Mountain Manor Senior Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 6101 Fair Oaks Boulevard, Carmichael, California 95608
- CMS Provider Number
- 555889
- Inspections on file
- 25
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Mountain Manor Senior Residence during CMS and state inspections, most recent first.
A resident re-admitted with hypovolemic shock and muscle weakness, and with intact cognition per BIMS, had a hospital order for metoprolol 100 mg BID. When the order was transcribed into the facility’s EMR, an LPN incorrectly entered the dose as 200 mg BID, and the MAR reflected this error, documenting administration of a 200 mg dose. The NP later confirmed the correct dose should have been 100 mg BID and noted that an incorrect dose could worsen low BP and cause dizziness or a fall, while the DON confirmed the transcription error, which was inconsistent with facility policies requiring accurate documentation and medication administration per prescriber orders.
A resident with acute respiratory failure and hydration issues did not receive IV therapy in accordance with professional standards, as the physician's order for a one-time IV bolus lacked clarification on infusion duration, and LNs failed to document key aspects of IV therapy, including insertion details, site assessments, pharmacy communication, and administration times. These deficiencies were confirmed by the DON and were not in line with facility policy or nursing regulations.
A resident with severe cognitive impairment and a history of wandering was not consistently monitored for proper placement and functionality of their alarm bracelet, as required by physician orders and facility policy. Documentation in the MAR and TAR did not show that checks were performed every shift or daily, and staff confirmed the lack of monitoring and documentation.
A resident with diabetes received rapid-acting insulin before eating, contrary to the physician's order to administer the medication with meals. Both the nurse and the resident confirmed the insulin was given prior to the meal, and facility policy requires medications to be administered as ordered, particularly regarding timing with meals.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with dementia, depression, and anxiety was prescribed trazodone for insomnia, but the care plan did not address sleep issues or the new medication. Both a nurse and the DON confirmed the absence of a care plan for insomnia, despite facility policy requiring comprehensive care plans for all identified needs.
A resident with vascular dementia developed a bruise on the right cheek, and although a physician ordered monitoring every shift, the care plan was not updated to reflect this change in condition. Staff interviews and record reviews confirmed that the care plan lacked necessary revisions and did not include the new monitoring interventions as required by facility policy.
Surveyors identified multiple failures in food safety and sanitation, including an unclean ice machine, damaged kitchen equipment, improper food labeling and storage, spoiled produce, and inadequate monitoring and cleaning of the resident food refrigerator and freezer. These deficiencies were confirmed by dietary and maintenance staff and were not in accordance with facility policies or professional standards.
The facility did not ensure accurate documentation and accountability of controlled substances, including missing entries on the MAR for two residents who received hydrocodone/APAP, incomplete shift-to-shift controlled drug count records due to missing nurse signatures, and incomplete documentation of narcotic removal from the emergency kit. These failures were confirmed by staff and were not in accordance with facility policies.
Surveyors found that multi-dose medications were not labeled with open or discard dates, prescription medications lacked pharmacy labels to identify the intended resident, and expired drugs were present in storage. Medications with different administration routes were stored together, and loose pills were not properly disposed of. Staff interviews confirmed these practices were inconsistent with facility policy and manufacturer instructions.
Two dietary aides were unable to accurately describe or perform the correct manual dishwashing procedures, including proper wash, rinse, sanitize steps, water temperatures, and sanitizer immersion times, despite having been marked as competent and trained. This failure had the potential to affect all residents receiving food from the kitchen due to improper sanitation of dishware.
The facility did not adhere to prescribed therapeutic diet menus and portion sizes, resulting in residents on CCHO diets receiving incorrect desserts, residents on fortified diets not receiving required fortified foods, and residents on large portion diets being served less protein than specified. These failures were confirmed by dietary staff and were not in accordance with the facility's menu spreadsheets and diet manual.
The facility did not implement Enhanced Barrier Precautions for several residents with wounds, indwelling medical devices, or infections, as required by policy, and failed to provide appropriate signage and PPE. Additionally, a CNA was observed distributing meal trays to multiple residents without performing hand hygiene between each, contrary to facility protocols.
Four residents experienced ongoing discomfort and sleep disruption due to excessive noise from staff and hallway activity, including yelling and loud conversations, with some residents resorting to using blankets or privacy curtains to reduce the impact. Despite complaints and a facility policy emphasizing comfortable noise levels, staff actions and inactions led to a persistently noisy environment.
A resident with dementia, depression, and anxiety was prescribed trazodone for insomnia, but staff and the DON confirmed that no care plan was developed to address the resident's sleep issues or trazodone use, contrary to facility policy requiring comprehensive, measurable care plans.
A resident with vascular dementia developed a bruise on the right cheek, which was documented and monitored per physician order, but the care plan was not updated to reflect this change in condition. Both nursing staff and the DON confirmed the care plan should have been revised according to facility policy.
A nurse administered calcium carbonate to a resident without clarifying an unclear physician's order regarding the correct dosage. The nurse gave one 500 mg tablet, though the order referenced 1250 mg, and later acknowledged the need for clarification. The DON confirmed that staff are expected to clarify unclear orders, in accordance with facility policy.
A resident with chronic respiratory failure and a language barrier was care planned to use a communication board for effective communication. Despite this, staff were unable to locate or use the communication board during care, making communication difficult and not following the resident's care plan.
A resident with an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath was observed receiving only 1 L/min, despite still experiencing symptoms. This was confirmed by a nurse, and the DON stated that staff are expected to follow physician orders accurately.
The QAA committee did not include the Medical Director as a required member during a quarterly QAPI meeting, as confirmed by review of meeting records and facility policy.
A resident was prescribed and administered levofloxacin for a UTI despite having no symptoms and only asymptomatic bacteriuria on lab results. The antibiotic was started based solely on a hospital urinalysis, without clinical justification, contrary to the facility's Antibiotic Stewardship policy.
A resident with congestive heart failure was transferred to the hospital multiple times without being provided the required written bed hold notification. Documentation was incomplete or missing for each transfer, with no evidence that the bed hold policy was communicated or acknowledged as required by regulation.
A resident with cognitive impairment and a history of falls eloped from the facility unaccompanied, resulting in a fall and complaints of pain. The resident, assessed as a moderate risk for wandering, left during a time when staff were attending to another resident. The facility's elopement policy lacked specific preventive interventions.
A resident with heart problems was moved to a new room without advance notice or consent, violating their rights. The facility's policy requires prior notification and consent, but no documentation was found in the resident's medical record. The move was discussed in a morning meeting, but the resident was informed abruptly and left confused about the change.
The facility failed to maintain food safety standards, with issues including an unclean ice machine, spoiled tomatoes in storage, improperly stored metal pans, staff personal items in food storage, and a dusty juice dispenser. The CDM and RD acknowledged these deficiencies, which were against facility policies.
The facility did not replace two opened emergency drug kits in the medication room, as required by policy. E-kit #53, containing controlled medications, and e-kit #49, containing oral medications, were accessed multiple times but not replaced by the pharmacy. The ADON confirmed that staff should have ensured replacement with the next delivery, as the pharmacy delivers twice daily.
Two residents experienced medication errors, leading to a facility error rate of 5.41%. One resident received an incorrect dose of famotidine, while another did not receive their prescribed metoprolol succinate due to a pharmacy delivery issue. The facility's policies for medication administration were not followed, resulting in these errors.
A survey found multiple deficiencies in medication storage and labeling at a facility. Six inhalers lacked open dates, two insulin vials were expired, and expired glucometer solutions were found, risking inaccurate readings. Blister packs were misplaced, and loose pills were discovered in a medication cart. The ADON acknowledged these issues, confirming the need for proper labeling and storage.
The facility did not follow the therapeutic diet menu during a lunch service, affecting five residents. Residents on a CCHO diet received a full serving of dessert instead of half, and a resident on a mechanical soft diet was served a salad with croutons, contrary to dietary guidelines. The CDM and RD acknowledged these errors, which were not in line with the facility's dietary policies.
The facility failed to complete the MDS Admission Assessment within the required 14 days for two residents. One resident with dementia had their assessment completed 28 days after admission, while another with altered mental status had theirs completed 26 days post-admission. The DON acknowledged the late submissions, which did not comply with the facility's policy.
A facility failed to create a comprehensive care plan for a resident with end-stage renal disease who required dialysis. Despite the resident's admission records indicating dependence on dialysis and scheduled treatments, there was no care plan addressing her dialysis needs. Staff confirmed the absence of a care plan, which is required by the facility's policy to meet residents' needs.
A resident with a tibial plateau fracture was observed wearing a leg/knee immobilizer without a physician's order. The PT confirmed the need for the immobilizer, but the order was missing from the records. The ADON admitted forgetting to document the order after hospital clarification, violating the facility's policy on recording verbal orders.
A resident with dementia had long, dirty fingernails, which were not addressed by the facility staff. The CNAs noticed the issue but failed to inform the Licensed Nurse or Activities Aide, and no nail care plan was initiated despite the resident's self-care deficiency. The facility's policy on daily nail cleaning was not followed, increasing the risk of infection.
A resident with muscle weakness and physical debility did not receive the prescribed treatment to float her heels while in bed, as observed during a facility survey. Despite an active order to prevent skin breakdown, the resident's feet were not floated, and this was confirmed by a licensed nurse. The ADON emphasized the expectation for staff to follow physician orders and document any refusals.
A resident with cataracts and syncope was not provided with necessary prescription eyeglasses, despite documented need in her assessment. Staff interviews confirmed the oversight, with the Social Worker failing to facilitate referrals for the eyeglasses. The facility's policy requires social services to coordinate such referrals based on resident needs.
The facility failed to ensure two residents were free from unnecessary medications. A resident was prescribed an anti-anxiety medication without a stop date, despite a recommendation to include one. Another resident was given an antibiotic for recurring UTIs without a specified duration, even though the last UTI was documented two years prior. Both cases violated the facility's policies on medication orders.
A CNA in a COVID-19 unit failed to wear a face shield or goggles while assisting a COVID-19 positive resident, despite facility policy and visible signage requiring such PPE. The CNA wore an N-95 mask, gown, and gloves, but did not fully comply with the infection control protocols. Interviews with staff confirmed the PPE requirements, and the facility's policy outlined the necessity of these measures.
The facility did not post daily staffing information at the beginning of each shift for a census of 38 residents. Staffing details were not posted over the weekend and were delayed during weekdays, contrary to the facility's policy requiring posting within two hours of the day shift start. This was confirmed by the Staffing Coordinator and Assistant Director of Nursing.
Several residents on therapeutic diets did not receive the correct menu items or portion sizes as prescribed, including those on CCHO and fortified diets who were served incorrect desserts or missed fortified foods, and others who received less protein than required. These failures were confirmed by dietary staff and had the potential to compromise nutritional status.
Medication Transcription Error Leads to Incorrect Metoprolol Dose
Penalty
Summary
The facility failed to ensure that metoprolol was administered according to physician orders for one resident. The resident was re-admitted in February 2026 with hypovolemic shock and muscle weakness, and had an MDS BIMS score of 13/15, indicating intact cognitive function. Hospital physician orders dated 2/18/26 directed that the resident was to receive metoprolol 100 mg twice daily. However, when the orders were transcribed into the facility’s electronic medical record on 2/18/26, the metoprolol dose was incorrectly entered as 200 mg to be given twice daily. The resident’s MAR for 2/18/26 reflected the incorrect order, stating “Metoprolol 100 mg, give 200 mg two times a day,” and documented that one 200 mg dose was administered on 2/19/26 at 8 a.m. An LPN confirmed administering the 200 mg dose, and another LPN acknowledged making a medication error during transcription of the hospital physician orders by entering 200 mg instead of 100 mg twice daily. The NP stated the resident was supposed to receive 100 mg twice daily and that an incorrect dose could further exacerbate the resident’s low blood pressure and lead to dizziness or a fall. The DON confirmed that the metoprolol order had been transcribed incorrectly and stated that nursing staff should enter physician orders as written. Facility policies required that documentation in the medical record be complete and accurate and that medications be administered in accordance with prescriber orders.
Failure to Clarify and Document IV Therapy Orders and Administration
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for a resident who had acute respiratory failure with hypoxia and hydration problems due to nausea and vomiting. Specifically, the physician's order for a one-time IV bolus was not clarified to specify the infusion duration, and licensed nurses did not thoroughly document all aspects of the IV therapy. This included missing documentation of the date and time of IV insertion, the IV catheter gauge, IV site assessment results, and the resident's response to the therapy. Additionally, the licensed nurses did not document when the physician's order was faxed to the pharmacy or whether the pharmacy received the order, which was necessary to ensure timely delivery of IV supplies. There was also a lack of documentation regarding the start and end times of the IV bags administered, including the IV bolus. These documentation gaps were confirmed during interviews and record reviews with the Director of Nursing, who acknowledged that the orders should have been clarified and that all aspects of IV therapy should have been properly recorded. A review of the facility's policy and procedure for IV therapy staff responsibilities indicated that verification and clarification of physician orders, notification of pharmacy, and documentation of all aspects of IV therapy are required. The Nursing Practice Act Rules and Regulations also outline the responsibilities of nursing staff in administering medications and therapeutic agents as ordered by a physician. The failure to follow these standards resulted in incomplete documentation and unclear communication regarding the resident's IV therapy.
Failure to Monitor and Document Alarm Bracelet Checks for High-Risk Resident
Penalty
Summary
A resident with Alzheimer's disease, dementia, and major depressive disorder, who was assessed as high risk for wandering and elopement, was observed wearing an alarm bracelet intended to alert staff if the resident attempted to leave the facility unattended. The resident's care plan and physician's orders required that the alarm bracelet be checked for placement every shift and for functionality every day shift. However, a review of the Medication Administration Record (MAR) and treatment administration records (TAR) for the relevant month showed no documentation that these checks were being performed as ordered. Interviews with facility staff, including a licensed nurse and the Director of Staff Development, confirmed that there was no evidence the alarm bracelet was being monitored for placement or functionality as required. Both staff members acknowledged the importance of these checks to ensure the device was working properly. The facility's policy on safety and supervision also required that interventions to reduce accident risks, such as monitoring safety devices, be implemented correctly and consistently. The lack of documentation and monitoring represented a failure to follow professional standards of practice, facility policy, and physician orders.
Insulin Administered Prior to Meal in Violation of Physician Order
Penalty
Summary
A resident with a diagnosis of diabetes mellitus and an intact cognitive status, as indicated by a BIMS score of 15, was admitted to the facility and had an active physician's order for rapid-acting insulin aspart to be administered subcutaneously with meals according to a sliding scale. On the day in question, a licensed nurse checked the resident's blood sugar, which was 167, and administered 1 unit of insulin aspart before the resident had eaten lunch. Both the nurse and the resident confirmed that the insulin was given prior to the meal, and lunch was not served until later. Facility policy requires that medications, including insulin, be administered in accordance with physician orders and within specified time frames, particularly for medications ordered to be given with meals. The Director of Staff Development confirmed that staff are expected to follow physician orders for insulin administration and acknowledged that the insulin was administered too early, not in accordance with the order. The facility's policies on medication and insulin administration were reviewed and supported the requirement for timing insulin with meals.
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 notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Develop Comprehensive Care Plan for Insomnia and Medication
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including dementia, depression, anxiety, and a personal history of other mental and behavioral disorders. The resident had a physician's order for trazodone to be administered at bedtime for insomnia, but the care plan did not address the resident's sleep issues or the use of trazodone. During interviews and record reviews, both a licensed nurse and the Director of Nursing confirmed that there was no specific care plan developed for the resident's sleep or insomnia. The facility's policy requires that a comprehensive care plan with measurable objectives and timetables be developed and implemented for each resident to address their physical, psychosocial, and functional needs. Despite this policy, the care plan for the resident in question did not include interventions for insomnia or the newly ordered medication, resulting in a failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Plan to Monitor Performance: 1. Medical Records will audit each resident for complete care plans after admission, when new orders are received, and quarterly to ensure completeness. Any missing care plans will be provided to staff to correct. A record of the audits will be provided to the DON to review and present to the quarterly QA committee. If needed, further corrective action will be created and implemented. All corrective action will be completed by 5/26/25. F 656
Failure to Update Care Plan After Resident Sustained Bruising
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in condition, specifically the development of a bruise on the right cheek. The resident, who had a diagnosis of vascular dementia, was admitted in April 2025. Documentation showed that on 4/17/25, the resident sustained facial bruising, and a physician's order was issued on 4/18/25 to monitor the discoloration every shift. Despite these events, the resident's care plan was not updated to reflect the new condition or the required monitoring interventions. Interviews with facility staff confirmed that the expectation was to update the care plan whenever a resident experienced a change in condition. A review of the care plan on 4/23/25 revealed that it did not include information about the bruising or the monitoring order. The facility's policy also required care plans to be revised as residents' conditions changed, but this was not followed in this instance.
Plan Of Correction
Plan to Monitor Performance: 1. Medical Records will audit all SBARs and COC reports to ensure that care plans are updated per this POC. Any missing or unrevised care plans will be presented to the DON and nurse responsible to be corrected. A record of the audits will be reported to the DON. 2. The Director of Nursing will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months. The QAPI committee will evaluate the effectiveness of interventions and make changes as needed until substantial compliance is achieved and maintained. The facility will complete all corrective action with F657 by 5/26/25.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, and distributed in accordance with professional standards of food service safety. Observations revealed that the ice machine was not properly cleaned, with visible yellow-orange, pink, black, and yellow substances that could be wiped away, and rough surfaces inside the machine. The maintenance supervisor confirmed these findings and stated that cleaning was performed monthly, but the presence of residues indicated inadequate cleaning. The registered dietitian and facility policies confirmed that the ice machine should be cleaned and sanitized according to manufacturer instructions to prevent microbial contamination. Further deficiencies were observed in the maintenance and sanitation of kitchen equipment and food storage practices. The blade of the can opener was found to be chipped and worn, and nonstick cooking pans had significant scratches on their surfaces, both of which could lead to physical contamination of food. Multiple food items in refrigerators, dry storage, and the walk-in freezer were inconsistently dated, with some items lacking opened or used by dates, and some being past their manufacturer’s use-by dates. Opened food packages were not properly resealed, and thawing meat was not labeled with a pull date. Produce items, including tomatoes and oranges, were found to be spoiled with visible mold, and the certified dietary manager confirmed that staff had not been checking vegetables as required. Additional issues were identified with the resident food refrigerator, where the freezer section was not clean and lacked a thermometer for temperature monitoring. Temperature logs were incomplete, with missing entries for several days and incorrect temperature recordings for the freezer. The infection preventionist confirmed these findings and acknowledged that the charge nurse was responsible for monitoring temperatures. Facility policies required that refrigerators and freezers be kept clean, monitored, and maintained at appropriate temperatures, but these procedures were not followed, contributing to the overall deficiency.
Failure to Accurately Account for and Document Controlled Substances
Penalty
Summary
The facility failed to ensure accurate accountability and documentation of controlled substance medications for its residents. For two residents who had physician orders for hydrocodone/APAP, the Controlled Drug Record (CDR) indicated that doses were removed from the medication cart, but these administrations were not documented on the Medication Administration Record (MAR). This discrepancy was confirmed during interviews with the Director of Nursing (DON), who stated that nurses were expected to document every pill removed and administered, as outlined in the facility's policies. Additionally, the facility did not consistently obtain signatures from both the off-going and on-coming nurses on the controlled drug shift-to-shift count records for two medication carts. Review of these records revealed multiple missing signatures for various shifts, which was acknowledged by nursing staff and the DON. Facility policy required both nurses to count and sign for controlled medications at each shift change to ensure accountability. Furthermore, the removal of a narcotic medication from the emergency kit (e-kit) was not fully documented. During an inspection, a narcotic e-kit was found with a log indicating a tramadol tablet had been removed, but the date and time of removal were not recorded. Both the Infection Preventionist/Interim Staff Development and the DON confirmed that staff were expected to complete the log in full, in accordance with facility policy.
Plan Of Correction
Plan to Monitor Performance: 1. The DSD will monitor the controlled drug records at each cart to ensure they are signed by the outgoing and incoming nurses properly. Checks will be done daily for 1 month and then weekly for the next 4 months to ensure continued compliance. 2. The DON will audit emergency kit logs weekly for 4 weeks, then monthly for 3 months to ensure complete documentation. 3. Random controlled substance reconciliation audits will be conducted by the Consultant Pharmacist during monthly visits. The Director of Nursing will report audit findings to the Quality Assurance and Performance Improvement (QAPI) committee quarterly for review and recommendations. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained. All corrective action to be completed by 5/26/25.
Medication Labeling, Storage, and Expiration Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices during observations and interviews. Several multi-dose medications, including Tubersol, blood glucose test strips, and budesonide inhalation solution, were found opened and not labeled with the date of opening or discard date, despite manufacturer instructions and facility policy requiring such labeling. Additionally, expired medications such as ceftriaxone were present in storage areas, and some medications lacked pharmacy labels to identify the intended resident, including insulin pens, Sea Aloe supplement, and nitroglycerin tablets. Further inspection of medication carts revealed that prescription medications with different routes of administration, such as transdermal patches and oral medications, were stored together, contrary to facility policy. Loose pills were also found in medication drawers, and staff confirmed these should have been disposed of properly. Inhalers and other medications with limited stability after opening were not labeled with opened dates, as required by manufacturer guidelines and facility procedures. Interviews with staff, including the Infection Preventionist and a licensed nurse, confirmed awareness of the labeling and storage requirements, but acknowledged the deficiencies observed. The Director of Nursing also confirmed that medications should be labeled with at least the resident's name and that expired or loose medications needed to be removed and disposed of. Facility policies reviewed by surveyors supported these requirements for proper labeling, storage, and disposal of medications.
Plan Of Correction
Corrective Action for Affected Residents: On 4/21/25, the following immediate actions were taken: All corrective action to be completed by 5/26/25 F 761 F 761
Dietary Staff Lacked Competency in Manual Dishwashing Procedures
Penalty
Summary
The facility failed to ensure that two dietary aides were able to safely and effectively carry out the functions of the food and nutrition service, specifically regarding the manual dishwashing process using two-compartment sinks. During interviews, both dietary aides were unable to accurately verbalize the correct steps for manual dishwashing, including the proper sequence of wash, rinse, sanitize, and air-dry, as well as the required water temperatures and immersion times for sanitizing. One aide incorrectly stated the steps and was unsure about the necessary water temperature and sanitizer immersion time, while the other aide described using a large bucket as a third compartment and reported an insufficient immersion time of one to two seconds. Both aides had previously been checked off as competent in this procedure and had attended an in-service training on the topic. The Certified Dietary Manager and Registered Dietitian confirmed that staff responsible for dishwashing should have a thorough understanding of the manual dishwashing process, especially in situations where the dishwashing machine is unavailable. Review of facility policies indicated the correct procedure, including specific water temperatures and a 60-second immersion in sanitizer, which was not followed or understood by the aides. The deficiency had the potential to affect all 45 residents who received food from the kitchen, as the aides' lack of knowledge could compromise the safety and sanitation of dishware.
Failure to Follow Therapeutic Diet Menus and Portion Requirements
Penalty
Summary
The facility failed to follow prescribed therapeutic diets as outlined in their menu spreadsheets during lunch meal services. On two separate occasions, residents on Consistent Carbohydrate (CCHO) diets received incorrect desserts: three residents were served pineapple Bavarian cream square instead of pineapple tidbits, and another resident received pudding instead of the specified CCHO dessert. These discrepancies were confirmed by both the Certified Dietary Manager (CDM) and the Registered Dietitian (RD), who stated that the menu and spreadsheet should have been followed to ensure residents received the correct items for their dietary needs. Additionally, during another meal service, fifteen residents on fortified diets did not receive the required super soup, and two residents on large portion diets were served three ounces of meat instead of the prescribed four ounces. The facility's menu spreadsheets and diet manual specified the correct items and portion sizes for these diets. Both the CDM and RD acknowledged these failures during interviews, confirming that the meals provided did not match the ordered diets as required by facility policy and resident care plans.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement infection control practices for multiple residents, specifically by not initiating Enhanced Barrier Precautions (EBPs) for residents with wounds, indwelling medical devices, or infections. Several residents were identified as having conditions such as chronic wounds, PICC lines, wound vacs, MRSA infections, and other indwelling devices, all of which required EBPs according to facility policy. Observations and interviews confirmed that there was no EBP signage posted, and personal protective equipment (PPE) was not made available outside or inside the rooms of these residents, despite physician orders and policy requirements. Staff interviews, including those with licensed nurses and the Infection Preventionist (IP), confirmed that EBPs were not implemented as required for residents with wounds, indwelling devices, or infections. The IP and Director of Nursing (DON) acknowledged that the facility's EBP policy was not followed, and that residents who should have been on EBPs were not provided with appropriate signage or PPE. This lapse was observed across multiple residents, each with specific medical needs that warranted EBPs, such as open wounds, wound vacs, PICC lines, and active infections. Additionally, a Certified Nurse Assistant (CNA) was observed passing lunch trays to several residents without performing hand hygiene between residents. The CNA admitted to not following hand hygiene protocols, and the IP confirmed that staff were expected to perform handwashing or sanitizing between serving meals. The facility's hand hygiene policy required the use of alcohol-based hand rub or soap and water before and after handling food or assisting residents with meals, but this protocol was not followed during the observed meal service.
Failure to Maintain Comfortable Noise Levels for Residents
Penalty
Summary
The facility failed to maintain a comfortable noise level for four residents, resulting in decreased comfort and disrupted sleep. Observations and interviews revealed that staff frequently left room doors open at night, and certified nursing assistants often yelled to each other across hallways during care, contributing to excessive noise. Residents with insomnia and partially intact memory reported difficulty falling asleep and staying asleep due to the persistent noise, which included loud talking, laughing, and screeching by staff during both day and night shifts. One resident resorted to covering their head with a blanket to muffle the noise, while another used privacy curtains to reduce the sound from the hallway. Residents consistently described the environment as loud and disruptive, with noise issues persisting despite occasional temporary improvements after complaints. The facility's own policy emphasized the importance of maintaining comfortable noise levels to support a homelike environment, but staff actions and inactions, such as failing to close doors and engaging in loud conversations, directly contributed to the deficiency. The DON acknowledged that residents needed a calm environment for rest and healing, yet the facility did not prevent ongoing noise disturbances.
Plan Of Correction
MOUNTAIN MANOR SENIOR RESIDENCE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. MOUNTAIN MANOR SENIOR RESIDENCE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes MOUNTAIN MANOR SENIOR RESIDENCE's written credible allegation of compliance for the deficiencies noted. F 584 F 584 F 584
Failure to Develop Care Plan for Insomnia and Trazodone Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including dementia, depression, anxiety, and a history of other mental and behavioral disorders. The resident had a physician's order for trazodone to be administered at bedtime for insomnia. Upon review of the resident's medical record and care plans, both a licensed nurse and the Director of Nursing confirmed that there was no specific care plan addressing the resident's sleep issues or insomnia, despite facility policy requiring measurable objectives and timetables to meet each resident's needs.
Failure to Update Care Plan After Resident Sustained Bruising
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in condition, specifically a bruise to the right cheek. The resident, who was admitted with vascular dementia, sustained facial bruising as documented in the SBAR Communication Form and Progress Note. Following this incident, a physician's order was issued to monitor the discoloration on the resident's right cheek every shift. Despite these documented changes and the facility's policy requiring care plans to be updated as residents' conditions change, the care plan for this resident was not revised to reflect the new injury. Both a licensed nurse and the Director of Nursing confirmed during interviews that the expectation was to update the care plan after such changes, but this was not done in this case.
Failure to Clarify Unclear Medication Order Prior to Administration
Penalty
Summary
Licensed Nurse 2 (LN 2) failed to clarify a physician's order for calcium carbonate before administering the medication to a resident. During a medication pass, LN 2 prepared and gave one tablet of 500 mg calcium carbonate, despite the physician's order indicating 'calcium carbonate 1250 (500 Ca) mg, give one tablet by mouth two times a day.' LN 2 acknowledged that the order was unclear and should have been clarified with the physician prior to administration to ensure the correct dosage was given. The Director of Nursing (DON) confirmed that nursing staff are expected to clarify unclear orders with the physician and that nurses should contact the doctor whenever in doubt. The facility's medication administration policy also requires staff to consult the attending physician or medical director if a dosage is believed to be inappropriate or excessive. The failure to clarify the order resulted in the resident receiving a potentially incorrect dosage of medication.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with a communication barrier due to language. The resident, admitted with chronic respiratory failure, was assessed as having no memory problems and communicated only in Russian. The care plan specified the use of a communication board to facilitate communication between staff and the resident. However, during multiple observations and interviews, it was found that the communication board was not available in the resident's room, and staff were unable to effectively communicate with the resident without it. Staff, including a licensed nurse and a social worker, confirmed the absence of the communication board and acknowledged the difficulty in communicating with the resident as a result. The Director of Nursing also confirmed that the care plan required the use of a communication board and emphasized its importance for providing appropriate care. A review of facility policy indicated that communication boards should be provided for non-bilingual staff to communicate with residents who have language barriers, but this was not implemented for the resident in question.
Plan Of Correction
The DSD or designee (in conjunction with Social Services) will conduct daily audits of residents requiring communication boards for 2 weeks, then weekly for 1 month, and monthly thereafter to ensure devices are present and properly utilized. The Social Services Director will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee quarterly for 2 quarters or until substantial compliance is achieved and maintained. The QAPI committee will make recommendations for additional interventions or modifications as needed. All corrective action will be completed by 5/26/25.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of anxiety disorder was not provided respiratory care services in accordance with the physician's order. The physician had ordered oxygen to be administered at two liters per minute via nasal cannula as needed for shortness of breath. However, during an observation, the resident was found receiving oxygen at only one liter per minute while still experiencing shortness of breath. This discrepancy was confirmed by a licensed nurse, who acknowledged that the oxygen concentrator was set below the ordered rate. The Director of Nursing stated that the expectation was for nurses to follow the physician's order accurately to ensure proper care. A review of the facility's policy on oxygen administration also indicated the need to verify the physician's order, including the rate of oxygen flow.
Plan Of Correction
All corrective action will be completed by 5/26/25.
QAA Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included all required members, specifically the Medical Director (MD), for a census of 45 residents. During a review of the facility's quarterly Quality Assurance and Performance Improvement (QAPI) meeting records, it was confirmed by the Administrator that the MD did not attend the QAPI meeting held in April 2024. The sign-in sheet for the meeting did not include the MD's name or signature, despite facility documentation and policy indicating that the MD is a required member of the QAA committee.
Antibiotic Prescribed Without Clinical Indication
Penalty
Summary
A resident was admitted to the facility without a diagnosis of urinary tract infection (UTI) and had a hospital urinalysis and culture that showed asymptomatic bacteriuria, with no symptoms or clinical indications for antimicrobial treatment. Despite this, an order for levofloxacin, an antibiotic, was initiated for the resident for chronic UTI and UTI prophylaxis, and the medication was administered over a period of several days. The resident did not exhibit any UTI symptoms such as painful or frequent urination, strong urine odor, or fever during their stay at the facility. The Infection Preventionist confirmed that the antibiotic was started based solely on the hospital urinalysis result, without supporting clinical symptoms. Facility policy on Antibiotic Stewardship requires that laboratory results and current clinical situations be communicated to the prescriber to determine if antibiotic therapy should be modified or discontinued. In this case, the policy was not followed, as the antibiotic was prescribed and administered without adequate clinical or laboratory findings to justify its use.
Plan Of Correction
5. All corrective action will be completed by 5/26/25.
Failure to Provide Bed Hold Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide proper bed hold notification to a resident who was transferred to the hospital on three separate occasions. Documentation review showed that the required written notice regarding the bed hold policy was not present in the resident's chart for any of the transfers. Specifically, there was no evidence of a completed bed hold notification form, no date or time of notification, no name of the person who provided the notification, and no indication of whether the bed hold was accepted or declined. Additionally, there was no signature from the resident or their representative to confirm that the notification was given. The resident involved had a diagnosis of congestive heart failure and was admitted to the facility in 2025. The resident was transferred to the hospital on three occasions, but in each instance, the facility did not provide the required written information about the bed hold policy as outlined in their own policy and federal regulations. Interviews with medical records staff confirmed the absence of proper documentation and notification for each transfer event.
Resident Elopement and Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent the elopement of a resident who was admitted with cognitive impairment, dementia, difficulty in walking, and a history of falling. The resident, who had a severe cognitive impairment score and was assessed as a moderate risk for wandering, left the facility unaccompanied. The incident occurred when the resident, who was in a wheelchair but able to ambulate with assistance, was left in the hallway for better visibility. During a time when the nursing staff was attending to another resident with a change of condition, the resident managed to wheel himself to the door and ambulate across the street to a neighboring facility. The resident was found lying on the ground by a passerby and complained of neck and knee pain, stating he had hit his head. The facility's policy on elopements, dated 2007, was reviewed and found to lack specific interventions to prevent such incidents. The administrator confirmed that the resident had no prior incidents of attempting to leave the facility and that staff had been monitoring him closely due to his fall risk. However, the lack of adequate supervision and preventive measures led to the resident's elopement and subsequent fall.
Resident Moved Without Advance Notice or Consent
Penalty
Summary
The facility failed to honor a resident's right to receive advance notice before a room change, resulting in a violation of the resident's rights. The resident, who was admitted in the spring of 2024 with heart problems and was his own responsible party, was moved to another room without prior notification or consent. On the day of the move, the resident was informed abruptly by a staff member and was left confused about the reason for the move, the location of the new room, and the identity of the new roommate. The resident expressed that he did not consent to the room change and suspected it might be due to a conflict with a staff member. The facility's policy, revised in May 2027, requires advance notice and consent for room changes, including an explanation of the reason for the move and an introduction to the new roommate. However, there was no documented evidence in the resident's medical record that such notice or consent was obtained. The Social Service Director confirmed that the room change was discussed during an Interdisciplinary Team meeting on the morning of the move, but no prior consent was documented. The Administrator acknowledged that the room change should have been discussed with the resident beforehand, and the Social Service Director verified the lack of documentation regarding the resident's consent or notification.
Food Safety Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain food safety standards in several areas, as observed during a survey. The ice machine in the kitchen was found to have black and pink substances at the bottom of the ice evaporator unit and pink slimy substances on the water curtain. The Certified Dietary Manager (CDM) and the Registered Dietitian (RD) acknowledged the need for more frequent cleaning to prevent bacterial growth. The facility's Ice Machine Sanitation Log indicated that the last cleaning was done a month prior, and the manufacturer's manual emphasized the importance of regular cleaning to prevent slime and mold. In the dry storage area, 11 out of 15 tomatoes were found with black and white indented spots, indicating spoilage. The CDM confirmed the tomatoes were rotten and should be discarded. The RD also stated that produce should be fresh and checked daily for spoilage. The facility's policy on storing produce highlighted the need to discard spoiled items to prevent further spoilage. Additional deficiencies included several metal pans being stored while still wet and containing food debris, which the CDM confirmed was against the facility's policy of air-drying and cleaning pans before storage. Personal belongings of staff were found in the dry storage area, contrary to the facility's policy. Lastly, the juice dispenser was observed to have significant dust on the vent, which the RD acknowledged needed cleaning to prevent bacterial growth.
Failure to Replace Emergency Drug Kits
Penalty
Summary
The facility failed to maintain pharmacy services for its residents, as evidenced by two opened emergency drug kits in the medication room that were not replaced by the pharmacy according to the facility's policy. During an inspection, it was observed that e-kit #53, containing controlled medications, was accessed on 5/29/24, and e-kit #49, containing oral medications, was accessed on 5/30/24, 6/1/24, and 6/2/24. Despite these kits being used, they were not replaced by the pharmacy, which was confirmed by Licensed Nurse 1 during an interview. The Assistant Director of Nursing acknowledged that the failure to replace the e-kits could result in certain drugs not being available when needed. The ADON confirmed that the staff should have followed up with the pharmacy to ensure the e-kits were replaced with the next delivery, as the pharmacy delivers medications twice daily. The facility's policy, dated 4/2007, states that medications used from the emergency kit must be replaced upon the next routine drug order, which was not adhered to in this instance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two errors identified during the observation of medication administration. For one resident, a licensed nurse administered famotidine, a medication for heartburn and stomach acid reflux, incorrectly by giving only one 10 mg tablet instead of the prescribed two tablets totaling 20 mg. This discrepancy was noted during a medication pass, and the nurse was unable to account for the incorrect pill count. The facility's policy requires medications to be administered according to physician orders, with a triple-check system to ensure accuracy, which was not adhered to in this instance. In another case, a resident did not receive their prescribed dose of metoprolol succinate, a medication for high blood pressure, because it was not available. The nurse discovered the absence of the medication during the administration process and contacted the pharmacy, which had failed to deliver the medication due to a packaging error. The facility's policy mandates that medications be available as prescribed, but this was not ensured, leading to the medication error. These incidents resulted in a medication error rate of 5.41%, exceeding the acceptable threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. Six metered-dose inhalers were found in Medication Cart A without open dates, which is crucial for determining their expiration once opened. The inhalers included medications such as umeclidinium, vilanterol, fluticasone furoate, and budesonide, all of which have specific post-opening expiration periods. Licensed Nurse 1 and the Assistant Director of Nursing (ADON) acknowledged the oversight, with the ADON confirming that open date labels should have been applied to prevent the use of expired medications. Additionally, two expired insulin vials were discovered in the medication refrigerator. The vials of insulin glargine and lispro had surpassed their expiration dates, which should have been 28 days post-delivery due to the lack of cold storage during delivery. The ADON confirmed the expiration and acknowledged that the vials should have been removed from active storage. Furthermore, expired glucometer control solutions were found in Medication Cart A, which could lead to inaccurate glucometer readings for residents. The ADON confirmed the expiration and the potential impact on resident care. The survey also revealed prescription medication blister packs lodged in the rear gap of Medication Cart A, which could result in missed medication doses for residents. Loose pills were also found in the cart, indicating a lack of orderly storage. The ADON acknowledged these issues, confirming that medication storage areas should be kept clean and organized to prevent such occurrences. The facility's policies on medication storage and administration were reviewed, highlighting the requirement for proper labeling and the prohibition of using outdated or deteriorated drugs.
Dietary Menu Non-Compliance During Lunch Service
Penalty
Summary
The facility failed to adhere to the therapeutic diet menu during a lunch service, affecting five residents. Four residents on a consistent carbohydrate (CCHO) diet, intended for diabetes management, received a full serving of fruit mix crumble cake instead of the prescribed half serving. Additionally, a resident on a small portion diet also received a full serving of the dessert, contrary to the dietary guidelines. These discrepancies were observed during the lunch service, and the Certified Dietary Manager (CDM) acknowledged the errors, confirming that the menu specified a half serving for both CCHO and small portion diets. Furthermore, a resident on a mechanical soft texture diet, which is designed for individuals with chewing or swallowing difficulties, was served a chopped salad with croutons, despite the menu indicating that croutons should be excluded. The Registered Dietitian (RD) confirmed that the presence of croutons posed a risk to residents with swallowing difficulties. The RD emphasized the importance of following the menu to ensure the safety and nutritional needs of the residents. The facility's policy and job descriptions for dietary staff highlighted the necessity of adhering to the prescribed diets and ensuring tray accuracy, which was not followed in these instances.
Delayed MDS Admission Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) Admission Assessment within the required 14 calendar days after admission for two residents out of a census of 38. Resident 9, who was admitted with diagnoses including dementia and cognitive communication deficit, had their comprehensive Admission Assessment completed 28 days after admission. Similarly, Resident 21, admitted with altered mental status, had their assessment completed 26 days post-admission. During an interview and record review, the Director of Nursing acknowledged the late completion and submission of these assessments, which was not in accordance with the facility's policy and procedure for MDS completion and submission timeframes.
Failure to Develop Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was dependent on renal dialysis and had end-stage renal disease. The resident was admitted to the facility with a diagnosis that included dependence on dialysis, and it was observed that the resident had a peritoneal dialysis tube connected to her left abdominal area. The resident confirmed that she underwent dialysis on specific days of the week. Despite this, a review of the resident's medical records revealed that there was no care plan addressing her dialysis care and interventions. Interviews with facility staff, including a licensed nurse and the Assistant Director of Nursing, confirmed the absence of a care plan for the resident's dialysis needs. The facility's policy on comprehensive person-centered care plans requires the development and implementation of care plans that include measurable objectives and timetables to meet residents' needs. The lack of a care plan for the resident's dialysis care decreased the facility's potential to address her individualized and specific needs.
Resident Wears Immobilizer Without Physician's Order
Penalty
Summary
The facility failed to provide services that meet professional standards of quality care for a resident who was allowed to wear a left leg/knee immobilizer without a physician's order. The resident was admitted with a left tibial plateau fracture after a fall and was observed wearing the immobilizer during an initial tour. The physical therapist confirmed that the immobilizer should be worn at all times as ordered from the hospital to prevent the knee from bending or flexing. Upon review of the Order Summary Report, it was verified by a licensed nurse and the Director of Rehab that there was no physician's order for the immobilizer. The Assistant Director of Nursing, who admitted the resident, acknowledged forgetting to write the order after clarifying it with the hospital doctor. The facility's policy requires verbal orders to be recorded immediately, which was not followed in this case, leading to the deficiency.
Failure to Maintain Nail Care for Resident
Penalty
Summary
The facility failed to maintain proper nail care for a resident, identified as Resident 25, who was admitted with dementia. During an observation, it was noted that the resident had long fingernails packed with a brownish-black substance. The Certified Nurse Assistant (CNA) acknowledged the condition of the nails and stated the intention to inform the Licensed Nurse and Activities Aide for nail care. However, the Activities Aide was unaware of the issue, and the Licensed Nurse, who later discharged the resident, was also not informed. Another CNA noticed the condition but forgot to report it. The resident's care plan indicated a deficiency in self-care, but there was no specific nail care plan initiated. The facility's policy required daily cleaning of nails, which was not followed. The Assisting Director of Nursing stated that CNAs should have performed daily hand hygiene and cleaned the nails with soapy water if trimming was not possible. The failure to maintain nail hygiene decreased the facility's potential to prevent infection, as dirty nails are a known source of infection.
Failure to Implement Physician's Order for Heel Floating
Penalty
Summary
The facility failed to provide care in accordance with professional standards for one resident, identified as Resident 2, who did not receive the prescribed treatment to float her heels while in bed. This order was intended to prevent skin breakdown. Resident 2 was admitted with diagnoses including muscle weakness and age-related physical debility. During an observation and interview, it was noted that Resident 2's feet were not floated as per the physician's order, despite the presence of edema. Licensed Nurse 4 confirmed the oversight and acknowledged the active order for heel floating. The Assistant Director of Nursing stated that nursing staff are expected to follow physician orders and that any refusal by the resident should be communicated to the doctor and documented in the care plan. The facility's policy on medication and treatment orders requires adherence to safe and effective order writing and implementation.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 15, had access to necessary vision services, specifically prescription eyeglasses. Resident 15, who was admitted in July 2023 with diagnoses including cataracts and syncope, was observed squinting while watching television and using a magnifying glass for reading. Despite the resident's need for corrective lenses being documented in her Minimum Data Set assessment dated April 2024, the facility had not provided the required eyeglasses. Interviews with facility staff, including the Social Worker and the Assistant Director of Nursing, confirmed that Resident 15 required eyeglasses to watch television properly and that the Social Worker had not yet facilitated the necessary referrals for obtaining them. The facility's policy on referrals, revised in December 2008, indicated that social services personnel are responsible for coordinating resident referrals based on their needs. This oversight resulted in Resident 15 not having the eyeglasses needed to maintain good vision.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident 2 was prescribed an anti-anxiety medication, hydroxyzine hydrochloride, without a stop date, despite a recommendation from the Pharmacy Consultant to include one. The medication was administered three times in May 2024, and the Nurse Practitioner confirmed the absence of a stop date during a review. The Assistant Director of Nursing acknowledged the oversight, noting that the medication should have been limited to a 14-day period as per the facility's policy. Resident 3 was prescribed an antibiotic, ciprofloxacin hydrochloride, for recurring urinary tract infections without a specified duration of treatment. The Pharmacy Consultant noted the absence of a stop date but did not provide recommendations. The Nurse Practitioner agreed that the medication had been ordered for too long, and the Infection Preventionist confirmed that the last documented UTI was in June 2022. The facility's policy requires complete antibiotic orders, including start and stop dates, which was not adhered to in this case.
Infection Control Breach in COVID-19 Unit
Penalty
Summary
The facility failed to adhere to infection control practices for a resident diagnosed with COVID-19. During an observation, a Certified Nursing Assistant (CNA) entered the room of a COVID-19 positive resident without wearing a face shield or goggles, despite the visible signage indicating the requirement for such personal protective equipment (PPE). The CNA was observed wearing an N-95 mask, gown, and gloves while assisting the resident with a meal, but did not comply with the full PPE protocol as outlined by the facility's policy. Interviews with the CNA and a Licensed Nurse confirmed the PPE requirements for the COVID-19 unit, which included the use of an N-95 mask, gown, gloves, and either goggles or a face shield. The facility's policy, dated May 2023, also specified these PPE requirements for staff caring for residents with suspected or confirmed COVID-19 infection. The Infection Preventionist reiterated the necessity of these PPE measures during an interview, highlighting the deviation from established protocols in this instance.
Failure to Post Daily Staffing Information Timely
Penalty
Summary
The facility failed to ensure that staffing information was posted daily at the beginning of each shift for a census of 38 residents. Observations revealed that the Daily Staffing information was not posted on the weekend of 6/1/24 and 6/2/24, and during weekdays, it was posted late, after 9:30 a.m., instead of within two hours of the beginning of the day shift at 6 a.m. This lapse was confirmed by the Staffing Coordinator, who acknowledged the failure to post the staffing information timely and attributed the weekend oversight to the receptionist. Interviews with the Staffing Coordinator and the Assistant Director of Nursing confirmed that the responsibility for posting staffing information was not fulfilled as per the facility's policy. The policy, dated 7/16, mandates that the facility post the number of nursing personnel responsible for providing direct care to residents daily and within two hours of the start of the day shift. The failure to adhere to this policy resulted in residents and visitors being unable to access information about the staff ratio and the number of staff providing care.
Failure to Follow Therapeutic Diet Menus and Portion Sizes
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided according to the prescribed menu and physician orders during lunch meals on two consecutive days. Specifically, three residents on a Consistent Carbohydrate (CCHO) diet received pineapple Bavarian cream square instead of the prescribed pineapple tidbits, and another resident on the same diet received pudding instead of the correct CCHO dessert. The facility's menu spreadsheet indicated that pineapple tidbits should have been served, and both the Certified Dietary Manager (CDM) and Registered Dietitian (RD) confirmed that the observed desserts did not comply with the menu requirements for CCHO diets. Additionally, during a meal service, fifteen residents on fortified diets did not receive the required super soup, which is intended to provide extra calories and nutrients for those unable to consume adequate amounts of food. The menu spreadsheet specified that super soup should be provided for fortified diets, but it was omitted during the meal service. Furthermore, two residents on large portion diets received only three ounces of meat instead of the four ounces specified in the menu spreadsheet. The RD explained that large portion diets are necessary for residents who need more protein or have specific preferences, and the correct portion size is essential to meet their nutritional needs. These failures were observed during direct dining and meal service observations, and were acknowledged by both the CDM and RD. The facility's own diet manual and job descriptions for dietary staff require strict adherence to menu specifications and portion sizes for therapeutic diets. The deficiencies had the potential to compromise the medical and nutritional status of a significant number of residents who received meals from the facility's kitchen.
Plan Of Correction
Corrective Action for Affected Residents: On 4/23/25, the Registered Dietitian reviewed the nutritional status of Residents 11, 21, 35, and 17 who received incorrect CCHO desserts, and Residents 1, 2, 3, 7, 15, 18, 20, 21, 25, 28, 30, 38, 39, 41, and 396 who did not receive super soup for fortified diets, and Residents 6 and 17 who received incorrect portion sizes. No adverse effects were identified. The Certified Dietary Manager immediately corrected portion sizes and therapeutic diet components for all affected residents. Identifying other Residents having the Potential to be Affected: On 4/23/25, the Registered Dietitian conducted a comprehensive review of all residents receiving therapeutic diets to ensure proper menu items and portion sizes were being provided. The CDM reviewed all current therapeutic diet orders against the menu spreadsheet to ensure alignment. Measures put into place or Systemic Changes: 1. The CDM will in-service all dietary staff: - Proper portion sizes for therapeutic diets - Following menu spreadsheets accurately - Importance of therapeutic diet compliance - Proper documentation of menu substitutions 2. Kitchen staff will measure protein portions using standardized serving utensils and scales to ensure accurate portions. Plan to Monitor Performance: 1. The CDM or designee will audit 10 therapeutic diet trays daily for 2 weeks, then 3x/week for 2 weeks, then weekly for 1 month to ensure compliance with menu spreadsheet and proper portions. 2. The RD will conduct weekly random audits of 5 therapeutic diet trays for 4 weeks, then monthly for 2 months. 3. Results of all audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee quarterly by the Food Service Director. The QAPI committee will analyze data for patterns and trends and make recommendations for continued monitoring or modification of plan as needed until substantial compliance is achieved and maintained. All corrective action to be completed by 5/26/25. 2. The Maintenance Supervisor will be in-serviced by the CDM on proper ice machine cleaning procedures per manufacturer's guidelines. 3. The Director of Nursing will in-service all nursing staff on proper temperature monitoring and documentation for resident unit refrigerators/freezers. Plan to Monitor Performance: 1. The CDM or designee will conduct weekly audits for 4 weeks, then monthly for 12 months of: - Ice machine cleanliness - Equipment condition - Food storage practices - Temperature logs - Food labeling compliance 2. The Director of Nursing or designee will audit resident unit refrigerator/freezer temperature logs daily for 4 weeks, then weekly for 12 months. 3. Results of all audits will be reported to the Quality Assurance Performance Improvement (QAPI) Committee quarterly for review and additional interventions as needed until substantial compliance is achieved and maintained for 3 consecutive months. All corrective action to be completed by 5/26/25.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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