not administered as ordered.
The facility failed to remove expired medications from stock in one of its medication rooms. An open vial of Aplisol was found without a label indicating when it was opened, and 15 expired Afluria syringes were stored in the refrigerator. Interviews with staff confirmed these medications should have been discarded according to facility policies.
A kitchen staff member was inadequately trained on the proper use of sanitizer test strips, leading to incorrect testing of a QUAT sanitizer solution. The staff member initially used the wrong test strip and did not follow the correct procedure, resulting in an inaccurate reading. The issue was identified during an observation, and it was noted that the facility's training did not cover the correct testing procedure.
The facility failed to follow the prescribed portion sizes for residents on pureed and mechanical soft diets during a lunch service. Residents on a pureed diet received less chicken than required, and those on a mechanical soft diet received less zucchini. The error was due to the use of incorrect scoop sizes by the cooks, as confirmed by the RD.
Two residents with severe cognitive impairments were fed by CNAs standing over them, violating their dignity. The CNAs admitted they should have been at eye level, as confirmed by facility staff and policy.
The facility failed to ensure call lights were within reach for two residents, both with severe cognitive impairments and mobility issues. One resident had the call light tied to the bedrail, out of reach, while another had it placed on the side of the bed inaccessible to their functional hand. Staff interviews confirmed the importance of having call lights accessible, as per facility policy.
A resident with a history of hypertension, obesity, and diabetes exhibited redness in both eyes, which was not reported to the physician by the LTC facility staff. Despite the redness being observed by an LVN for several days, it was assumed to have been documented, leading to a delay in care. The facility's policy requires notifying the physician of such changes, but this was not adhered to, resulting in a deficiency.
A resident with severe cognitive impairment was left exposed during personal care when a CNA failed to pull the privacy curtain, despite the presence of a roommate. The facility's policy requires privacy to be maintained to preserve resident dignity.
The facility failed to develop comprehensive care plans for two residents, leading to potential inadequate care. One resident with multiple diagnoses, including diabetes and cataracts, had no care plan for eye redness despite physician orders. Another resident with an inguinal hernia lacked a care plan for its management, affecting his eating due to abdominal discomfort. The absence of care plans was confirmed by nursing staff and contradicted facility policy requiring updates for new problems or changes in condition.
A facility failed to update a care plan for a resident who experienced bladder incontinence after a urinary catheter was removed. The resident, with dementia and psychosis, was at risk of UTIs due to inconsistent care. Staff interviews confirmed the care plan should have been revised to address the incontinence.
A resident with morbid obesity and hemiplegia was at risk for pressure ulcers due to the facility's failure to set the Low Air Loss (LAL) mattress according to the physician's order. The mattress was set for a lower weight than the resident's actual weight, as confirmed by staff observations and interviews. This oversight could lead to skin breakdown, contrary to the facility's policy requiring proper mattress settings based on weight.
A resident with an indwelling catheter was found with the catheter unsecured and the catheter bag touching the floor, contrary to the facility's policy. An LVN confirmed the bag should not touch the floor, and the DON acknowledged the issue, stating that RNs were informed to secure the catheter and keep the bag off the floor.
The facility failed to provide proper respiratory care for two residents. One resident's nasal cannula was improperly placed, and another resident received incorrect oxygen flow and lacked proper labeling of the nasal cannula. Additionally, the second resident's oxygen saturation was not documented, and they were without oxygen for 15 minutes during ADL assistance.
A resident with arthritis and dementia experienced severe pain without proper assessment or timely medication in an LTC facility. Despite a physician's order for regular pain assessments and medication, the resident was left in distress, and the LVN failed to document or reassess pain levels. The facility's policy on pain management was not followed, leading to delayed care.
A resident with an inguinal hernia expressed a desire for surgery, but the LTC facility failed to follow up on the surgery plan, despite the resident's intact cognition and capacity to make medical decisions. The facility did not document any attempts to contact the physician or obtain necessary oncologist clearance, leading to a deficiency in care.
The facility failed to implement its infection control program effectively, leading to several deficiencies. Unlabeled urinals and wash basins were found in a shared restroom, and two residents had unlabeled urinals at their bedside tables, posing a risk of cross-contamination. Additionally, a CNA provided care to a resident with a foot wound without wearing an isolation gown, despite the resident's risk of infection. The facility lacked specific policies and procedures to ensure proper labeling and use of protective equipment.
A resident's shared bathroom in an LTC facility was found to have a non-functioning call light, which is crucial for safety and emergency communication. The resident, who requires substantial assistance due to severe cognitive impairment and limited mobility, was unaware of the issue. The Director of Staff Development confirmed the deficiency, and the Maintenance Staff noted that no reports of defective call lights were made this month, despite the facility's policy requiring immediate reporting and replacement of such issues.
The facility did not post the daily nurse staffing information in a prominent place accessible to residents and visitors. The Director of Staff Development updated the information, but the Administrator forgot to post it, resulting in outdated information being displayed. The facility's policy requires staffing data to be posted at the beginning of each shift.
The facility was found non-compliant with federal regulations limiting the number of residents per room during a recertification survey. Eight rooms exceeded the four-resident limit, with some rooms having up to six beds. The Administrator acknowledged the issue, citing room waivers, but surveyors noted potential impacts on privacy and care quality. Residents did not express concerns about room sizes during interviews.
The facility failed to meet the required 80 square feet per resident in multiple resident bedrooms, affecting 18 out of 41 rooms. Despite having room waivers, the facility's Client Accommodation Analysis showed several rooms with insufficient space. Observations indicated that care was not hindered, and no concerns were raised by the resident council.
The facility failed to treat two residents with respect and dignity by not honoring their preferences and choices regarding ADLs. One resident experienced a fall and injury after CNAs forcibly changed her diaper against her will, while another resident reported physical pain and distress from a similar incident. These actions contradicted the facility's policy on resident rights.
The facility failed to ensure that a resident's call light was within reach, despite the resident's significant medical conditions and care plan intervention. The call light was found on the floor, and the resident had to yell for assistance, which was confirmed by an LVN who acknowledged the importance of keeping call lights accessible.
A facility failed to ensure proper diabetes management for a resident with Diabetes Mellitus (DM) by not verifying discharge orders, monitoring blood sugar levels, or administering insulin. The resident was found unresponsive and later died after being diagnosed with Diabetic Ketoacidosis (DKA) and critically high blood sugar levels.
Failure to Notify Physician/Family After Fall and to Provide Ordered Restorative Therapy
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician and the responsible party after a resident sustained a fall with a resulting laceration, and failure to carry out and report refusals of ordered restorative treatments. The resident was admitted with hepatic encephalopathy, dysphagia, and a cognitive communication deficit, and an MDS dated 2/19/2026 documented moderately impaired cognition and a need for supervision or partial/moderate assistance with multiple ADLs, including toileting hygiene, bathing, dressing, eating, oral hygiene, and personal hygiene. On 2/18/2026, progress notes documented that the resident was found on the floor with a forehead cut measuring 2.0 x 0.1 cm, 911 was called, EMS determined there were no significant injuries requiring hospital transport, and the wound was cleansed and monitored. However, in the change in condition fall note for that date and time, there was no documentation that the physician or family were notified of the fall and injury. On 2/23/2026, a telephone/verbal physician order was obtained for a Restorative Nurse Assistant to perform active ROM to both upper extremities and ambulation with a front wheel walker three times weekly for three months. Review of the restorative treatment record from 2/23/2026 through 2/26/2026 showed blanks, indicating that no restorative treatments were provided during that four-day period. During interviews, the resident reported wanting to get out of bed but feeling that his legs were heavier and that he felt tired, and the RN supervisor stated the resident was being monitored for fluid retention. The RNA reported that she had not performed the ROM and ambulation treatments because the resident had not been feeling well on those days, and there was no documentation that the physician was notified of the resident’s refusals of the ordered restorative exercises.
Failure to Care Plan for Non‑English Communication Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans addressing communication needs in residents whose preferred language was not the dominant language used in the facility. For one resident admitted with diagnoses including diabetes mellitus, muscle weakness, and malignant neoplasm of the large intestine and rectum, the admission record and MDS identified a preferred non-dominant language and a desire for an interpreter to communicate with doctors and health care staff. During interview, this resident reported understanding only some English words, not being fluent, and needing assistance to communicate needs. Observation showed a RN Supervisor using another licensed nurse to translate in the resident’s primary language, and the resident stated he could not communicate his needs in English. Despite this, the MDS coordinator confirmed there was no person-centered care plan developed to address this resident’s communication limitations and need for services in the preferred language. The second resident was admitted with hepatic encephalopathy, dysphagia, and a cognitive communication deficit, and the MDS documented moderately impaired cognition and the need for supervision or assistance with multiple ADLs. Progress notes indicated this resident also needed and wanted an interpreter to communicate with doctors or health care staff. During interview conducted in the resident’s primary language, the resident stated he could not make himself understood and could not fluently understand the language spoken in the facility, and he was unable to explain to staff that his television did not work and that the only audible channel was not in a language he understood. The MDS coordinator acknowledged that, based on the MDS information, both residents should have had person-centered care plans reflecting their communication limitations and language needs, but no such care plans existed. This failure occurred despite facility policies on accommodation of residents’ communication needs and resident rights, which required identification of communication requirements, documentation of preferences, and inclusion of these needs and interventions in the plan of care.
Failure to Check Blood Glucose Prior to Administering Hypoglycemic Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with a physician’s order for monitoring blood glucose prior to administering hypoglycemic medications. A resident with diagnoses including Diabetes Mellitus, muscle weakness, and malignant neoplasm of the large intestine and rectum was admitted on 2/6/2026. The resident’s MDS dated 2/13/2026 documented moderately impaired cognition and the need for varying levels of assistance with activities of daily living. Telephone/verbal orders dated 2/7/2026 directed that the resident receive Glipizide 2.5 mg and Metformin 500 mg twice daily with meals, with fasting blood sugar checks ordered before breakfast at 6:30 AM and at bedtime at 9:00 PM, and instructions to call the physician if blood sugar was less than 70 or greater than 400. The resident’s care plan for diabetes, dated 2/7/2026, indicated the resident would be free from signs and symptoms of hypoglycemia. Review of the Medication Administration Record for 2/7/2026 showed that the fasting blood sugar ordered for 6:30 AM was not documented as completed prior to medication administration, and the DON confirmed that if it was not marked on the MAR, it was not done. The MAR further showed that the resident received Metformin 500 mg twice daily with meals and Glipizide 2.5 mg at 9:00 AM on 2/7/2026 without a recorded blood glucose check beforehand. The DON stated that the blood sugar should have been checked in the morning prior to medication administration as ordered and explained that when the order was entered, it was timed to begin at 9:00 PM and not before breakfast. The facility’s medication administration policy, revised 6/26/2025, stated that when medication administration is dependent on vital signs or testing, such as point-of-care blood glucose, the testing must be completed and recorded prior to administration, which did not occur in this instance.
Failure to Revise Care Plan for Ongoing Medication Refusal
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-centered care plan with specific, measurable objectives and interventions for a resident who persistently refused medications. The resident had multiple significant cardiac and metabolic diagnoses, including atherosclerotic heart disease, hypertensive heart disease with heart failure, cardiomyopathy, and type 2 diabetes mellitus, and was ordered 15 active medications (14 oral and 1 clonidine transdermal patch). Despite this complex regimen, the resident repeatedly refused most medications over an extended period, taking only the clonidine patch, while remaining alert, oriented, and frequently going out on pass with a family member. The resident’s care plan for medication refusal, initiated on 6/30/25 and revised on 7/29/25 and 10/14/25, contained only four original interventions: assess the reason for refusal, document refusals and actions taken, encourage medication compliance with explanation of risks and benefits, and notify the physician for complications. No new or modified interventions were added despite ongoing, documented noncompliance with medications. Physician notes over several months documented that the resident was noncompliant with blood pressure medications except the clonidine patch and remained noncompliant with medications and care despite education on risks. The electronic MAR for January 2026 showed the resident refused all medications except the clonidine patch for the entire review period. Interdisciplinary team (IDT) meeting notes showed that while the resident’s medication refusal was noted on 6/30/25, subsequent IDT meetings did not include discussion or reassessment of this issue. Nursing staff reported that when the resident refused medications, they provided education, documented the refusal, and informed the nursing supervisor, but the RN supervisor acknowledged there were no additional interventions or assessments beyond re-education and documentation. The RN supervisor also stated she had not contacted the pharmacist to investigate potential medication-related issues contributing to the refusals and had limited documented communication with the physician, with the last recorded contact several months earlier. The administrator stated she was not aware of the resident’s ongoing medication refusals. The facility’s own person-centered care planning policy required the IDT to prepare, review, and revise the comprehensive care plan and to implement interventions designed to meet resident objectives, which was not carried out in this case.
Late Administration of Scheduled Morning Medications Beyond Allowed Time Window
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered within the facility’s required time window for one resident. During an observation, an LVN was seen preparing and administering a group of seven scheduled medications for a resident, including docusate sodium 100 mg, escitalopram 10 mg, levetiracetam (Keppra) 500 mg, losartan 50 mg, a multivitamin with minerals, vitamin D3 125 mcg (5000 IU), and ferrous sulfate 325 mg. The resident was seated in a wheelchair while the LVN measured the resident’s blood pressure and then prepared and administered the medications. The administration occurred at approximately 11:00 AM, even though the medications were scheduled for 9:00 AM, placing the administration more than one hour after the scheduled time. Interviews with staff confirmed that the facility’s policy required medications to be administered within one hour before or one hour after the scheduled time, and that nurses were to follow the “Right Time” as part of the six rights of medication administration. The RN supervisor stated that morning medications were scheduled at 9:00 AM with an 8:00 AM to 10:00 AM administration window, and acknowledged that with an average assignment of 30 residents per nurse and approximately 5 minutes per resident, some medication passes could extend beyond the 2-hour window. The LVN who administered the medications acknowledged awareness that the medications for this resident were late and attributed the delay to unforeseen events on the unit. The facility’s written policy confirmed the requirement to administer medications within the ordered time window, which was not met in this instance.
Failure to Properly Label and Store Dry Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to its own policies and procedures regarding the storage and labeling of dry food items in the kitchen's dry storage area. During an observation with the Registered Dietitian (RD), several food items, including a bag of powdered cheese, gelatin mix, chocolate cake mix, breadcrumbs, and coconut flakes, were found either without an opened date or stored beyond the recommended storage period. Specifically, a bag of dried cheese powder dated 3/28/2025 was found to have exceeded its storage period, and multiple opened food items lacked labels indicating when they were opened. The RD confirmed that these items should have been dated upon opening to ensure proper rotation and timely disposal. Additionally, inconsistencies were noted between the delivery/received dates on storage bins and the individual food packages inside the bins, such as with pasta. The facility's policy requires that opened products be placed in containers with tight-fitting lids, labeled, and dated, and that stock be rotated according to specific timeframes for each product. The RD acknowledged the importance of correct dating for maintaining food quality and knowing when to discard items. These lapses in following established food storage guidelines had the potential to affect 113 out of 117 residents who receive food from the kitchen.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) provided feeding assistance to a resident while standing over the resident, rather than sitting at eye level as required by facility policy. The resident, who had contractures in both hands, dysphagia, unspecified dementia, and was on a mechanically altered, pureed, nectar thick diet, was observed lying in bed with the head of the bed elevated during the feeding. The CNA stated that a chair was not used because one could not be found, resulting in the CNA feeding the resident while standing. The CNA acknowledged that staff are expected to sit at eye level with residents during feeding to avoid making them feel rushed and to maintain dignity. Interviews with the CNA and a registered nurse confirmed that the standard practice is for staff to be seated and at eye level with residents during meals to promote communication, ensure comfort, and uphold the resident's dignity. Facility policy also requires staff to interact with residents in a manner that accommodates their physical limitations and maintains their dignity. The failure to follow these procedures during mealtime assistance for this resident constituted a lack of respect and dignity, as required by resident rights regulations.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain informed consent for the administration of a psychotropic medication, Ativan, for a resident diagnosed with dementia and anxiety disorder. The resident was assessed as having the capacity to understand and make decisions, with moderately impaired cognition noted in the Minimum Data Set. Despite a physician's order for Ativan to be administered twice daily for anxiety, a review of both the paper and electronic health records revealed that no informed consent form for the use of Ativan was present for the relevant period. Both the Medical Records staff and the Registered Nurse Supervisor confirmed the absence of the required documentation, and the Director of Nursing also verified that the consent form could not be located in the resident's records. Facility policy required that informed consent be obtained and documented before administering psychoactive medications, with written consent to be renewed every six months. The lack of a signed and dated consent form for the psychotropic medication was acknowledged by staff as a violation of resident rights and a failure to follow established procedures. The deficiency was identified through interviews, record reviews, and policy examination, all confirming that the necessary informed consent process was not completed or documented as required.
Failure to Resolve Resident Grievance Regarding Wi-Fi Connectivity
Penalty
Summary
The facility failed to promptly address and resolve a grievance raised by a resident regarding the need for Wi-Fi extenders to improve connectivity for personal devices, such as a phone and television. The resident, who had diagnoses including congestive heart failure, hypertension, and anemia, and was cognitively intact, repeatedly brought up the issue during Resident Council Meetings and directly to the administrator. Documentation showed that the facility acknowledged the request and initiated discussions with IT and maintenance, including obtaining equipment and seeking vendor quotes for installation. However, there was a lack of timely follow-up and communication with the resident about the status of the installation, and no rationale was provided to the resident for the delay. Interviews with the resident and staff confirmed ongoing difficulties with Wi-Fi connectivity, affecting both residents and staff operations. The administrator was unable to provide documentation of interactions with maintenance or evidence of follow-up with the resident regarding the unresolved grievance. The facility's policy required the administrator, as the Grievance Official, to ensure timely follow-up and provide written decisions upon request, but this process was not completed, resulting in the resident's grievance remaining unresolved and impacting the resident's quality of life.
Failure to Maintain Accessible Advance Directives and POLST in Resident Record
Penalty
Summary
The facility failed to ensure that the Advance Directives Acknowledgement Form and the Physician Orders for Life-Sustaining Treatment (POLST) were obtained and readily accessible in the hard copy medical record for one resident. During a review of the resident's admission record, it was noted that the resident had diagnoses including bipolar disorder and paranoid schizophrenia, with documentation indicating fluctuating capacity to understand and make decisions. The resident's Minimum Data Set assessment also showed severely impaired cognition. Despite these factors, both the Social Services Designee and the Registered Nurse Supervisor confirmed during interviews and record reviews that the advance directive acknowledgement form and POLST were not present in the resident's medical record. The Director of Nursing also acknowledged that these documents must be readily accessible in the resident’s hard copy medical record to guide licensed nurses in providing care according to the resident’s wishes during emergencies. The facility’s policy and procedures require that written information about advance directives be provided upon admission, but this was not reflected in the resident’s record. The absence of these critical documents was directly observed and confirmed by multiple staff members during the survey.
Failure to Develop Comprehensive Care Plans for Residents with New Conditions and Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of abdominal pain, GERD, and Type 2 Diabetes Mellitus, the facility did not create a care plan to address new onset abdominal pain, despite documentation of moderate pain and a physician's order for hospital transfer. The resident had moderate cognitive impairment and required significant assistance with daily activities. Staff interviews confirmed that a care plan should have been implemented following the change in condition, but none was created, and the facility's policy requiring care plan updates after changes in condition was not followed. Another resident, admitted with diagnoses including Type 2 Diabetes Mellitus, diabetic neuropathy, depression, and bipolar disorder, was prescribed Depakote for poor impulse control and verbal aggression. Physician orders required monitoring for medication side effects and target behaviors. However, no care plan was initiated to address the use of Depakote, its intended purpose, or the monitoring of its effectiveness and side effects. Staff interviews confirmed the absence of a care plan for this medication, despite facility policy mandating comprehensive care plans for each resident that include measurable objectives and timeframes for meeting medical, nursing, mental, and psychosocial needs. The facility's failure to develop and update care plans in response to changes in condition and new medication orders resulted in incomplete documentation and a lack of individualized interventions for the residents involved. Staff and leadership acknowledged these omissions and confirmed that facility policies and procedures were not followed in these instances.
Failure to Provide Supportive Devices for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when staff failed to provide necessary supportive devices, such as pillows or wedges, for a resident with quadriplegia and multiple sclerosis, as required by the resident's care plan and the facility's policy. The resident, who was severely cognitively impaired and dependent on staff for all mobility and positioning, was observed lying in bed with the upper and lower body facing opposite directions and without any supportive devices in place. After morning ADL care, the CNA left the room without ensuring the resident was positioned comfortably or with proper support. Interviews with the LVN and Director of Nursing confirmed that the resident was not in a comfortable or appropriate position and that supportive devices were necessary due to the resident's limited mobility and inability to reposition independently. The facility's policy required staff to maintain good body alignment and provide proper equipment to redistribute pressure and support extremities and the head, which was not followed in this instance.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Provide Adequate Mealtime Assistance for Resident Requiring Moderate Support
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to provide adequate nutritional care and services to a resident who required moderate assistance with eating. The resident, admitted with diagnoses including dysphagia, severe protein-calorie malnutrition, and dementia, was assessed as having severely impaired cognition and needing moderate assistance for activities of daily living, including eating. The care plan and physician orders specified a mechanical soft diet and interventions such as monitoring and anticipating the resident's needs. Despite these documented requirements, observations showed that the resident's breakfast tray was placed in front of her without necessary assistance, such as cutting bread into smaller pieces or ensuring all items were within reach. The resident was seen struggling to cut her food and unable to access her snack and water without help. Interviews with staff confirmed that the CNA did not provide the required assistance, such as cutting food and setting up the tray appropriately, as outlined in the resident's care plan and facility policy. The facility's policy required nursing staff to provide assistance to residents who have difficulty feeding themselves, but this was not followed in the case of this resident. The failure to provide the necessary support was directly observed and corroborated by staff interviews and record reviews.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that indicated the required social services were not made available or delivered to residents as needed. The lack of these services directly impacted the residents' ability to attain or maintain their optimal well-being.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions or inactions by staff, nor does it mention specific residents or incidents, but it clearly notes the absence or inadequacy of an infection prevention and control program.
Non-Functioning Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that residents did not have access to a functioning means to request assistance while in these locations. The report specifically notes the absence of a working call system, but does not provide additional details about individual residents, their medical history, or their condition at the time of the deficiency.
Failure to Follow Fall Management Policies and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow its own policies and procedures regarding fall prevention and management for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident with Alzheimer's disease and severe cognitive impairment, the care plan required that the resident not be left unattended during toileting. However, a CNA left the resident alone in the restroom with the door closed for privacy, contrary to the care plan. This lack of supervision led to an unwitnessed fall, resulting in a laceration to the right brow bone, abrasions, and the need for transfer to an acute care hospital for further treatment, including sutures. The facility also failed to update the resident's fall risk assessment after the incident and did not document all interventions recommended by the interdisciplinary team (IDT) following the fall. In the case of another resident with a history of sepsis, diabetes with neuropathy, and muscle weakness, the facility did not ensure that an IDT meeting was conducted after the resident sustained a fall and was readmitted to the facility. The resident was assessed as high risk for falls, and the care plan included frequent safety monitoring and fall risk precautions. Despite this, there was no documentation of an IDT meeting or review of the fall, as required by the facility's fall management policies. The absence of this review meant that the circumstances of the fall and the effectiveness of the care plan interventions were not evaluated by the IDT. Both cases demonstrate that the facility did not adhere to its established fall management programs, which require timely updates to care plans, post-fall assessments, and IDT reviews after falls. The failure to implement and document these interventions and reviews resulted in residents being left at risk for further accidents and injuries, as evidenced by the unwitnessed fall and subsequent injury in one resident and the lack of post-fall IDT review in another.
Resident Rooms Exceed Maximum Occupancy Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms accommodated no more than four residents per room, as required by federal regulations. During a recertification survey, it was observed that eight rooms contained either five or six beds, with several of these rooms fully occupied. The Client Accommodation Analysis and direct observations confirmed that these rooms exceeded the maximum occupancy limit. The surveyors noted that all rooms in question had individualized beds, bedside tables, overbed tables, and resident care equipment, and residents did not report concerns about room size or space during interviews. Despite the presence of adequate space for beds and equipment, the facility's practice of housing more than four residents per room in multiple-resident rooms did not comply with federal requirements. The facility had submitted a waiver letter and had policies in place for management to observe and ensure rooms met residents' needs without adversely affecting health and safety. However, the survey findings indicated that the number of beds and occupants in these rooms exceeded the regulatory limit, constituting a deficiency.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 18 out of 41 resident rooms met the minimum required space of 80 square feet per resident in multiple occupancy rooms. This was identified through observation, interviews, and record review during a recertification survey. The Administrator confirmed that these rooms did not meet the required square footage and stated the facility's intention to continue applying for a room waiver for these rooms. The Client Accommodation Analysis documented the specific square footage per resident for each deficient room, all of which fell below the regulatory requirement. During the survey, the rooms were observed and no immediate issues related to room size were identified. A review of the facility's Room Waiver Request Letter confirmed the ongoing deficiency and stated that the room sizes did not adversely affect residents' health and safety. Additionally, a group interview with the resident council revealed no concerns from residents regarding room sizes. The California Department of Public Health recommended continuation of the facility's room waiver.
Failure to Initiate NPO Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan reflecting a resident's current therapeutic diet order of nothing by mouth (NPO), as required by facility policy. The resident was admitted with diagnoses including adult failure to thrive and Alzheimer's disease, and a physician's order was in place for NPO status due to the resident's inability to swallow food or medications. Despite this, a review of the resident's active care plans showed no documentation or care plan addressing the NPO order. Interviews with both a registered nurse and the Director of Nursing confirmed that the resident's NPO status was not included in the care plan, even though the resident was at high risk for aspiration if given food or fluids by mouth. The facility's policy required that a comprehensive, person-centered care plan, including physician and dietary orders, be developed and implemented within 48 hours of admission, but this was not done for the resident in question.
Failure to Protect Resident from Physical Abuse During Perineal Care
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) was observed by a resident's responsible party (RP) being rough during perineal care, causing the resident to experience pain and distress. The RP reported the incident to the facility's Infection Preventionist (IP) nurse, who then informed a licensed vocational nurse (LVN). Despite this report, the CNA continued to be assigned to the resident for the remainder of the shift and the following day. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to effectively communicate her needs or discomfort due to a language barrier and her medical condition. The resident's care plan required staff to be gentle, explain procedures, and not rush care, but these interventions were not followed during the incident. On the following day, the RP again found the resident in distress, and the resident's roommate, who spoke the same language, reported hearing the resident screaming in pain while the CNA performed care. The CNA did not stop or seek assistance despite the resident's verbalizations of pain. The roommate expressed feeling scared and uncomfortable after witnessing the incident. Other staff members, including the LVN and registered nurse (RN), did not immediately recognize the rough care as potential abuse, did not report the incident to the abuse coordinator or administrator, and did not remove the CNA from caring for the resident until later in the day. Documentation and mandated reporting procedures were not followed at the time of the initial and subsequent complaints. The resident's medical history included traumatic subdural hemorrhage, type 2 diabetes, and major depressive disorder, with documentation indicating severe cognitive impairment and total dependence for mobility and personal care. The facility's policies required prompt reporting and investigation of abuse allegations, as well as protection of residents' rights and dignity. However, the failure to act on the initial and subsequent reports of rough care resulted in the resident being subjected to further distress and pain, and another resident experiencing fear and discomfort.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH), the Ombudsman, and Law Enforcement within two hours of an allegation of abuse, as required by both regulation and the facility's own policy. The allegation involved a certified nurse assistant (CNA) being rough during perineal care with a resident who was cognitively impaired and unable to make decisions. The responsible party (RP) observed the incident, reported it to the facility's Infection Preventionist (IP) nurse, and later to a registered nurse (RN), but the required notifications to authorities were not made until approximately 33 hours after the initial report. The CNA in question continued to be assigned to the resident after the allegation was reported, contrary to facility policy which requires immediate suspension of the accused staff member pending investigation. Documentation and interviews confirmed that the CNA provided care to the resident on both the day of the incident and the following day. The facility did not initiate an investigation or remove the CNA from resident care until after law enforcement was contacted by the RP and arrived at the facility. Multiple staff members, including the IP nurse, LVN, and RN, failed to recognize the incident as a reportable allegation of abuse and did not escalate or document the concern appropriately. The resident involved had a history of traumatic subdural hemorrhage, type 2 diabetes, and major depressive disorder, and was assessed as severely cognitively impaired and dependent for activities of daily living. The incident was witnessed by the RP and corroborated by the resident's roommate, who reported hearing the resident in distress and screaming during care. Despite these observations and the resident's inability to advocate for herself, the facility did not follow its own policies for reporting, investigation, and protection of the resident from further potential abuse.
Failure to Prevent and Investigate Abuse Leads to Resident Injury
Penalty
Summary
The facility failed to implement its policy and procedure to prevent, protect, report timely, and thoroughly investigate any allegation of abuse for a resident who reported rough handling by a certified nursing assistant (CNA) during activities of daily living. The resident, who had severe contractures and required careful handling, sustained an acute impacted fracture of the left upper arm, which was displaced, causing unbearable pain and discomfort, leading to hospitalization. The resident had a history of hypertension, weakness, polyarthritis, muscle wasting, and atrophy, and was admitted to the facility with these diagnoses. The resident's care plan indicated the need for careful handling to prevent trauma to the joints, but the CNA dismissed the resident's request for gentler care. The resident reported that the CNA was rough, ignored his pleas for gentleness, and handled him forcefully, causing significant pain. The resident's roommate corroborated the account, stating that the CNA handled the resident roughly and did not seek assistance from other staff. Despite the resident's complaints and visible injuries, the facility did not promptly report the abuse allegation or suspend the CNA involved. The Director of Nursing (DON) initiated an investigation but failed to interview the CNA or suspend him from work immediately. The facility's policy and procedure on abuse prevention and reporting were not followed, as the incident was not reported to the Department of Public Health in a timely manner, and the resident's allegation of abuse was not included in the Facility Reported Incident. The facility's failure to adhere to its policies resulted in the resident's injury and subsequent hospitalization.
Failure in Discharge Planning and Coordination
Penalty
Summary
The facility failed to provide appropriate discharge planning and assistance for a resident's safe discharge by not ensuring that home health services and durable medical equipment (DME) were arranged and confirmed for delivery prior to the resident's discharge. The resident, who had diagnoses including Parkinson's Disease, Dementia, and Difficulty in Walking, required substantial assistance with daily activities and was supposed to be discharged with home health services for physical and occupational therapy, medication management, and specific DME including a front-wheeled walker and a compact wheelchair. Interviews revealed a lack of coordination and communication among the facility's staff. The Social Service Director discussed discharge planning with the family but was not responsible for arranging home health services. The Case Manager, who was responsible for coordinating with the insurance company for authorizations, did not request or follow up on the necessary services and equipment. The Administrator confirmed that both the Social Service and Case Manager were responsible for ensuring discharge readiness and arrangements. As a result, the resident did not receive the required rehabilitation therapy or DME after being discharged home.
Failure to Complete and Document CNA Competency Assessments
Penalty
Summary
The facility failed to provide evidence that the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC) were completed for eight sampled CNAs. The Director of Nursing (DON) acknowledged that there was no system in place to track the CNAs' performance evaluations, which should have included a spreadsheet listing all active CNAs with their hire dates and last ACCC dates. Interviews with CNAs revealed that they could not recall when their last annual skill competencies were evaluated, indicating a lack of consistent assessment and training. During a review of the CNAs' employee files, no ACCC documentation was found for the sampled CNAs. The DON confirmed that only partial evidence of skills competencies, such as showering/bathing and donning and doffing gloves, was available, which did not account for the complete annual skills checks required. The facility's policy stated that competency assessments should be retained in employee files, but this was not adhered to, leading to a deficiency in ensuring CNAs' skills and competencies were up to date.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide the name and indication of medications to a resident before administration, affecting one of the seven residents observed for medication administration. During an observation, a Licensed Vocational Nurse (LVN) administered 11 medications, including two docusate sodium tablets, to a resident without informing them of the medication names and their purposes. The resident expressed a preference not to receive laxatives that morning, but the LVN had already administered the docusate tablets. The LVN acknowledged forgetting to inform the resident, which is a violation of the resident's rights to be informed and make decisions about their medication regimen. Additionally, the facility failed to account for six doses of controlled substances for four residents, leading to discrepancies in the medication accountability records. During an inspection of a medication cart, it was found that doses of oxycodone with acetaminophen, Lacosamide, lorazepam, and clonazepam were missing from the medication bubble packs compared to the counts on the Individual Narcotic Record accountability logs. The LVN admitted to administering these medications but failed to document the administrations on the accountability logs, which is against the facility's policy. The Director of Nursing confirmed that the LVN should have informed the resident of the medication details and that the failure to document controlled substance administrations could lead to potential medication errors and diversion. The facility's policies require immediate documentation of controlled substance administrations to ensure accountability and prevent errors. The failure to adhere to these policies resulted in a violation of resident rights and increased the risk of medication errors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.71% due to two medication errors out of twenty-four opportunities. These errors affected two residents during medication administration. One resident received a different form of calcium than what was prescribed by their physician, while another resident received a multivitamin with minerals instead of the prescribed multivitamin without minerals. During observations, it was noted that a Licensed Vocational Nurse (LVN) administered the incorrect multivitamin to a resident, and another LVN administered calcium with Vitamin D instead of the prescribed calcium without Vitamin D. These actions were confirmed through interviews with the LVNs, who acknowledged the errors and recognized them as medication errors. The Director of Nursing also confirmed that the medications were not administered as ordered by the physicians. The residents involved had specific medical conditions that required precise medication management. One resident had a history of kidney disease and was prescribed calcium for hypocalcemia, while the other resident had hypomagnesemia and was prescribed a multivitamin. The facility's policies and procedures for medication administration emphasize the importance of administering medications as prescribed, but these were not followed in these instances, leading to the medication errors.
Expired Medications Not Removed from Stock
Penalty
Summary
The facility failed to properly manage and dispose of expired medications in one of its medication rooms, specifically Medication Room Station 1 South West. During an observation, an open vial of Aplisol, used for tuberculosis diagnosis, was found in the refrigerator without a label indicating when it was opened, contrary to the manufacturer's guidelines which require it to be used or discarded within 30 days of opening. Additionally, 15 prefilled syringes of the Afluria influenza vaccine, which expired on June 30, 2024, were found stored in the refrigerator. These medications were not removed from stock as required by the facility's policies. Interviews with the LVN and the DON revealed that the lack of labeling on the Aplisol vial made it impossible to determine its expiration, and the expired Afluria syringes should have been discarded to prevent accidental use. The facility's policies stipulate that expired medications should be immediately removed from stock and stored in a designated area for disposal. The failure to adhere to these policies increased the risk of administering ineffective or potentially harmful medications to residents.
Inadequate Training of Kitchen Staff on Sanitizer Use
Penalty
Summary
The facility failed to ensure that a kitchen staff member, identified as Dishwasher 1 (DW 1), was routinely trained and evaluated for competency in their duties. During an observation, DW 1 was found using a chlorine sanitizer test strip in a quaternary ammonium (QUAT) sanitizer solution, which is incorrect. The test strip did not change color, indicating a lack of understanding of the proper procedure. The Dietary Supervisor (DS) intervened, providing the correct test strip and instructing DW 1 on the proper method, which involves immersing the strip for 10 seconds. Initially, DW 1 dipped the strip for only one second, resulting in no color change. Upon following the correct procedure, the sanitizer was found to be at an acceptable concentration of 200 parts per million (PPM). Further investigation revealed that the facility's in-service training did not include instructions on testing sanitizer solutions, and the dishwasher's job description emphasized maintaining a safe and sanitary environment. The Registered Dietitian (RD) confirmed that the QUAT solution should be at least 200 PPM and noted a recent change in the test strip product, which may have contributed to the confusion. The manufacturer's instructions for the QUAT sanitizer test strips clearly stated the need for a 10-second immersion to obtain an accurate reading, highlighting a gap in staff training and competency evaluation.
Deficiency in Adhering to Prescribed Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for residents on pureed and mechanical soft diets during the lunch service on 7/9/2024. Specifically, 12 residents on a pureed diet received 4 ounces of chicken oregano instead of the required 5 and 1/3 ounces, and 46 residents on a mechanical soft diet received 2 and 2/3 ounces of zucchini instead of the prescribed 4 ounces. This discrepancy was observed during the tray line service, where the cooks used incorrect scoop sizes, leading to the serving of smaller portions than indicated in the facility's food portion and serving guide. Interviews with the cooks revealed that they mistakenly used smaller scoops, resulting in the under-serving of chicken and zucchini. The Registered Dietician (RD) confirmed the error and emphasized the importance of following the menu and spreadsheet to ensure residents receive the correct portions to meet their nutritional needs. The facility's policy and procedure on menus, revised in 2014, mandates adherence to the written menu to meet the nutritional requirements set by the food and nutrition board of the national research council.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity and respect for two residents during meal assistance. Certified Nursing Assistants (CNAs) were observed standing over the residents while feeding them breakfast, which violated the residents' rights to dignity and respect. Resident 16, who was severely cognitively impaired and required substantial assistance with eating, was fed by CNA 1 while lying in bed with the head elevated. Similarly, Resident 80, who also had severe cognitive impairment and required moderate assistance with eating, was fed by CNA 3 in the same manner. Both CNAs acknowledged that they should have been at eye level with the residents to maintain their dignity. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nurses (DON), confirmed that the CNAs should have been seated at eye level with the residents during feeding to uphold their dignity. The facility's policy on resident rights emphasizes care that promotes dignity and prohibits demeaning practices. The observations and interviews indicate a failure to adhere to these standards, compromising the residents' dignity during meal times.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, as required by the facility's policy and procedure. Resident 357, who has major depression, aphasia, and Parkinsonism, was observed with the call light tied to the right bedrail, out of reach. Despite the care plan indicating the need for the call light to be within easy reach, the resident was unable to use it to call for assistance. The Director of Nursing acknowledged the importance of having the call light accessible to the resident. Similarly, Resident 26, who has Parkinsonism, hypertensive heart disease, diabetes, and right hemiparesis, was found with the call light attached to the right upper corner of the bed, inaccessible to the resident's functional left hand. The care plan for Resident 26 also required the call light to be within easy reach, especially given the resident's fall risk and communication deficit. The Licensed Vocational Nurse and Occupational Therapist both confirmed that the call light should be accessible to the resident's left hand. The facility's policy, dated 1/1/2012, mandates that call cords be placed within the resident's reach to enable them to alert nursing staff. The failure to adhere to this policy for both residents was confirmed through observations and interviews with staff, including the Director of Nursing, who emphasized the necessity of having the call light within reach to accommodate residents' needs and ensure their safety.
Failure to Report Change in Condition for Resident's Eye Redness
Penalty
Summary
The facility failed to report a significant change in condition for a resident, identified as Resident 48, who exhibited redness in both eyes. This deficiency was identified through observation, interview, and record review. Resident 48, who has a medical history including hypertension, obesity, type 2 diabetes mellitus with diabetic nephropathy, and bilateral age-related cataract, was observed with reddened eyes. Despite the redness being noted by staff, it was not reported to the attending physician in a timely manner, resulting in a delay in receiving necessary care and treatment. On the morning of the incident, Resident 48 was observed with redness in the sclera of both eyes and reported that the redness had been present since the previous morning. The resident expressed discomfort and a need for eye drops, which had not been administered. Licensed Vocational Nurse (LVN) 6 acknowledged noticing the redness for two to three days but did not report it, assuming it had already been documented. LVN 3, responsible for the resident's care on the day shift, did not assess the eyes, as assessments were scheduled weekly, and no report was received from the Certified Nurse Assistant (CNA). Interviews with the Director of Nurses (DON) and Registered Nurse (RN) 2 confirmed that the redness should have been reported to the physician for monitoring and potential intervention. The facility's policy on Change in Condition Notification requires notifying the attending physician of any sudden and marked adverse change in a resident's condition. However, this protocol was not followed, leading to a delay in addressing the resident's eye condition.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident during personal care. A certified nurse assistant (CNA) was observed cleaning a resident without clothes in their room without pulling the privacy curtain, leaving the resident exposed. This incident occurred while the resident's roommate was present, further compromising the resident's privacy. The CNA admitted to forgetting to pull the curtain, which is a necessary step to ensure privacy during such procedures. The resident involved had severe cognitive impairment and required substantial assistance with personal hygiene. The facility's policy mandates that privacy must be provided to all residents, including those who are cognitively impaired, to preserve their dignity. Interviews with the registered nurse and the director of nurses confirmed that the privacy curtain should have been used to prevent exposure and maintain the resident's dignity, as outlined in the facility's policy on resident rights and quality of life.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential inadequate care. Resident 48, who was readmitted with multiple diagnoses including hypertension, obesity, type 2 diabetes with diabetic nephropathy, and bilateral cataracts, was observed with redness in both eyes. Despite having physician orders for eye health and artificial tears, there was no care plan addressing the intervention for the eye redness. The lack of a care plan was confirmed by RN 2 and the Director of Nurses (DON), who acknowledged the importance of a care plan to communicate necessary interventions and monitor the resident's condition. Similarly, Resident 99, admitted with an inguinal hernia and weight loss, did not have a care plan for the management of the hernia. The resident, who had intact cognition, reported abdominal discomfort affecting his eating. RN 1 confirmed the absence of a care plan for the hernia, and the DON stated that a care plan should have been in place. The facility's policy requires care plans to be updated with new problems or changes in condition, which was not adhered to in these cases.
Failure to Update Care Plan for Resident's Incontinence Post-Catheter Removal
Penalty
Summary
The facility failed to review and revise a resident-centered care plan for a resident, identified as Resident 93, who experienced occasional bladder incontinence following the removal of a urinary catheter. The comprehensive care plan, initially developed upon admission and revised months later, did not address the resident's incontinence after the catheter was removed. This oversight resulted in inconsistent care and services for the resident, who was at risk of urinary tract infections. Resident 93 was admitted with diagnoses including dementia and psychosis, and had a urinary catheter due to urinary retention. The care plan aimed to prevent urinary infections and trauma related to catheter use. However, after the catheter was removed, the care plan was not updated to reflect the resident's incontinence. Interviews with facility staff, including a registered nurse and the Director of Nurses, confirmed that the care plan should have been revised to include interventions for the resident's incontinence, but this was not done.
Failure to Set LAL Mattress Correctly for Resident
Penalty
Summary
The facility failed to implement appropriate care and services to prevent the development of pressure ulcers for a resident, identified as Resident 15, by not ensuring the Low Air Loss (LAL) mattress was set according to the physician's order. The physician had ordered the LAL mattress to be set at a level suitable for a body weight of 275 pounds, but it was observed to be set at a level for 150 pounds, which was too soft for the resident's actual weight of 281 pounds. This discrepancy was noted during observations and interviews with facility staff, including a Certified Nursing Assistant and the Director of Staff Development, who acknowledged the incorrect setting. Resident 15 had a history of morbid obesity and hemiplegia following a cerebral infarction, with severely impaired cognitive skills requiring substantial assistance for daily activities. The facility's policy required that air mattresses be set according to the resident's weight and checked routinely to ensure proper functioning. However, the LAL mattress was not set correctly, potentially putting the resident at risk for skin breakdown. The Director of Nursing confirmed the physician's order and the resident's weight, acknowledging that the mattress setting was incorrect and could lead to discomfort and failure to prevent skin breakdown.
Failure to Secure Indwelling Catheter and Maintain Hygiene Standards
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, which is a flexible tube inserted into the bladder for continuous urinary drainage. The deficiency was identified when the catheter was observed to be unsecured and the catheter bag was touching the floor. This was noted during an observation and interview with an LVN, who acknowledged that the urinary bag should not be in contact with the floor, even if the bed is in a low position. Another LVN confirmed that the catheter tubing should be anchored to the resident's leg to prevent pulling or dislodgement. The Director of Nurses (DON) was interviewed and acknowledged the issue, stating that they had spoken to the RNs about securing the catheter and ensuring the urinary bag is kept off the floor. The facility's policy on catheter care, dated June 10, 2021, specifies that the catheter should be anchored to prevent excessive tension and that the catheter tubing, bag, or spigot should not touch the floor. This failure to adhere to the policy placed the resident at risk for potential accidental dislodgement of the catheter and urinary tract infection.
Deficient Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide proper oxygen therapy and necessary respiratory care services for two residents, Resident 31 and Resident 50. For Resident 31, who was using a nasal cannula for continuous oxygen therapy, the device was improperly placed on the resident's right cheek instead of the nostrils. This was observed during a general observation and confirmed by a Licensed Vocational Nurse (LVN) who noted the nasal cannula was not correctly positioned. The Director of Nursing (DON) acknowledged that the nasal cannula should have been properly placed to ensure effective oxygen treatment as ordered by the physician. For Resident 50, the facility failed to label the nasal cannula with the date of the last change, as required by the physician's order. Additionally, Resident 50 was observed receiving oxygen at 4 liters per minute (LPM) instead of the prescribed 2 LPM. The lack of proper labeling and incorrect oxygen flow rate were confirmed by LVN 3 and the DON. Furthermore, Resident 50's oxygen saturation and respiratory rate were not documented on the day of observation, and the resident was found without oxygen for 15 minutes during assistance with activities of daily living (ADL), which led to fluctuating oxygen saturation levels. The facility's policy and procedure for oxygen therapy, issued in November 2017, indicated that oxygen should be administered per physician orders under safe and sanitary conditions. However, the observations and interviews revealed that the facility did not adhere to these procedures, resulting in deficiencies in the respiratory care provided to Residents 31 and 50.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 65, who was observed experiencing pain without being assessed or reassessed according to the facility's policy. Resident 65, who has a history of arthritis, muscle wasting, osteoarthritis, and dementia, was admitted with a physician's order to assess pain every shift and administer Methocarbamol for knee and leg pain. However, on the evening shift of 7/9/2024, there was no documented evidence of a pain assessment, and the resident was observed in distress, calling for help and holding her knees. During an interview, Resident 65 reported severe pain, rated 10/10, but the Licensed Vocational Nurse (LVN) in charge did not administer pain medication early due to concerns about the resident's psychiatric medication schedule. The LVN did not assess the resident's pain or reassess after administering the scheduled pain medication. The Registered Nurse (RN) and Director of Nurses (DON) later confirmed that the LVN should have assessed and documented the resident's pain and attempted non-pharmacologic interventions before administering medication. The facility's policy requires licensed nurses to assess pain upon admission, quarterly, and when there is a new onset or exacerbation of pain. It also mandates reassessment within one hour after administering pain medication. The failure to follow these procedures resulted in delayed care for Resident 65, potentially affecting her well-being and healing process.
Failure to Follow Up on Resident's Surgery Plan
Penalty
Summary
The facility failed to provide medically-related social services for a resident diagnosed with an inguinal hernia, which led to a deficiency in care. The resident, who was admitted with a history of inguinal hernia and weight loss, expressed a desire to proceed with surgery. Despite having intact cognition and the capacity to make medical decisions, the facility did not follow up on the resident's surgery plan. The resident's medical records indicated a pending surgery consult and a need for clearance from oncology, but there was no documented evidence of the facility's attempts to contact the physician or follow up on the surgery after an initial note on 4/17/2024. Observations and interviews revealed that the resident experienced abdominal discomfort, affecting their ability to eat, and repeatedly expressed a desire for surgery. Staff, including RNs and the DON, acknowledged the resident's wish for surgery but cited the need for oncologist clearance as a barrier. The facility's policies on referrals and resident rights emphasize the coordination of outside services and honoring residents' medical choices, but these were not effectively implemented in this case, resulting in the resident's medical choice not being honored and potential discomfort due to the delay in surgery.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program effectively, as evidenced by several deficiencies observed during a survey. In one instance, a shared restroom for Room A, which accommodates six residents, was found to have an unlabeled urinal and three rectangle wash basins placed on top of the toilet reservoir tank. A Certified Nursing Assistant (CNA) admitted to using the urinal for emptying a resident's urinary catheter drainage bag without knowing the ownership of the wash basins. The Infection Prevention Nurse (IPN) and the Director of Nurses (DON) acknowledged the importance of labeling and dating urinals and wash basins to prevent cross-contamination, although the facility lacked a specific policy for this practice. Additionally, the facility failed to ensure that urinals at the bedside tables of two residents were labeled with their names and the date of first use. Both residents had moderately impaired cognitive status and required assistance with daily activities. During an observation, a CNA noted the presence of unlabeled urinals with urine at the bedside tables of these residents, acknowledging that they should have been emptied, labeled, and dated to prevent infection. Interviews with nursing staff confirmed that unlabeled urinals could lead to bacterial growth and cross-contamination, posing an infection control issue. Furthermore, the facility did not ensure that staff used appropriate protective equipment when providing care to a resident with a foot wound. A CNA was observed assisting the resident without wearing an isolation gown, despite the resident's risk of infection due to a diabetic foot ulcer. The IPN confirmed that enhanced barrier precautions, including the use of gowns and gloves, should be employed during high-contact care activities for residents with wounds. However, the facility did not have a system to input enhanced barrier precaution orders in residents' medical records, leading to a lack of adherence to infection control protocols.
Non-Functioning Call Light in Resident's Bathroom
Penalty
Summary
The facility failed to provide a functioning call light in the shared bathroom of a resident, identified as Resident 357. This deficiency was discovered during an observation and interview with the resident, who was found to be awake, alert, and able to respond to questions. The resident, who has diagnoses including major depression, aphasia, and Parkinsonism, and requires substantial assistance with activities of daily living, was unaware that the call light was not working. The resident expressed that having a working call light in the bathroom is important for safety in case assistance is needed. Further investigation revealed that the Director of Staff Development confirmed the non-functioning call light and emphasized its importance for resident safety. The Maintenance Staff (MS) stated that monthly checks are conducted on call lights, but no reports of defective call lights were made this month. The facility's policy requires that defective call lights be reported and replaced immediately, highlighting a lapse in adherence to this policy. The last entry in the facility's Nurse Call System logbook was dated prior to the observation, indicating a potential gap in monitoring and maintenance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This deficiency was identified during an observation and interview with the Director of Nurses (DON) and the Administrator (ADM). The DON stated that the Director of Staff Development (DSD) was responsible for updating and posting the staffing information daily in a designated area. However, during an observation, it was found that the staffing information posted was dated the previous day. The ADM admitted that although the DSD had updated the staffing information and left a printout in the DSD's office, the ADM forgot to post it. According to the facility's policy, the staffing data should be updated and posted at the beginning of each shift, before 6 AM, to ensure accessibility to all residents and visitors.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with federal regulations regarding the maximum number of residents per room, as observed during a recertification survey. Specifically, eight out of 41 rooms were found to accommodate more than the allowed four residents per room. Rooms 2, 19, 23, 26, and 39 each had five beds, while other rooms had six beds, with varying numbers of residents occupying them. This arrangement potentially compromised the residents' privacy and the quality of care and safety due to inadequate space for nursing care and emergency services. During the survey, the facility's Administrator acknowledged the situation, stating that the facility had room waivers approved by the Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirements. Despite the waivers, the surveyors noted that the rooms did not meet the federal requirement of no more than four beds per resident room. However, during a resident council interview, no concerns were raised by the residents regarding room sizes. The facility's room waiver letter indicated that the rooms had adequate space for nursing care and that multiple beds per room would not adversely affect the residents' health and safety.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident care areas in multiple resident bedrooms met the required 80 square feet per resident, as mandated by regulations. This deficiency was identified in 18 out of 41 resident rooms during a recertification survey. The facility's administrator acknowledged the issue and stated that the facility had room waivers approved by the Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirements. The facility planned to continue applying for these waivers. The Client Accommodation Analysis submitted by the facility indicated that several rooms did not meet the required square footage per resident, with some rooms having as little as 51.1 square feet allocated per resident. Despite the deficiency, observations during the survey indicated that the size of the rooms did not interfere with the care and services provided by the staff. Residents were observed to have adequate space for their beds, dressers, and care equipment. Additionally, during a group interview with the resident council, no concerns were raised regarding room sizes. The facility's waiver request letter stated that the arrangement of the rooms provided adequate space for nursing care and did not adversely affect the health and safety of the residents.
Failure to Honor Resident Preferences and Dignity
Penalty
Summary
The facility failed to treat two residents with respect and dignity by not honoring their preferences and choices regarding activities of daily living (ADL). Resident 2, who was admitted with a diagnosis of depressive disorder and adult failure to thrive, required partial to moderate assistance with personal hygiene. Despite care plans indicating that staff should not rush the resident and should explain all necessary procedures, Resident 2 experienced a fall during care when two CNAs forcibly changed her diaper against her will. This incident led to Resident 2 sustaining a bump on her head and being sent to the hospital for further evaluation. Resident 2 reported feeling upset and dehumanized by the experience, stating that the CNAs held her down and ignored her pleas to stop, which ultimately led to her fall while trying to retrieve her personal belongings from the floor using a grabber tool. Resident 3, who was admitted with a diagnosis of heart disease and muscle weakness, also experienced a lack of respect and dignity in her care. Despite a care plan that emphasized not rushing the resident and allowing her to complete tasks at her own pace, an unnamed CNA entered her room early in the morning, removed her covers, and forcibly changed her diaper without her consent. Resident 3 reported that the CNA's actions caused her physical pain and distress, as the CNA did not honor her requests to stop. This behavior was corroborated by an LVN who stated that residents have the right to refuse care and that their wishes must be honored. The facility's policy and procedure on resident rights, which was revised in 2012, indicated that staff should provide all residents with kindness, respect, and dignity, and honor their exercise of rights. The policy also emphasized encouraging residents to participate in planning their daily care routines, including ADLs. However, the actions of the CNAs in both cases directly contradicted these guidelines, leading to the deficiencies observed by the surveyors.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 4, who had significant medical conditions including Hemiplegia, Hemiparesis, and Parkinsonism. Resident 4 required substantial assistance with activities of daily living and had fluctuating capacity to understand and make decisions. During an observation, the call light was found on the floor, out of reach for Resident 4, who stated that she had to yell to get the attention of staff when she required assistance. This was confirmed by a licensed vocational nurse (LVN) who acknowledged the importance of keeping call lights within reach and stated that it was the responsibility of the facility staff to ensure this. A review of Resident 4's care plan indicated an intervention to keep the call light within easy reach, which was not followed. The facility's policy on the call system also emphasized the importance of providing a mechanism for residents to promptly communicate with nursing staff. The failure to adhere to this policy and the care plan intervention resulted in a deficiency that could delay necessary assistance for Resident 4.
Failure to Ensure Proper Diabetes Management for Resident
Penalty
Summary
The facility failed to ensure that a resident with Diabetes Mellitus (DM) received appropriate treatment and care in accordance with professional standards of practice. Upon admission from a General Acute Care Hospital (GACH), the facility did not verify all discharge orders for diabetes management with the attending physician. The resident, who had a history of DM and was receiving insulin prior to admission, did not have orders for blood sugar monitoring or insulin administration upon arrival at the facility. This oversight persisted throughout the resident's six-day stay at the facility, during which the resident's blood sugar levels were not monitored, and no insulin was administered despite the resident's known condition and previous treatment regimen at the GACH. The resident's care plan included instructions to monitor for signs and symptoms of hypoglycemia and hyperglycemia, but there was no documented evidence that this monitoring occurred. The Medication Administration Record (MAR) showed that the resident was administered Sitagliptin daily, but there were no records of blood sugar monitoring or any communication with the physician regarding the need for such monitoring. On the sixth day, the resident was found unresponsive and was transferred to the GACH via 911, where they were diagnosed with Diabetic Ketoacidosis (DKA) and had a critically high blood sugar level of 823 mg/dL. The resident was admitted to the ICU, where they received an insulin drip and vasopressin but ultimately expired six days later. Interviews with facility staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that there was a lack of communication and verification of the resident's diabetes management orders upon admission. The DON and other staff members acknowledged that there were no orders to monitor the resident's blood sugar or administer insulin, and they did not take steps to verify these orders with the attending physician. The facility's policies and procedures for diabetic care, admission, and physician orders were not followed, leading to the resident's critical condition and subsequent death.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
